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Based on observation and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure their total number of beds available for inpatients did not exceed 25. Failure to ensure the CAH maintained a 25 bed count could potentially result in the CAH's ability to provide adequate care and services. The CAH administrative staff identified a census of 8 inpatients at the beginning of the survey.

Findings include:

1. Observation during tour of the inpatient care area with the Assistant Medical/Surgical Nurse Manager on 2/4/19 at 11:40 AM revealed 26 beds were available for inpatient use.

2. During at interview on 2/4/19 at 11:45 AM, the Assistant Medical/Surgical Nurse Manager acknowledged the hospital's total number of beds available for inpatients was 26 that included 1 crib stored in an equipment room in the inpatient area.

During an interview on 2/4/19 at 12:20 PM, the Medical/Surgical Nurse Manager confirmed the hospital's total number of beds available for inpatients was 26 that included 1 crib stored in an equipment room in the inpatient area.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 1 of 1 Medical/Surgical Nursing Unit emergency supply crash cart. The CAH staff reported 25 certified bedsand had 8 patients on entrance. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, indicating the staff should not use the supplies for patient care.


Findings included:

1. Review of the policy "Crash Cart Checking" effective 5/2018, revealed in part, "To assure the proper function and adequate supply of items needed in an emergency situation. Crash cart checks are performed to check for adequate levels....and outdated items to be replaced."

2. During a tour on 2/04/2019 around 12:00 PM of the Medical Surgical Unit, an observation of the medical surgical Crash Cart revealed the following:

a. 1 of 1 2.5 Endotracheal tube (a small tube inserted through the mouth or nose into the windpipe to establish an airway) expired 1/2019

b. 1 of 1 gray 4 ml blood tube, expired 1/14/2019

c. 1 of 1 vacuette Holdex blood tube holder, expired 1/14/2019

3. Review of the Crash Cart checklist located in a notebook on top of the crash cart, revealed the staff checked the crash cart in January for the presence of outdated supplies. A 3 inch yellow post-it note was placed on the checklist and instructed staff to "Pull and Replace at end of January: 1 vacuette 4th drawer, 1 Gray Blood Tube, size 2.5 ET-Tube". The Crash Cart had not had the February outdate check completed.

4. During an interview at the time of the observations, the Medical Surgical Nurse Manager, verified the supplies had expired, should have been pulled at the time the check was completed, and the staff should not use the supplies.


II. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) Staff failed to follow the manufacturer's instructions for the ACCU-CHEK Inform Blood Glucose Monitoring System when it failed to label a newly opend bottle of glucose control solution with the opened date on the label. Failure to follow the ACCU-CHEK Inform Blood Glucose Monitoring System manufacturer's instructions for use may result in inaccurate blood glucose readings. The CAH reported the Medical Surgical Unit performed approximately 215 blood glucose checks per month and the Cardiac Rehab unit performed approximatley 39 blood glucose checks per month.

Findings include:

1. Observation on 2/4/2019 during a tour of the Medical Surgical Unit revealed two separate but identical ACCU-CHEK Inform Glucose Monitoring Systems in their respedtive cases. Each case contained one bottle of Control 1 and one bottle of Control 2. Each of these 4 control bottles had an expiration date of 2020-5-31. Each of the 4 control vials had been opened. None of the 4 control vials were labled with the date opened.

2. Observation on 2/6/2019 at 8:55 AM while on tour of the Cardiac Rehab Unit, ACCU-CHEK Glucose Monitoring System Control bottles 1 and Control Bottle 2 were opened and not labeled with date opened.

2. Review of the ACCU-CHEK Inform manufacturer's booklet, dated 2004 revealed in part, "Note: When you open a new bottle of glucose control solution, write the date on the label. Do not use the control solution for more than 90 days after opening..."

2. Review of Policy "Blood Glucose Monitoring", effective 1/2019, revealed in part, " Verify the control solution lot number and expiration date for both the high and low solutions. If the epiration date of the solution has been reached, obtain a new bottle from the laboratory." The policy fails to direct the staff to write the date on the label when the new bottle is opened.

3. During an interview on 2/14/2019 while on tour of the Medical Surgical Unit the Medical Surgical Nurse Manager verified the control bottles had not been labeled when opened.

I. Based on observations, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy oversight of sample medications in 1 of 1 provider-based outpatient professional services clinic.

The CAH reported, between 7/1/18 to 1/31/19, the Rheumatology Clinic treated 346 patients and the Ophthalmology Clinic treated 645 patients.

The Professional Clinic Manager confirmed 73 rheumatolgic sample injectable and oral medications and 169 ophthalmologic sample medications.

Failure of pharmacy oversight in the dispensing of sample medications could result in outdated, recalled, or otherwise unusable medications being available for physicians and mid-level providers to give to patients, as well as, the potential for theft of medications by unauthorized persons.

Findings include:

1. Observation during tour of the Professional Services Clinic rheumatology refrigerator on 2/6/19 at 2:35 PM with the Professional Clinic Manager, revealed the refrigerator stored multiple rheumatolgic sample injectable and oral medications.

During an interview, at the time of the observation, the Professional Clinic Manager reported when the samples are received by the rheumatologist, the medical assistant enters the medications on log sheets. She obtained the log sheets for review which showed separate sheets for each medication and documented information about the sample and a record of dispensing. The Professional Clinic Manager reported the CAH pharmacist did not play a role in oversight of the sample medications in the clinic, although aware they stored some. She confirmed documentation of varied content information on the multiple logs, incomplete documentation of information and inaccurate or lack of the total number of samples stored.

2. Observation during tour of the Professional Clinic nurses station storage cabinet, on 2/6/19 at 2:45 PM with Professional Clinic Manager revealed the cabinet stored 169 ophthalmologic sample medications available for patient use.

During an interview, at the time of the observation, Staff F, Medical Assistant, reported she did not maintain any logs of the sample medications. She explained the pharmaceutical representative provided a receipt of the samples provided which served as the inventory of samples on hand and when medications were dispensed, she only documented the information in the patient record. Staff F reported when all the samples from a specific receipt were gone, she discarded the receipt. She acknowledged she lacked any receipts for sample medications, despite currently having samples stored in the cabinet.

During an interview on 2/7/19, at 8:20 AM, the Director of Pharmacy confirmed she knew the Professional Services Clinic stored sample medications but did not have a role in oversight of the medications. She reported professional pharmacy standards would include accurate accounting of medications received, dispensed and an accurate inventory of medications on hand. The Director of Pharmacy acknowledged, without an accurate accounting of inventory, the CAH could not ensure unauthorized diversion of the medications and she would not be able to inform the clinic of medication recalls, since did not know what medications were stored in the clinic.

During an interview on 2/7/19, at 9:40 AM, the Professional Services Clinic Manager acknowledged the lack of complete and accurate accounting of the ophthalmologic sample medications.

Review of a CAH pharmacy policy titled "Samples: Drug", approved 12/2018, revealed the policy failed to identify the need for pharmacy oversight of drug samples within the CAH. The policy identified the need for a sign-in log to document, at a minimum, date of receipt, name/strength of sample, lot number, manufacturer of drug, quantity received and expiration date. The policy identified the need for a dispensing log to document, at a minimum, date of use, patient name, name/strength of drug, lot number, manufacturer of drug, quantity dispensed, directions for use and physician name.

Review of the logs for the current rheumatolgic sample injectable and oral medications revealed the logs failed to document all of the minimum information identified in the CAH policy and did not include an accurate accounting of the quantity of each medication currently stored. The CAH failed to maintain logs for the ophthalmologic sample medications in accordance with their sample drug policy.




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I. Based on observation, document review, and staff interview, the CAH's administrative staff failed to ensure Professional Clinic Provider H discarded 9 of 9 multi-dose vials after opening them in a direct patient care area (clinic patient exam room). Failure to discard multi-dose vials after using the vials in a direct patient care area could potentially result in bacterial contamination from the environment getting into the vial and contaminating the vial. If the bacteria contaminated the vial, the bacteria could potentially pass to the next patient and potentially cause the next patient to develop a life-threatening infection. The Professional Clinic Nurse Manager revealed that the Professional Clinic Provider H performed approximately 5 joint injections per month.

Findings include:

1. Observations on 2/06/18 at approximately 3:00 PM, during the tour of the JCHC Professional Clinic, revealed 9 opened multi-dose medication vials (a vial designed for use on multiple patients, if medication is not withdrawn in a patient care area), in the locked medication/supply cabinet located in the Professional Clinic Nurses Station. The vials of medications are utilized in the orthopedic clinic for joint injections to relieve inflammation and pain in the patient's affected joint and are identified as follows:

a. xylocaine 1%, labeled open date 2-(smeared number)-19, expiration date 11/20
b. xylocaine 1%, labeled open date 1-28019, expiration date 2/20
c. 0.5% Bupivicaine HCL and epinephrine 1:200,000, labeled open date 1/31/19, expiration date 11/19
d. 0.5% Bupivicaine Hydrochloride, labeled open date 1/24/19, expiration date 10/2019
e. xylocaine 2% with epinephrine 1:200,000, labeled open date 1/31/19, expiration date 9/19
f. Betamethasone sodium phosphate and Betamethasone Acetate, labeled open date 1/14/19
g. Betamethasone sodium phosphate and Betamethasone Acetate, labeled open date 1/29/19
h. 0.5% Bupivicaine HCL and epinephrine 1:200,000, labeled open date 1/22/19, expiration date 11/2019
i. 0.5% Bupivicaine Hydrochloride, labeled open date 1/30/19, expiration date 10/19

2. During an interview on 2/6/18, at the time of the observation of the opened multi-dose medication vials, Staff Nurse G revealed Professional Clinic Provider H takes the medication vial of choice to the clinic patient's exam room, draws up the dosage of medication to be given, injects the medication into the affected joint and Staff Nurse G returns the open vial to the medication cabinet. Staff Nurse G reported Staff Nurse G would label a newly opened vial with the date. Staff Nurse G divulged Staff Nurse G had no knowledge that a multi-dose medication vial accessed at the patient's bedside is can no longer be used for multiple patients.

3. During an interview on 2/7/19 at 7:30 AM, the Chief Nursing Officer revealed the critical access hospital does not have a policy regarding the use of multi-dose medication vials.

4. During an interview on 2/7/19 at 8:20 AM, the Director of Pharmacy acknowledged if a provider opened a multi-dose vial of medication in a patient care area, the provider should discard the multi-dose vial at the end of the procedure and not use the multi-dose vial for another patient. The Director of Pharmacy verified the medication to be administered needed to be prepared in a clean area, away from patient care, the syringe labeled and taken to the patient room.


II. Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure that outdated medications were not available for patient use. Failure to remove outdated medications from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications for patient use after the manufacturer's expiration date indicating staff should not use the medication for patient care. The Opthamology Clinic sees aproximately 92 patients a month.

Findings included:

1. Observations on 2/6/2019, during a tour of the JCHC Professional Clinic, revealed outdated Opthamology Sample Medications, readily available to be provided to patients, in a locked medication/supply cabinet at the Professional Clinic Nurses' Station. The outdated Sample medications are listed as follows:

a. Simbrinza, 28 total samples, 28 outdated, expired 1/2019
b.Travatan, 39 total samples, 15 outdated, expired 12/2018
c. Ilevro 0.3%, 26 total samples, 26 outdated, 9 expireded 4/2018, 6 expired 8/2018, 10 expired 11/2018
d. Besivance 0.6%, 10 total samples, 10 outdated
e. Istalol 1 total sample, 1 outdated, expired 7/2018

2. During an interview on 2/6/19, at the time of the observation the Professional Clinic Nurse Manager revealed it is the responsibility of the clinic nurse to monitor for outdated medications. The Pharmacy department staff was not involved with the managment of the Professional Clinic Sample Medications, including checking for outdated medications. The Professional Clinic Manager was not aware of any facility policies or procedures related to the managment of sample medications, including checking for outdated sample medications.

3. During an interview on 2/7/2019 at 8:20 AM, the Director of Pharmacy revealed the Director of Pharmacy was aware that the Professional Clinic had medication samples available to be provided to the clinic's patients and that the pharmacy was not involved in the managment of the medications within the Professional Clinic, including the management of sample medications. Each department that stocks medications has some asssigned to monitor medication outdates.

4.Review of policy "Expiration Dates" effective 12/2017, "affected departments: RX....Purpose: to keep drugs safe and effective, Policy: Expiration dates shall be assigned according to this policy. ....Expiration dates for ambulatory care prescription products....in no casse shall the assigned date exceed the manufacturer's expiration date."

I. Based on observation, document review and staff interviews the critical access hospital's administration failed to have safe medication preparation and administration policies and procedures in place to ensure that routine preparation of injectable medications take place in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed. Failure to prepare medications in a designated clean medication area could potentially result in bacterial contamination from the environment getting into the vial and contaminating the vial. If the bacteria contaminated the vial, the bacteria could potentially pass to the next patient and potentially cause the next patient to develop a life-threatening infection. The Professional Clinic Nurse Manager revealed that the Professional Clinic Provider H performed approximately 5 joint injections per month.

Findings include:

1. Observations on 2/06/18 at approximately 3:00 PM, during a tour of the JCHC Professional Clinic, revealed 9 opened multi-dose medication vials (a vial designed for use on multiple patients, if medication is not withdrawn in a patient care area), in the locked medication/supply cabinet located in the Professional Clinic Nurses Station. The vials of medications are utilized for joint injections to relieve inflammation and pain in the affected joint and are identified as follows:

a. xylocaine 1%, labeled open date 2-(smeared number)-19, expiration date 11/20
b. xylocaine 1%, labeled open date 1-28019, expiration date 2/20
c. 0.5% Bupivicaine HCL and epinephrine 1:200,000, labeled open date 1/31/19, expiration date 11/19
d. 0.5% Bupivicaine Hydrochloride, labeled open date 1/24/19, expiration date 10/2019
e. xylocaine 2% with epinephrine 1:200,000, labeled open date 1/31/19, expiration date 9/19
f. Betamethasone sodium phosphate and Betamethasone Acetate, labeled open date 1/14/19
g. Betamethasone sodium phosphate and Betamethasone Acetate, labeled open date 1/29/19
h. 0.5% Bupivicaine HCL and epinephrine 1:200,000, labeled open date 1/22/19, expiration date 11/2019
i. 0.5% Bupivicaine Hydrochloride, labeled open date 1/30/19, expiration date 10/19

2. During an interview on 2/6/18, at the time of the observation of the opened multi-dose medication vials, Staff Nurse G revealed the opened vials of medication are used for joint injections in the orthopedic clinic. Professional Clinic Provider H takes the medication vial of choice to the clinic patient's exam room, draws up the dosage of medication to be given, injects the medication into the patient's affected joint and Staff Nurse G returns the open vial to the medication cabinet at the nurses station. Staff Nurse G reported Staff Nurse G would label a newly opened vial with the date. Staff Nurse G divulged Staff Nurse G had no knowledge that a multi-dose medication vial accessed at the patient's bedside is can no longer be used for multiple patients. Staff Nurse G was not aware of any policies related to the use of multi-dose vials or safe medication injection practices.

3. During an interview on 2/7/19 at 7:30 AM, the Chief Nursing Officer revealed the critical access hospital does not have a policy regarding the use of multi-dose medication vials.

4. During an interview on 2/7/19 at 8:20 AM, the Director of Pharmacy acknowledged if a provider opened a multi-dose vial of medication in a patient care area, the provider should discard the multi-dose vial at the end of the procedure and not use the multi-dose vial for another patient. The Director of Pharmacy verified the medication to be administered needed to be prepared in a clean area, away from patient care, the syringe labeled and taken to the patient room.

Based on observation, document review, and staff interview, the Critical Access Hospital's administrative staff failed to ensure radiology staff regularly checked 37 of 37 lead shielding devices for cracks and holes in the lead shielding. Failure to check the lead shielding devices resulted in the radiology staff failing to identify cracks and holes which developed between the times the radiology staff checked the lead shielding devices. Failure to identify cracks and holes in the lead shielding devices could potentially result in the radiology staff exposing patients and staff to undesired radiation, potentially causing genetic damage or cancer. The Radiology Department Manager identified the radiology staff performed approximately 700 radiology procedures per month.

Findings include:

1. Observations during a tour of the radiology department on 2/5/19 at approximately 2:20 PM with the Radiology Department Manager revealed many lead aprons and other lead shielding devices (lead lined aprons and other devices used to protect patients and staff from undesired exposure to radiation) in the department.

2. Review of the policy titled "Inspection and Care of Radiation Protection Garments," dated revised 2/2004, revealed in part, "...All lead garments belonging to the Department of Radiology will be inspected annually and removed from use if significant flaws are demonstrated...."

3. Review of documents revealed the lack of documentation of inspection of lead shielding devices.

4. During an interview on 2/5/19 at 2:45 PM, the Radiology Department Manager acknowledged the radiology staff failed to check the lead shielding devices since before September 2017. The Radiology Department Manager verified the radiology staff was to check the lead shielding devices annually and did not know the last time they were checked.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 radiologists selected for review, received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital (Physician D and Physician E).

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff reported Physician D, Radiologist, provided services to 2,263 patients and Physician E, Radiologist provided services to 574 patients from 1/1/18 to 12/31/18.

Findings include:

1. Review of the CAH's network Physician Services Agreement - Exhibit B, signed in 10/2015, showed the Peer Review Services agreement failed to identify the obligation to provide external peer review for radiologists.

2. Review of a CAH policy titled "Peer Review for Health Care Providers", approved 11/2018, revealed in part" .... Medical Staff Peer Review will be performed to assure that the quality and appropriateness of the diagnosis and treatment furnished by physicians . . . Jefferson County Health Center Surgeons, Radiology Medical Director, Ophthalmologist, Oncologist ... will have one randomly selected chart reviewed at the same rate by an outside reviewer ... "

During an interview on 2/6/19, at 3:00 PM, Quality Director/Risk Management, reported she is responsible to send cases to the CAH network hospital for external peer review. She reported the external peer review contract with their network hospital does not include radiology and confirmed she did not have external peer review complete for the selected radiologists.

Based on interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to ensure patient records were documented with a referral number from the Organ Procurement Organization (OPO) for two of three patients (Patient #5 and Patient #7) who died while receiving care at the hospital.

Finding include:

Review of Patient #5's medical record revealed the facility failed to ensure a referral number was obtained from the OPO after the death of the patient. Patient # 5 was brought to the hospital and seen in the Emergency Department (ED) before being admitted to the inpatient unit of the hospital on 11/16/18 with a diagnosis of Pneumonia, Respiratory Failure, and Urinary Tract Infection. The record indicated Patient # died on 11/17/18 from complications related to the diagnosis of the patient. Further review of the record revealed a "Report of Death" form in Patient #5's record was completed on 11/17/18 and the "Record of Death" form revealed hospital staff notified the patient's family, a local funeral home, and the OPO of the patient's death on 11/17/18. However, Patient #5's medical record did not have a referral number from the OPO documented in the patient's record to validate the OPO was notified of the patient's death.

On 02/05/19, a review of Patient #7's medical record revealed the facility failed to ensure a referral number was obtained from the OPO after the death of the patient. Patient #7 was brought to the ED of the hospital by ambulance after the patient was found unresponsive. Patient #7's diagnosis in the record was Cardiac Arrest and the record indicated the patient's eyes were "fixed and dilated" upon arrival with sounds of respiratory activity. The record indicated Patient #7 died on 01/07/19 from a recent heart attack. Further review of the record revealed a "Report of Death" form in Patient #7's record was completed on 01/04/19 and the "Record of Death" form revealed hospital staff notified the patient's family, a local funeral home, and the OPO of the patient's death on 01/04/19. However, Patient #7's medical record did not have a referral number from the OPO documented in the patient's record to validate the OPO was notified of the patient's death.

On 02/05/19 at 3:00 PM, an interview was conducted with the Chief Operating Officer (COO), Chief Nursing Officer (CNO), and ED Nurse Manager. During the interview, the ED Nurse Manager and the CNO confirmed hospital staff failed to document a referral number on the "Record of Death" forms found in the medical records of Patient #5 and Patient #7. The CNO stated she had been informed the OPO had only recently started providing referral numbers to the hospital when contacted about a death in the hospital and would provide documentation from the OPO to determine when the practice of providing referral numbers to the hospital started.

On 02/07/19, a review of electronic communication between the ED Nurse Manager and the OPO revealed the OPO began utilizing referral numbers at the end of 2017. The communication stated, "Beginning in December 2017, Iowa Donor Network (IDN) has utilized referral ID numbers for every referral call made to IDN. These Referral ID numbers are unique to every patient that is referred to IDN. It is recommended that the hospital staff who makes the referral call document the ID number in the patient chart, this number is provided by IDN at the time of the referral call."

On 02/06/19, a review of the facility's policy titled, "Deceased Patients; Referral/Release of Body; Organ and Tissue Donation Protocol", dated revised 12/2013 and last approved 05/2018, indicated the hospital was responsible to document the referral call to the OPO in the patient's record of every patient who dies while receiving care in the hospital.

Based on review of swing bed patient rights and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights to include the right to:

a. unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment,
b. refuse to participate in experimental research,
c. choose his or her attending physician,
d. retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other patients,
e. share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,
f. choose or to refuse to perform services for the facility and the facility must not require a patient to perform services for the facility,
g. the facility must inform each patient before, or at the time of admission, and periodically during the patient's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.

The CAH administrative staff identified a census of 5 swing bed patients at the beginning of the survey and an average of 15 swing bed patients admitted per month. Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of document, provided to swing bed patients, titled "JEFFERSON COUNTY HEALTH CENTER Patient Rights & Responsibilities", dated revised 2/2104, lacked the following swing bed patient rights:
a. unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment,
b. refuse to participate in experimental research,
c. choose his or her attending physician,
d. retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other patients,
e. share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,
f. choose or to refuse to perform services for the facility and the facility must not require a patient to perform services for the facility,
g. the facility must inform each patient before, or at the time of admission, and periodically during the patient's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.

2. During an interview on 2/6/18 at 9:10 AM, the Chief Nursing Officer and the Quality Improvement Director confirmed the lack of the above swing bed patient rights provided to their swing bed patients.

Based on review of policies, medical records, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation (rehab) services for 7 of 8 swing bed patients (Patients #1, 2, 3, 4, 8, 9, and 10). Failure to ensure a physician ordered specialized rehab services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition. The CAH administrative staff identified a census of 5 swing bed patients at the beginning of the survey.

Findings include:

1. Review of policies/procedures revealed the lack of a policy/procedure that addressed orders for specialized rehab services for swing bed patients were written by a physician.

2. Review of Patient #1's open medical record revealed Patient #1 was admitted for swing bed services on 2/3/2019 with diagnosis of hyponatremia (low sodium level in the blood). An electronic order entry dated 2/3/19 at 12:15 PM revealed Hospitalist A, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 2/3/19 at 12:15 PM revealed Hospitalist A, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

Review of Patient #2's open medical record revealed Patient #2 was admitted for swing bed services on 1/29/2019 with a diagnosis of pneumonia. An electronic order entry dated 1/29/19 at 4:15 PM revealed Hospitalist B, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/29/19 at 4:15 PM revealed Hospitalist B, ARNP, ordered Occupational Therapy and Evaluation & Treatment. An electronic order entry dated 1/30/19 at 7:15 PM revealed Hospitalist B, ARNP, ordered Speech Therapy and Evaluation & Treatment.

Review of Patient #3's open medical record revealed Patient #3 was admitted for swing bed services on 1/29/2019 with diagnosis of liver disease. An electronic order entry dated 1/29/19 at 1:45 PM revealed Hospitalist C, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/29/19 at 1:45 PM revealed Hospitalist C, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

Review of Patient #4's open medical record revealed Patient #4 was admitted for swing bed services on 1/27/2019 with diagnosis of pneumonia. An electronic order entry dated 1/27/19 at 12:15 PM revealed Hospitalist C, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/27/19 at 12:15 PM revealed Hospitalist C, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

Review of Patient #8's closed medical record revealed Patient #8 was admitted for swing bed services on 1/3/2019 with diagnosis of a bleed in the brain following a fall. An electronic order entry dated 1/3/19 at 6:30 PM revealed Hospitalist A, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/3/19 at 6:30 PM revealed Hospitalist A, ARNP, ordered Occupational Therapy and Evaluation & Treatment. An electronic order entry dated 1/4/19 at 10:45 PM revealed Hospitalist A, ARNP, ordered Speech Therapy and Evaluation & Treatment.

Review of Patient #9's closed medical record revealed Patient #9 was admitted for swing bed services on 1/19/2019 with diagnosis of post knee replacement. An electronic order entry dated 1/19/19 at 2:45 PM revealed Hospitalist C, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/19/19 at 2:45 PM revealed Hospitalist C, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

Review of Patient #10's closed medical record revealed Patient #10 was admitted for swing bed services on 1/9/2019 with diagnosis of generalized weakness. An electronic order entry dated 1/9/19 at 9:30 AM revealed Hospitalist C, Advanced Registered Nurse Practitioner (ARNP), ordered Physical Therapy and Evaluation & Treatment. An electronic order entry dated 1/9/19 at 9:30 AM revealed Hospitalist C, ARNP, ordered Occupational Therapy and Evaluation & Treatment.

3. During an interview on 2/4/19 at 3:30 PM, the Clinical Information Technology (IT) Nurse stated ARNP's order physical, occupational, and speech therapy for swing bed patients and was not aware ARNPs could not write orders for therapies for swing bed patients.

During an interview on 2/6/19 at 2:45 PM, the Clinical IT Nurse acknowledged the lack of a policy/procedure that addressed orders for specialized rehab services for swing bed patients were written by a physician.

During an interview on 2/6/19 at 4:20 PM, the Chief Nursing Officer acknowledged the lack of a policy/procedure that addressed orders for specialized rehab services for swing bed patients were written by a physician.