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Based on review of Board of Directors, Medical Staff meeting minutes, document review and staff interviews, the Board of Directors (governing body) failed to ensure the Board of Directors administered policies to determine and maintain quality health care at the Critical Access Hospital.

The Board of Trustees failed to ensure the Medical Staff followed their bylaws when credentialing and granting medical staff privileges to providers at the Critical Access Hospital. Please refer to C-962.

The cumulative effect of the systemic failure and deficient practices resulted in the facility's inability to ensure quality health care provided to patients.

Based on document review, credential file review and staff interviews, the Critical Access Hospital's (CAH) Board of Directors failed to ensure the CAH's Medical Staff evaluated and recommended practitioners for appointment to the medical staff for 12 of 14 providers selected for review (Advanced Nurse Practitioner A, Certified Nurse Midwife B, General Surgeon C, General Surgeon D, Hospitalist/Emergency Room Physician E, Otolaryngologist F, Orthopedic Surgeon G, Family Medicine Physician H, Family Medicine Physician I, Certified Registered Nurse Anesthetist J, General Surgeon K and Emergency Medicine Physician Assistant L). Failure of the Medical Staff to review the qualifications of the practitioners could potentially result in practitioners receiving privileges beyond the providers' or CAH staff's capabilities to safely provide quality care to the patients at the CAH. The CAH administrative staff identified 36 Medical Staff members credentialed to provide care to patients on-site at the CAH.

Findings include:

1. Review of the CAH network agreement, effective 12/20/2010, revealed in part "... Hospital is responsible for credentialing of it's medical practitioners through appropriate medical staff committee ... ".

2. Review of the CAH network agreement for credentialing, privileging and peer review, effective 12/14/2016, revealed in part "... Hospital retains the ultimate decision making authority with respect to all credentialing privileging and peer review decisions pursuant to Hospital's Medical Staff Bylaws ...".

3. Review of the CAH Medical Staff bylaws, adopted by the Medical Staff on 3/14/2017 and approved by the Board of Directors on 5/17/2017, revealed in part "... all appointments and reappointments to the Medical Staff are made by the Board acting upon the recommendation of the Credentials Committee and the Executive Committee ... the Credentials Committee shall evaluate Applicants for Medical Staff membership and make recommendations on such applications the Executive Committee and Board ... within four (4) weeks of receipt of the Credentials Committee's recommendations, the Executive Committee will review and evaluate the recommendations of the Credentials Committee, and will forward a recommendation for membership status and clinical privileges to the Board ... :.

4. Review of the CAH Board of Directors Bylaws, adopted on 12/14/2016, revealed in part " ... The Corporation shall have a medical staff ("Medical Staff") organized under Medical Staff Bylaws approved by the Board. The Medical Staff shall be responsible to the Board for the quality of all medical care provided to patients in the hospital facility, and for the ethical and professional practices of its members ... The Medical Staff Executive Committee shall be responsible for making recommendations to the Board concerning initial staff appointments, reappointments, and the assignment or curtailment of privileges ...".

5. Review of the CAH policy titled "Medical Staff/Allied Health Professional Appointment and Reappointment", revised on 1/31/19, revealed in part " ... [Network Hospital's name] Credentialing Services to perform Credentialing and re-credentialing functions ... [CAH] retains the right to approve, deny, terminate, or suspend any practitioners per [CAH] Medical Staff Bylaw procedures. Review of providers profiling information and privileging information at the time of appointment and reappointment will be coordinated by [Network Hospital's name] Credentialing Services ... The [Network Hospital's name] Board of Trustees and the [CAH] Board appoint all members to the medical staff in accordance with established policies ... ".

6. Review of credential files for the identified providers revealed the following:

a. Advanced Nurse Practitioner A's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 8/21/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 9/26/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

b. Certified Nurse Midwife B's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 6/19/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 7/25/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

c. General Surgeon C's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 9/18/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 10/24/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

d. General Surgeon D's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 10/16/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 11/28/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

e. Family Medicine Physician E's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 4/17/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 5/23//2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

f. Otolaryngologist F's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 4/17/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 5/23/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

g. Orthopedic Surgeon G's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 8/22/2019 and the CAH Board of Directors approved the appointment to CAH medical staff on 9/25/2019. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

h. Family Medicine Physician H's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 8/21/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 9/26/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

i. Family Medicine Physician I's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 8/21/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 9/26/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

j. Certified Registered Nurse Anesthetist J's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 4/17/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 5/23/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

k. General Surgeon K's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 7/25/2019 and the CAH Board of Directors approved the appointment to CAH medical staff on 8/28/2019. The credential file lacked documentation the CAH's Medical Staff approved the appointment.

l. Emergency Medicine Physician Assistant L's credential file revealed the Network Hospital Credentials Committee approved the appointment to CAH Medical Staff on 6/19/2018 and the CAH Board of Directors approved the appointment to CAH medical staff on 7/25/2018. The credential file lacked documentation the CAH's Medical Staff approved the appointment.


7. During an interview on 2/18/2020 at 1:30 PM, the CAH Compliance Specialist and the Network Hospital Manger of Credentialing Services reported the network hospital receives and processes all applications and required information related to appointments and reappointments to the CAH's medical staff. The information goes to the Network Hospital Credentials Committee and the Network Hospital Medical Executive Committee for approval. The Compliance Specialist reported that a list of recommended appointments is forwarded to the CAH medical staff for informational purposes but the CAH medical staff do not receive the credential files to review and do not vote on the recommendations. The list of recommendations then go to the CAH Board of Directors for approval.

8. During an interview on 2/18/2020, at 4:25 PM, the Compliance Specialist confirmed a credentialing agreement with the Network Hospital and the Medical Staff bylaws identified the delegation of authority to the Network Hospital to recommend appointments and reappointments to the CAH medical staff and she confirmed the CAH's current system bypasses the CAH medical staff's ability to approve or deny appointments to the medical staff.

9. During an interview on 2/20/2020, at 12:30 PM, the Vice Chief Medical Officer reported the CAH medical staff only receives a list of names, approved and recommended by the network hospital, for appointment to the CAH medical staff. He reported previous to approximately 3 years ago, the CAH medical staff received the credential files to review and evaluate, and would then vote on the appointment to the medical staff. The CAH Vice Chief Medical Officer confirmed the CAH medical staff do not receive the credential files to review and does not vote on appointments to the CAH medical staff, thus the CAH's medical staff had to trust the Network Hospital staff's judgement.

Based on policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for CAH patients, in conjunction with the mid-level provider, for 2 of 2 applicable mid-level providers selected for review. (Advanced Registered Nurse Practitioner A and Certified Nurse Midwife B). Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

The hospital staff identified the mid-level providers provided care to patients in 2019 as follows:

- Advanced Registered Nurse Practitioner A (ARNP): 312 encounters
- Certified Nurse Midwife (CNM) B: 11 deliveries

Findings include:

1. Review of the CAH policy titled "Allied Health Professionals Roles, Responsibilities and Supervision", revised 1/23/2017, revealed the policy identified the Medical Staff will provide medical direction, oversee and consult on all patient care and physician requirements for countersignatures but failed to identify a system which ensured physicians conducted a periodic chart review of care provided by mid-level providers to the CAH's patients.

2. During an interview on 2/19/2020, at 10:45 AM, the Compliance Specialist reported the CAH requires a physician to sign off on certain portions of a mid-level provider's chart and some of the mid-level providers had peer review on charts conducted by the Network Hospital, but confirmed the CAH lacked a system to ensure a CAH physician periodically reviews the care of CAH patients in conjunction with the mid-level provider.

Based on policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a mid-level provider participated in a periodic review of the care provided to CAH patients, in conjunction with a physician, for 2 of 2 mid-level providers selected for review. (Advanced Practice Nurse Practitioners A and Certified Nurse Midwife B). Failure to ensure a mid-level provider participated with a physician in a periodic review of the mid-level provider's patient medical records could potentially result in the mid-level misdiagnosing patient and/or providing inappropriate or substandard patient care.

The hospital staff identified the mid-level providers provided care to patients in 2019 as follows:

- Advanced Registered Nurse Practitioner (ARNP) A: 312 patients
- Certified Nurse Midwife B: 11 deliveries

Findings include:

1. Review of a CAH policy title "Allied Health Professionals Roles, Responsibilities and Supervision", revised 1/23/2017, revealed the policy identified the Medical Staff will provide medical direction, oversee and consult on all patient care and physician requirements for countersignatures but failed to identify a system which ensured physicians conducted a periodic chart review of care provided by mid-level providers to the CAH's patients.

2. During an interview on 2/19/2020, at 10:45 AM, the Compliance Specialist reported the CAH requires a physician to sign off on certain portions of a mid-level provider's chart and some of the mid-levels have had peer review on charts conducted by the Network Hospital, but confirmed the CAH lacked a system to ensure a CAH physician periodically reviews the care of CAH patients in conjunction with the mid-level provider.

I. Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 applicable mid-level practitioners selected for review (Advanced Registered Nurse Practitioner A and Certified Nurse Midwife B), are evaluated by a physician from the CAH medical staff to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the mid-level practitioners. Failure to ensure all mid-level practitioners are evaluated by a member of the CAH medical staff affects the CAH's ability to assure the mid-level practitioners provide quality care to the CAH patients.


The CAH administrative staff identified the physicians provided care to patients in 2019 as follows:

- Advanced Registered Nurse Practitioner A: 312 patient visits
- Certified Midwife B: 11 deliveries

Findings include:

1. Review of the Medical Staff Bylaws, adopted by the Medical Staff on 3/14/2017 and approved by the Board of Directors on 5/17/2017, revealed in part "... Clinical Privileges ... The recommendations ... will be based on a review of clinical privileges, ongoing professional performance data, continue professional education and training ... medical record review, reports from relevant quality improvement activities ...".

2. Review of a CAH policy titled "Allied Health Professionals Roles, Responsibilities and Supervision", revised 1/23/2017, revealed the policy identified the Medical Staff will provide medical direction, oversee and consult on all patient care and physician requirements for countersignatures but failed to identify a system for the physician to conduct periodic chart review to evaluate the quality and appropriateness of the diagnosis and treatment of CAH patients by mid-level practitioners.

3. Review of the CAH policy titled "Medical Staff/Allied Health Professional Appointment and Reappointment, revised 1/21/2019, revealed in part "... Medical Staff Physician ... Participates in peer review activities that include periodic review of patient charts as well as quality improvement, infection control and safety practices ... ".

4. During an interview on 2/19/2020, at 10:45 AM, the Compliance Specialist reported the CAH requires a physician to sign off on certain portions of a mid-level provider's chart and some mid-level practitioners have peer review on charts conducted by the Network Hospital but confirmed the CAH lacked a system to ensure a CAH physician periodically reviews the care of CAH patients furnished by a mid-level practitioners.

5. During an interview on 2/19/2020, at 3:00 PM, the Compliance Specialist confirmed the CAH lacked evidence of evaluation, by a CAH physician, of the quality and appropriateness of the diagnosis and treatment furnished to CAH patients by Advanced Registered Nurse Practitioner A and Certified Nurse Midwife B.




II. Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 5 active physicians selected for review received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH. (General Surgeon C and General Surgeon D). Failure to ensure all medical staff members received outside entity peer review by the appropriate entity, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the physicians provided care to patients in 2019 as follows:

- General Surgeon C: 207 patient visits
- General Surgeon D: 4 patient visits

Findings include:

1. Review of the CAH network agreement, effective 12/20/2010, revealed in part "... Hospital is responsible for credentialing of it's medical practitioners through appropriate medical staff committee ... Hospital shall include Medical Record review as part of the determination of quality and medical necessity of medical care. Peer Review of Medical Staff will be included in overall Hospital quality assurance plan".

2. Review of the CAH Medical Staff Bylaws adopted by medical staff on 3/14/2017 and approved by the Board of Directors on 5/17/2017, revealed in part " ... It is the policy of the Hospital and the Medical Staff to engage in peer review to promote continuous improvement in the quality of care, patient safety and utilization. Peer review shall be conducted in accordance with Hospital's Peer Review Policy ..."

3. Review of the CAH Amended Credentialing, Privileging and Peer Review Delegation Services Agreement, effective 12/14/2016, revealed in part " ... At the discretion of the Hospital's Medical Executive Committee, and pursuant to the Hospital's Medical Staff bylaws, Hospital may request [Network Hospital] undertake peer review ... [Network Hospital] shall perform peer review services on behalf of Hospital, at Hospital's request ..."

4. Review of the CAH policy titled "Peer Review" revised 1/31/2019, revealed in part " ... Each provider who provides a service within their two year reappointment period at the [CAH], excluding "order only" providers, will be reviewed externally by [Network Hospital] peer review process ... results of peer review will be stored in the providers credentialing file ... ".

5. Review of credential files and external peer review completed for the applicable physicians selected for review revealed the following:

- General Surgeon C's credential file lacked external peer review completed by the CAH's Network Hospital. The CAH's governing body approved Physician C's reappointment to medical staff on 10/24/18.

- General Surgeon D's credential file lacked external peer review completed by the CAH's Network Hospital. The CAH's governing body approved Physician H's reappointment to medical staff on 11/28/18.


6. During an interview on 2/18/2020, at 4:25 PM, the Compliance Specialist reported the Network Hospital conducts peer review on CAH medical staff patient records to evaluate the quality of care based on established triggers. She acknowledged the CAH does not have a system in place to select at least 1 record per credential cycle for outside entity peer review, if a physician does not have a patient record that meets any of the trigger criteria.

7. During an interview on 2/19/2020, at 10:30 AM, the Compliance Specialist confirmed the CAH failed to ensure General Surgeon C and General Surgeon D received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH.

I. Based on staff interview and document review, the Critical Access Hospital (CAH) pharmacy staff failed to store Succinylcholine vials (medication used to relax muscles during surgery) in the anesthesia medication carts according to manufacturer's recommendations. Failure to ensure Succinylcholine is stored according to manufacturer's recommendations could potentially result in patients receiving a medication that does not work in the body as expected resulting in unintended consequences or side effects. The CAH's administrative staff identified the surgical services staff performed an average 546 surgical procedures per year.

Findings include:

1. Observations on 02/18/20 at approximately 1:00 PM during a tour of the pharmacy revealed multiple vials of Succinycholine in the pharmacy refrigerator.

2. During an interview at the time of the tour, the Pharmacy Manager explained they remove the Succinycholine from the pharmacy refrigerator and store it in the anesthesia carts for use by the Certified Registered Nurse Anesthetists (CRNAs) during surgery. The Pharmacy Manager marks each vial with a "use by" date that is 30 days after the succinycholine is removed from the pharmacy refrigerator.

3. Review of the manufacturer's recommendations for the storage of Succinylcholine revealed, in part: "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

4. During an additional interview at the time of the tour, Pharmacy Manager acknowledged the manufacturer recommended the CAH staff store the Succinylcholine for only 14 days after removing the Succinylcholine from the refrigerator.




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II. Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscopy procedure for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The Surgery Manager identified that the surgery staff performed an average of 220 endoscopy procedures per year.

Findings include:

1. Observations during a tour of the surgery department on 02/18/2020 at approximately 1:00 PM in Operating Room #1 (OR) revealed 1 of 1 bottle Hospira 1000 mL bottle of sterile water for irrigation connected to the endoscopy equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract). Review of the manufacturer's instructions indicated in part, " intended for use only as a single-dose or short procedure irrigation. When smaller volumes are required the unused portion should be discarded." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

2. During an interview on 02/18/2020 at the time of the tour, the OR Manager stated the surgery staff opened a bottle of sterile water for irrigation each day endoscopy procedures are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscopy procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscopy procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

3. During an interview on 02/18/2020 at approximately 2:45 PM, the OR Manager stated they reviewed the manufacturer's directions for the Hospira 1000 mL bottles of sterile water for irrigation. The OR Manager acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff notified the patient's physician following the discovery of a medication error for 5 of 7 medication errors reviewed. (Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6) and failed to document the date and time the nursing staff notified the physician for 1 of 7 medication errors reviewed (Patient #1). Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 8 patients on entrance, and an average daily census of 6 patients per day.

Findings include:

1. Review of the policy "Medication Errors," last revised 03/08/19, revealed in part, "Medication errors will be reported to the practitioner who ordered the drug as soon as possible or immediately if necessitated by patient care."

2. Review of a sample of medication errors revealed:

a. On 6//26/2019 at 9:09 PM the nursing staff discovered they failed to administer an anti-seizure medication to Patient #2. The medication error record lacked documentation of the date or time the nursing staff notified Patient #2's physician of the medication error.

b. On 03/02/2019, the nursing staff discovered that Patient #3 was not receiving the correct dose of Aspirin (used as a blood thinner). The medication error record lacked documentation of the date or time the nursing staff notified Patient #3's physician of the medication error.

c. On 12/09/2019 at 8:00 AM, the nursing staff discovered that Patient #4 was not receiving Warfarin (a medication used as a blood thinner). The medication error record lacked documentation of the date or time the nursing staff notified Patient #4's physician of the medication error.

d. On 05/25/2019 at 11:00 AM, the nursing staff discovered they failed to administer Patient #5's dose of Oxacillin (an antibiotic) at the correct time. The medication error record lacked documentation of the date or time the nursing staff notified Patient #5's physician of the medication error.

e. On 08/30/2019 at 8:30 PM, the nursing staff discovered they failed to administer a dose of Spironolactone (a medication to remove excess fluid from the body) to Patient #6. The medication error record lacked documentation the nursing staff notified Patient #15's physician of the medication error.

f. On 11/08/2019 at 8:00 AM, the nursing staff discovered they failed to administer the correct dose of insulin to Patient #1. The medication error record lacked documentation of the date or time the nursing staff notified Patient #1's physician.

3. During an interview on 02/19/2020 at 10:30 AM, the Compliance Specialist confirmed there was no documentation in the medication event document or the medial record of physician notification of the medication errors for Patient #2, Patient #3, Patient #4 and Patient #5. Compliance Specialist also confirmed there was no documentation in the medication event document or the medical record of the date and time the physician was notified of the medication error for Patient #1.

Based document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 3 of 3 reviewed open swing bed patients (Patient #10, Patient #11, and Patient #12) and 2 of 2 reviewed closed swing bed patients (Patient #6 and Patient #13). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehabilitation services appropriate to their medical condition. The CAH administrative staff identified 78 swing bed admissions in Fiscal Year 2019 with an average length of stay of 15 days.

Findings included:

1. Review of the CAH's policies/procedures revealed the CAH lacked a policy/procedure which addressed the requirement for a physician to order specialized rehabilitation services for swing bed patients.

2. Review of Patient #10's open medical record revealed the CAH staff admitted Patient #10 for swing bed level care on 02/14/2020. Advanced Registered Nurse Practitioner (ARNP, a nurse with advanced training to diagnose and treat patients) A wrote an order on 02/14/2020 at 02:01 PM for the Physical Therapist to evaluate and treat Patient #10 and for the Occupational Therapist to evaluate and treat Patient #10.

3. Review of Patient #11's open medical record revealed the CAH staff admitted Patient #11 for swing bed level care on 02/12/2020. ARNP A wrote an order on 02/12/2020 at 01:45 PM for the Physical Therapist to evaluate and treat Patient #11 and for the Occupational Therapist to evaluate and treat Patient #11.

4. Review of Patient #12's open medical record revealed the CAH staff admitted Patient #12 for swing bed level care on 02/03/2020. ARNP A wrote an order on 02/03/2020 at 02:31 PM for the Physical Therapist to evaluate and treat Patient #12 and for the Occupational Therapist to evaluate and treat Patient #12.

5. Review of Patient #6's closed medical record revealed the CAH staff admitted Patient #6 for swing bed level care on 08/13/2019. The CAH staff discharged Patient #6 on 09/26/2019. ARNP A wrote an order on 08/13/2019 at 03:43 PM for the Physical Therapist to evaluate and treat Patient #6 and for the Occupational Therapist to evaluate and treat Patient #6.

6. Review of Patient #13's closed medical record revealed the CAH staff admitted Patient #13 for swing bed level care on 11/07/2019. The CAH staff discharged Patient #13 on 11/21/2019. ARNP O wrote an order on 11/07/2019 at 09:00 PM for the Physical Therapist to evaluate and treat Patient #13 and for the Occupational Therapist to evaluate and treat Patient #13.

7. During an interview on 02/20/2020 at 10:45 AM, the Nurse Educator acknowledged that ARNP A wrote the therapy orders for Patient #10, Patient #11, Patient #12, and Patient #6 and ARNP O wrote the therapy orders for Patient #13 when the patients received swing bed services.

8. During an interview on 02/20/2020 at 11:55 AM, the Privacy Officer acknowledged a physician did not write the therapy orders for Patient #6, Patient #10, Patient #11, Patient #12, and Patient #13.