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Based on document review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure they met the state employment requirements for the identified individual responsible for the operation of the Food and Nutrition Services Department. The administrative staff identified a census of 2 inpatients at the time of the survey and an average census of 4 patients. The Food and Nutrition Services Manager reported the department served an average of 10 patient meals daily. Failure to ensure a qualified person manages the food service department could potentially result in poor dietary practices impacting the health and nutritional needs of the patients.

State rule:
51.20(3) b. If a licensed dietitian is not employed full-time, then one must be employed on a part-time or consultation basis with an additional full-time person who has completed a 250-hour dietary manager course and who shall be employed to be responsible for the operation of the food service.

Findings include:

During an interview on 9/16/2019, at 3:30 PM, the Site Administrator reported the Food and Nutrition Services Manager is employed by the Network Hospital system and confirmed the position included the responsibility for the department at the CAH. She explained the Network Hospital System allocates her time as a 0.2 FTE (Full Time Equivalent) employee of the CAH.

During an interview on 9/17/19, 8:30 AM, the Food and Nutrition Services Manager confirmed her position included the responsibility for the Food and Nutrition Services department. She reported she is considered a 0.2 FTE for the CAH and is a minimum of 1 day a week but may be more often depending on the department needs.

Review of the Food and Nutrition Services Manager job description identified the position is responsible for the management of the day to day operations for all work assigned to food operations.

Review of a document labeled "job code detail", dated 9/18/2019, identified the budgeted FTE for the Manager of Food and Nutrition Services as 0.1.

Review of a printed payroll detail showed the Food and Nutrition Services Manager worked 7.2 hours for pay period end date of 8/31/2019 and 8 hours for the pay period end date of 8/17/2019.

Based on observations and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the hot water temperatures at 1 of 1 off-site Out Patient Therapy Clinic remained at safe temperatures between 110 - 120 degrees Fahrenheit. Please refer to C-222.

The cumulative effect of this systemic failures and deficient practices resulted in the facility's inability to ensure patient safety. The CAH therapy staff identified 373 patient visits for fiscal year (July 1, 2018 to June 30, 2019) in the off-site Out Patient Therapy Clinic (22 patients between the ages of 0 - 10 years, 11 patients between the ages of 11 - 18 years, 129 between the ages 19 - 60 years of age, and 211 greater than 60 years of age).

I. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 1 of 1 sink available for patients to wash their hands in the off-site Out Patient Therapy Clinic. The CAH therapy staff identified 373 patient visits for fiscal year (July 1, 2018 to June 30, 2019) in the off-site Out Patient Therapy Clinic (22 patients between the ages of 0 - 10 years, 11 patients between the ages of 11 - 18 years, 129 between the ages 19 - 60 years of age, and 211 greater than 60 years of age). Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in the water causing burns to patients of the CAH.

Findings include:

1. Observations on 9/16/2019 at 3:05 PM, during a tour of the off-site Out Patient Therapy Clinic with the Therapy Supervisor, revealed 1 of 1 sink available for patients to wash their hands. Measurements taken at the time of the observations revealed the hot water was 130.3 degrees Fahrenheit.

Further observation and retesting of the hot water temperature at the patient hand washing sink on 9/16/2019 at 3:25 PM with Maintenance Mechanic F revealed the surveyor noted steam arising from the running hot water. Both Maintenance Mechanic F and the surveyor obtained a hot water temperature of 134.6 degrees Fahrenheit.

Additional observation and retesting of the hot water temperature at the patient hand washing sink on 9/17/2019 at 8:35 AM with the Maintenance Supervisor, revealed the Maintenance Supervisor obtained a temperature of 132.0 degrees Fahrenheit and the surveyor obtained a hot water temperature of 131.6 degrees Fahrenheit.

A random surveyor observation on 9/16/2019 at 3:50 PM with the Therapy Supervisor revealed a 10 year old patient that was being treated by a physical therapist. The Therapy Supervisor confirmed the physical therapist was treating a 10 year old patient.

2. During an interview, at the time of the 9/16/19 at 3:25 PM tour, Maintenance Mechanic F acknowledged the hot water temperature in the off-site Out Patient Therapy Clinic's sink was greater than 120 degrees Fahrenheit.

During an interview on 9/17/19 at 7:45 AM, the Maintenance Supervisor acknowledged the maintenance staff do not monitor the hot water temperature at the off-site Out Patient Therapy Clinic and the CAH does not have a policy to address hot water temperature.

During an interview, at the time of the 9/17/19 at 8:20 AM tour, the Maintenance Supervisor acknowledged the hot water temperature in the off-site Out Patient Therapy Clinic's sink was greater than 120 degrees Fahrenheit.



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II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the chair alarm sensor pads were only used for 30 days in accordance with the manufacturer's instructions for 7 of 7 Posey chair alarm sensor pads. Failure to ensure staff followed the manufacturer's instructions for use of chair alarm sensor pads could potentially result in the chair alarm not working as designed, and place patients at risk for injury and harm. The CAH staff identified a census of 2 patients at the start of the survey, and an average daily census of 4.

Findings include:

1. Observations during a tour of the inpatient unit on 09/16/19 at 11:40 AM with the Nursing Supervisor revealed 7 unwrapped Posey chair alarm sensor pads stored in the supply room. 7 of the 7 Posey unwrapped chair alarm sensor pads did not have any date on them indicating when they were initially used on a patient.

2. Review of the Posey Company manufacturer's instructions revealed, in part, "Sensor pads beyond expiration date are out of warranty and may not function properly, causing false alarm or no alarm. When putting sensor pad into use calculate expiration date 30 days from initial use. Discard sensor pad if: 1) expired, or 2) there is no expiration date, or 3) date cannot be clearly read."

3. During an interview at the time of the tour, Nursing Supervisor acknowledged that the chair pads had been used, and indicated they were only taken out of service if they were visibly worn or the wiring was frayed.


III. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) ambulance staff failed to ensure the Zoll Monitor/Defibrillator was checked daily to ensure the machine was functioning properly in 3 of 3 ambulances (#52-1, #52-2, #52-3). Failure to ensure the staff performed daily checks could potentially result in the monitor/defibrillator not working when needed, and place patients at risk for delayed treatment or potentially death. The CAH staff identified ambulances #52-1, #52-2, and #52-3 average approximately 910 runs per year.

Findings include:

1. Observations during a tour of Ambulance #52-1 on 09/17/19 beginning at 3:10 PM revealed a Zoll X Series monitor/defibrillator.

2. Review of daily checks dated from 05/01/19 to 09/17/19 at the time of the tour revealed ambulance staff failed to document a daily check for the monitor/defibrillator 45 of 119 days.

3. Observations during a tour of Ambulance #52-3 on 09/17/19 beginning at 3:10 PM revealed a Zoll X Series monitor defibrillator.

4. Review of daily checks dated from 05/01/19 to 09/17/19 at the time of the tour revealed ambulance staff failed to document a daily check for the monitor/defibrillator 56 out of 98 days.

5. Review of "Zoll X Series Operator's Guide," revealed the manufacturer requires a "Daily/Shift Check Procedure."

6. Observations during a tour of Ambulance #52-2 on 09/17/19 beginning at 4:00 PM revealed a Zoll E Series monitor/defibrillator.

7. Review of daily checks dated from 02/28/19 to 09/01/19 at the time of the tour revealed ambulance staff failed to document a daily check for the monitor/defibrillator 40 out of 70 days. The ambulance staff did not have documentation from 09/02/19 to 09/17/19.

8. During an interview at the time of the tour, Paramedic E confirmed that the monitor/defibrillator checks had not been documented every day for any of the 3 ambulances. Paramedic E stated could not confirm whether the monitor/defibrillator check had been done and not documented, or if the monitor check had not been done.

9. During an interview on 09/19/19, Chief Nursing Officer (CNO) confirmed the manufacturer requires a daily check on the Zoll X series only, and does not specifically state a daily check should be done on the Zoll E series. CNO further stated the expectation is that all monitor/defibrillators are checked daily regardless of whether or not the manufacturer specifically requires daily checks.



IV. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 2 of 3 ambulances (Ambulance #52-2, #52-3), 2 of 2 Phlebotomy Rooms in the Lab (Phlebotomy Room A and Phlebotomy Room B) and 1 of 1 Sleep Rooms. 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. The CAH administrative staff identified ambulances #52-2 and #52-3 average approximately 141 runs per year, the lab performed approximately 8,521 outpatient phlebotomy procedures per year, and Sleep Studies performed approximately 52 tests per year.

Findings included:

1. Observations during a tour of Ambulance #52-3 on 09/17/19 beginning at 3:10 PM revealed the following outdated supplies in the Field Bag:

a. 2 of 2 10 milliliter vials of Normal Saline, expired 05/01/2018
b. 1 of 1 IV Start Kit, expired 04/2018
c. 2 of 2 BD Insyte Autoguard IV, 14 gauge, expired 05/2018
d. 2 of 2 BD Insyte Autoguard IV, 16 gauge, expired 05/2018
e. 2 of 2 BD Insyte Autoguard IV, 18 gauge, expired 10/2017
f. 2 of 2 BD Insyte Autoguard IV, 22 gauge, expired 09/2017
g. 2 of 2 BD Insyte Autoguard IV, 24 gauge, expired 06/2018

2. Observations during a tour of Ambulance #52-3 on 09/17/19 beginning at 3:10 PM revealed the following outdated supplies in the IV box:

a. 1 of 1 BD Insyte Autoguard IV, 14 gauge, expired 08/2016
b. 2 of 2 BD Insyte Autoguard IV, 16 gauge, expired 04/2017
c. 1 of 3 BD Insyte Autoguard IV, 18 gauge, expired 10/2017
d. 1 of 5 BD Insyte Autoguard IV, 22 gauge, expired 09/2018
e. 4 of 5 BD Insyte Autoguard IV, 24 gauge, expired 10/2018

3. Observations during a tour of Ambulance #52-2 on 09/17/19 beginning at 4:00 PM revealed the following outdated supplies in the IV Field Kit:

a. 2 of 2 BD Insyte Autoguard IV, 14 gauge, expired 05/2018
b. 2 of 2 BD Insyte Autoguard IV, 16 gauge, expired 05/2018
c. 1 of 2 BD Insyte Autoguard IV, 20 gauge, expired 01/2019
d. 1 of 2 BD Insyte Autoguard IV, 22 gauge, expired 10/2018
e. 2 of 2 BD Insyte Autoguard IV, 24 gauge, expired 10/2018

4. Observations during a tour of Ambulance #52-2 on 09/17/19 beginning at 4:00 PM revealed the following outdated supply in the Green Airway Bag:

a. Mallinckrodt Tracheal Tube, 8 millimeter, expired 07/2018

5. Observations during a tour of Ambulance #52-2 on 09/17/19 beginning at 4:00 PM revealed the following outdated supplies in the Storage Cupboard:

a. 2 of 2 18 gauge IV filter needles, 1 expired 10/2015, 1 expired 11/2018.

6. During an interview at the time of the observation, Paramedic E verified the supplies had expired. Paramedic E stated that ambulance staff does monthly checks for outdates but said their list is not adequate and does not cover all the supplies that are stored in the ambulances.

7. During an interview at the time of the observations, the Site Administrator also verified the supplies had expired and indicated the supplies should have been pulled out of stock at the time the monthly check was completed, so staff could not use the supplies.

8. Observations during a tour of the Lab on 09/16/19, beginning at 3:00 PM, revealed the following outdated supplies in Phlebotomy Room A:

a. Top drawer of cart in an open box, 7 of 7 Prevantics 70% Isopropyl Alcohol swabs, expired 08/2019
b. Top drawer of cart in an open box, 6 of 36 Prevantics 70% Isopropyl Alcohol swabs, expired 10/2018
c. Top drawer of cart in an open box, 4 of 4 Prevantics 70% Isopropyl Alcohol swabs, expired 12/2017

9. Observations during a tour of the Lab on 09/16/19 beginning at 3:00 PM revealed the following outdated supplies in Phlebotomy Room B:

a. 1 of 1 500 milliliter bottle of Acetic Acid 5%, expired 08/22/19
b. 1 of 1 bottle of Acetic Acid 5% (unknown volume), expired 08/22/19

10. During an interview at the time of the observations, Lab Manager verified the supplies had expired and reported the lab staff checked monthly for outdated supplies but obviously missed some in their review.

11. Observations during a tour of the Sleep Room Lab on 09/16/19 at approximately 12:15 PM revealed the following outdated supplies:

a. 2 of 2 1 gallon jugs of distilled water, expired 06/30/19
b. 1 of 2 16 ounce 70% Isopropyl Alcohol, expired 07/2019

12. During an interview at the time of the observations, Nursing Supervisor confirmed the supplies were outdated and should not be used.

13. Review of policy, "Products with Outdates," last revised 03/2010, revealed in part, "To ensure the quality of supplies used in our hospitals and clinics a regular inspection procedure will be set up for each supply area...The manager for each area is responsible to check outdated supplies that are stocked in each area (outside of the supply rooms) at least once per month."



V. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) ambulance staff failed to follow the manufacturer's instructions for the Precision Xtra Blood Glucose System when it failed to properly date newly opened bottles of glucose control solution in 2 of 3 ambulances (Ambulance # 52-2, Ambulance #52-3). Failure to follow the manufacturer's instructions for use may result in inaccurate blood glucose readings which may adversely affect patient treatment. The CAH reported the 2 ambulances perform approximately 3 blood glucose checks per month.

Findings include:

1. Observations during a tour of Ambulance #52-2 on 09/17/19 beginning at 4:00 PM revealed two bottles of Medisense glucose controls in the case with the Precision Xtra Blood Glucose System. Each bottle was open, and both were labeled 09/07/19.

2. Observations during a tour of Ambulance # 52-3 on 09/17/19 beginning at 3:10 PM revealed two bottles of Medisense glucose controls in the case with the Precision Xtra Blood Glucose System. Each bottle was open, and both were labeled 10/18/19.

3. During an interview at the time of the tour, Paramedic E was unsure if the date on the bottles in Ambulances #52-2 and #52-3 reflected the date the bottles were opened, of if the date was when the bottles expired. Paramedic E was unsure of process for labeling Precision Xtra Blood Glucose System controls.

4. Review of the Precision Xtra User's Manual, revealed in part, "When you open a control solution bottle for the first time, count forward 90 days and write this date on the control solution bottle...Throw away any remaining solution after this date."

5. Review of policy "Blood Glucose Monitoring Programing using...Precision Xtra," revealed the CAH failed to identify a process for correctly dating and labeling the Medisense glucose control bottles.







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Based on review of policies, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually for 4 of 20 patient care departments (Plant Operations, Pulmonary Rehabilitation, Radiology, and Administration). The CAH administrative staff identified a census of 2 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy "Patient Focused Policy/Procedure Committee," revised 8/2018, revealed in part, "...At a minimum of every two years Patient Focus policies are reviewed and revised as necessary. Policies/procedures are reviewed by individuals with process knowledge and revised to reflect current practice...."

The policy failed to address the requirement to review policies annually by the required group of professionals, including a physician and a mid-level provider.

2. Review of the Critical Access Advisory Council Meeting minutes, dated June 24, 2019, revealed the group approved the policy manuals for Plant Operations, Pulmonary Rehabilitation, and Radiology. The meeting minutes lacked documentation a physician attended the meeting to approve the policy manuals.

Review of the Critical Access Advisory Council Meeting minutes, dated September 25, 2018, revealed the group approved the policy manuals for Administration. The meeting minutes lacked documentation a physician attended the meeting to approve the policy manuals.

3. During an interview on 9/18/2019 at 9:00 AM, the Site Administrator confirmed the lack of an annual policy review for Plant Operations, Pulmonary Rehabilitation, Radiology, and Administration by a physician. On further interview, the Site Administrator acknowledged the policy failed to address the requirement to review policies annually by the required group of professionals, including a physician and a mid-level provider.

Based on staff interview and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff documented the date and time the nursing staff notified the physician for 5 of 17 medication errors reviewed (Patient #7, Patient #8, Patient #9, Patient #10, Patient #11). Failure to document the date and time the nursing staff notified the physician of medication errors could potentially result in the physician lacking timely knowledge of the medication error and failing to potentially modify the patient's treatment plan, potentially resulting in a life-threatening complication. The CAH administrative staff reported a census of 2 patients on entrance, and an average daily census of 4.

Findings include:

1. Review of the policy "Medication Administration," last revised 04/2019, revealed in part, "Medication administration errors, adverse drug reactions, and medication incompatibilities ... will be reported immediately to the [attending] physician. Factual documentation should appear in the patient's chart."

2. Review of the policy "Occurrence Reporting," last revised 07/2015, revealed in part: "All drug administration errors ... will be reported immediately to the patient's medical provider in order that a patient evaluation and treatment (as indicated) may be conducted."

2. Review of medication errors revealed the following:

a. On 10/25/18 at 6:07 PM, the nursing staff discovered they administered an incorrect dose of Vancomycin (a medication used to treat infection) to Patient #7. The medication error record lacked documentation of the date or time the nursing staff notified Patient #7's physician of the medication error.

b. On 12/26/18 at 3:26 PM, the nursing staff discovered that the physician had not ordered Xarelto (a blood thinner medication), a medication that Patient #8 had been taking prior to admission. The medication error record lacked documentation of the date or time the nursing staff notified Patient #8's physician of the medication error.

c. On 3/16/19 at 8:20 AM, the nursing staff discovered they administered an incorrect dose of Vancomycin (a medication used to treat infection) to Patient #9. The medication error record lacked documentation of the date or time the nursing staff notified Patient #9's physician of the medication error.

d. On 06/06/19 at 1:08 PM, the nursing staff discovered they administered an incorrect dose of Levothyroxine (thyroid hormone replacement) to Patient #10. The medication error record lacked documentation of the date or time the nursing staff notified Patient #10's physician of the medication error.

e. On 07/01/16 at 8:16 AM, the nursing staff discovered they administered Invanse (a medication used to treat infections) 12 hours early to Patient #11. The medication error record lacked documentation of the date or time the nursing staff notified Patient #11's physician of the mediation error.

3. During an interview on 09/17/10 at 11:00 AM, the Med/Surg Director verified the medical records also lacked documentation of the date or time the nursing staff notified the physician of the medication error for Patients #7, Patient #8, Patient #9, Patient #10, and Patient #11.

Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 3 of 3 applicable radiologists selected for review (Physician B, Physician C, and Physician D), received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. 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 an approximate number of patients, in the past year, as follows:

- Physician B: 924 patients
- Physician C: 2,304 patients
- Physician D: 148 patients

Findings include:

1. Review of the CAH's network agreement, effective 9/9/2019, revealed in part, "[Network Hospital] will appoint a [Network Hospital] staff member to the credentialing body of the hospital ... This member will ... Participate in the performance review and the credentialing/privileging: recredentialing/re-privileging process of practitioners, which includes chart review ..."

2. Review of a document titled "Peer Review Services Agreement", dated 7/1/15, revealed in part " ... [Network Hospital] will provide medical record peer review of cases selected ... for the purposes of rendering an opinion regarding the medical necessity and/or quality of care for the treatment rendered ..."

3. Review of the CAH's medical staff bylaws, dated 8/3/2017, revealed in part "... [Network Hospital] Professional Review Committee (MOPRC) ... To assure that issues of quality related to individual physician performance have been identified in the peer review process and that appropriate and fair corrective action has been taken to address those quality issues ..."

4. Review of external peer review completed for the applicable physicians selected for review revealed the following:

a. The medical staff approved Physician B for reappointment to the Medical Staff on 1/10/2019. The Board of Trustees approved Physician B for reappointment to the Medical Staff on 2/7/2019. Physician B's file lacked the results of any external peer review conducted prior to Physician B's reappointment to the Medical Staff.

b. The medical staff approved Physician C for reappointment to the Medical Staff on 5/10/2018. The Board of Trustees approved Physician C for reappointment to the Medical Staff on 6/7/2018. Physician C's file lacked the results of any external peer review conducted prior to Physician C's reappointment to the Medical Staff.

c. The medical staff approved Physician D for reappointment to the Medical Staff on 3/8/2018. The Board of Trustees approved Physician D for reappointment to the Medical Staff on 4/5/2018. Physician D's file lacked the results of any external peer review conducted prior to Physician D's reappointment to the Medical Staff.

Review of a CAH policy titled, "... Professional Review Committee (MOPRC) ...", approved 1/10/19, revealed it lacked content to define an external peer review process for the CAH.

5. During an interview on 9/17/19, at 1:15 PM, the Manager of Physician Relations acknowledged the MOPRC policy addressed the peer review process for the entire network system but failed to delineate a process specific to the CAH to ensure completion of external peer review, to evaluate the quality of care provided by the physicians providing service to the CAH's patients, prior to reappointment.

6. During an interview on 9/18/2019, at 11:00 AM, the Director of Quality and Risk Management reported the CAH receives a compilation of peer review results for all of the radiologists practicing in Physician B, Physician C, and Physician D's group. She reported she would check to see if there were peer review results specific to Physician B, Physician C, and Physician D's care of the CAH's patients.

7. During an interview on 9/18/2019, at 3:45 PM, the Site Administrator confirmed the CAH failed to complete external peer review for Physician B, Physician C and Physician D prior to their reappointment to the medical staff.

Based on reviews of policies and patient medical records review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure activity personnel developed and implemented an ongoing activity program that included an activities care plan for 1 of 1 open swing bed patients (Patient #1) and 5 of 5 closed swing bed patient medical records reviewed (Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6). The CAH administrative staff identified a census of 1 swing bed patient at the beginning of the survey. Failure to provide an activity program that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well being and independence possible.

Findings include:

1. Review of the CAH policy "Swing Bed Unit Second Floor," revised 7/2018, revealed in part, "... The Activity Coordinator by completing the Therapeutic Recreation Skilled Nursing Assessment Paper Form implements an activity plan to encourage self-care, resumption of normal activities, and maintenance of an optimal level of psychosocial functioning...."

2. Review of open swing bed patient medical record for Patient #1 revealed the following:

a. Patient #1 admitted for swing bed skilled on 9/10/2019. Patient #1's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.


3. Review of closed swing bed patient medical records revealed the following:

a. Patient #2 admitted for swing bed skilled on 9/5/2019. Patient #2's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

a. Patient #3 admitted for swing bed skilled on 2/26/2019. Patient #3's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

a. Patient #4 admitted for swing bed skilled on 8/30/2019. Patient #4's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

a. Patient #5 admitted for swing bed skilled on 2/9/2019. Patient #5's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

a. Patient #6 admitted for swing bed skilled on 7/9/2019. Patient #6's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.


4. During an interview on 9/17/2019 at 4:40 PM, the Nursing Supervisor for Acute/Skilled verified the lack of an activities care plan for swing bed skilled Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6.

Based on review of policies and patient medical records, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure swing bed patients were initially assessed by a Registered Dietician for 1 of 1 open swing bed patient (Patient #1) and 5 of 5 closed swing bed patient medical records reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, and Patient #6). The CAH administrative staff identified a census of 1 swing bed patient at the beginning of the survey. Failure to ensure the skilled patients were initially assessed by a Registered Dietician could potentially result in patients receiving inadequate or excess nutrients, impacting their health and nutritional status.

Findings include:

1. Review of the CAH policy "Swing Bed Unit Second Floor," revised 7/2018, revealed in part, "...Patients on Swing Bed/Skilled level are initially assessed by the Registered Dietician and reassessed as needed for changes...."

2. Review of patient medical records revealed the following nutritional assessments by a Registered Dietician:

a. Patient #1 was admitted to swing bed status on 9/10/2019 with a diagnosis of muscle weakness. A nutritional assessment was documented as completed by a Registered Dietician on 9/16/2019, 6 days after the patient's admission to swing bed.

b. Patient #2 was admitted to swing bed status on 9/5/2019 with a diagnosis of an open wound following a leg fracture and was discharged on 9/13/2019. A nutritional assessment was not documented as completed by a Registered Dietitian during the patient's swing bed stay.

c. Patient #3 was admitted to swing bed status on 2/26/2019 with a diagnosis of need for therapy following hip surgery and was discharged on 3/14/2019. A nutritional assessment was documented as completed by a Registered Dietitian on 3/5/2019, 7 days after the patient's admission to swing bed.

d. Patient #4 was admitted to swing bed status on 8/30/2019 anemia and low blood pressure and was discharged on 9/13/2019. A nutritional assessment was not documented as completed by a Registered Dietitian during the patient's swing bed stay.

e. Patient #5 was admitted to swing bed status on 2/9/2019 with a diagnosis of congestive heart failure and shortness of breath and was discharged on 2/15/2019. A nutritional assessment was not documented as completed by a Registered Dietitian during the patient's swing bed stay.

f. Patient #6 was admitted to swing bed status on 7/9/2019 with a diagnosis of weakness following abdominal surgery and was discharged on 9/18/2019/ A nutritional assessment was not documented as completed by a Registered Dietitian during the patient's swing bed stay.


3. During an interview on 9/17/2019 at 4:40 PM, the Nursing Supervisor for Acute/Skilled acknowledged the above stated patient medical records lacked documentation the swing bed patients were initially assessed by a Registered Dietician in accordance with the CAH's policy.

During an interview on 9/16/2019 at 1:40 PM, Registered Dietician A reported a nutritional assessment should be completed on swing bed patients within 5 days of their admission to swing bed status.