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Based on observation, interview, and record review, the facility failed to follow their established policies and procedures related to the removal of expired medications from floor stock medications, in the obstetrics department. Findings include:

Review of the facility's policy titled, Unusable Drugs, last revised 9/14/22, showed:

- ..."Unusable medications and devices include those that are unsuitable for patient administration due to the following conditions:
- Discharged Patients' medications,
- Discontinued Medications, and
- Expired (outdated). ..."

During an observation on 9/12/23 at 11:05 a.m., in the obstetrics department medication room, the following expired medications were observed:

- Two vials of Famotidine 20 mg/2 ml, expired 7/23,
- One capsule of Nifedipine 10 mg, expired 8/16/23, and
- Two vials of Hydralazine 20 mg/ml, expired 7/23.

During an interview on 9/12/23 at 11:10 a.m., staff member E stated nursing staff checked every month for expired medications in the medication room. She stated no particular nurse was assigned or responsible for completing this specific task.

During an observation on 9/12/23 at 11:22 a.m., a sign out sheet for outdates showed:

- July 2023 was not documented as completed for the medication room,
- August 2023 was documented as completed on 8/21/23, and
- September 2023 was documented as completed on 9/4/23.

Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical (H&P), when a patient was admitted by a mid-level practitioner for 3 (#s 2, 3, and 15) of 19 sampled in-patients. Findings include:

1. Review of patient #2's medical record showed an admission date and H&P completed on 9/8/23, by staff member O, a mid-level practitioner. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

2. Review of patient #3's medical record showed an admission date and H&P completed on 9/5/23, by staff member P, a mid-level practitioner. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

3. Review of patient #15's medical record showed an admission date and H&P completed on 9/9/23, by staff member Q, a mid-level practitioner. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

During an interview on 9/12/23 at 12:45 p.m., staff member B stated a H&P performed by a mid-level practitioner was not currently being co-signed by a medical doctor. She stated the facility did not have a policy and procedure for this process.

Review of the facility's Medical Staff ByLaws did not specify a MD/DO needed to co-sign an admission H&P completed by a mid-level practitioner and to assume full responsibility for the H&P of the patient.

Based on interview and record review, the facility failed to provide a patient in a swing bed the information for the right to stay until rehabilitation goals were met for a safe discharge for 1 (#11) of 2 sampled swing bed patients. Findings include:

During an interview on 9/11/23 at 12:20 p.m., NF1 stated she was satisfied with most of the services provided by staff at the facility. She stated she was upset that staff left patient #11 on the toilet by himself, because he was 82 and just had back surgery. He was found on the floor in the bathroom the night before. She stated he had been having deliriums and hallucinations from his pain medication.

Review of patient #11's admission history and physical for the swing bed, dated 9/8/23, showed, "This procedure (second back surgery) has been a little slower of recovery and he is being admitted for a rehabilitation stay to hopefully get him stable with ambulation and also clearer mentation before he goes home. His wife understands that we can only offer a week or so of rehab stay and if it looks like he is going to need a longer recovery we will have to investigate other nursing homes that could complete a 3-week rehabilitation total."

Review of a care management note for patient #11, dated 9/11/23, showed the patient may need skilled nursing facility services for more extensive rehab. The wife really prefers the patient not go to a skilled nursing facility. "CM discussed again Swing Bed is short term."

During an interview on 9/11/23 at 3:30 p.m., staff member C stated the swing beds were for short stays only based on the facility surgery schedule. She stated she would talk to the physician about a longer stay for patient #11.

Review of patient #11's Physical Therapy note, dated 9/14/23, showed he was making progress but not yet meeting mobility goals.

During an interview on 9/14/23 at 10:25 a.m., staff member C stated the facility did not know swing bed stays could be longer than 2 weeks. She stated the physician had agreed patient #11 could stay until his rehabilitation goals were met. Staff member B stated the facility believed a skilled need, such as physical, occupational, or speech therapy, had to be present for the swing bed stay.