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Based on record review, staff interview and facility policy review, the facility failed to ensure care plans were kept current with interventions related to assessment of high fall risk for 2 of 23 sampled inpatient records (Patients 34 and 35) reviewed. The total sample was 41. Inpatient census was 6. Findings are:

A. Record review of facility policy titled "Fall Risk/Precautions" last revised 5/11 states "if the patient score totals 3 or more, fall precautions will be initiated. The fall risk is based on a possible score of 5 being the highest risk. The policy does not indicate fall risk will be incorporated into the patient's plan of care.

B. Record review revealed Patient 34 was admitted 3/19/12 to a Swing Bed. Review of the history and physical dated 3/20/12 noted the patient was admitted from another acute hospital after having open reduction internal fixation of a sacral fracture on 3/15/12. The patient had a prior fall in the facility while recovering from a lumbar fusion causing the sacral fracture and transfer. Initial nursing assessment dated 3/19/12 included a fall risk assessment. The patient was assessed at risk for falls with documentation of a fall within the past 3 months, impaired mobility, altered elimination, and at risk medications. The fall risk score was 4. Fall risk scores documented 3/20, 3/21, 3/22, 3/23, 3/24 and 3/26/12 all noted the patient's fall risk was high at 4. Review of the plan of care through discharge 3/26/12 failed to find the patient's fall risk was identified or included in the plan of care. Staff interview with RN (Registered Nurse)-A, Medical Surgical Clinical Manager, on 6/19/12 at 10:45 AM confirmed the plan of care does not include fall risk/interventions and "should have."

C. Record review revealed Patient 35 was admitted on 2/2/12 to a Swing Bed after an acute hospital stay from a fall that resulted in a C2 fracture (fracture of neck vertebrae) and subclavian dissection. Fall risk assessment by nursing documented on admission, 2/2/12 that the patient's fall risk was a 5 out of a possible score of 5. Review of daily fall risk assessments throughout the patients stay until discharge 2/8/12 noted the scores varied from 3-5. Record review of the plan of care throughout Patient 35's stay revealed the high fall risk was not identified or included in the plan of care. Staff interview with RN-A on 6/19/12 at 11:30 AM confirmed this finding.

Based on record review and staff interview the facility failed to ensure 6 of 12 surgical patients (Patients 17, 18, 19, 20, 21 and 22) had documentation of a physician evaluation immediately before surgery to evaluate the risk of the procedure to be performed. The total sample size was 41. The facility census was 6. Findings are:

A. Record review revealed the following patients failed to have documentation of a physician evaluation immediately before surgery
- Patient 17 - Left total knee on 4/16/12;
- Patient 18 - Total abdominal hysterectomy on 4/30/12;
- Patient 19 - Screening colonoscopy with biopsy on 5/1/12;
- Patient 20 - Creation of a right arterial-venous fistula on 5/24/12;
- Patient 21 - Left cataract removal on 5/14/12; and
- Patient 22 - Bilateral Myringotomy with tubes on 5/17/12.

B. Staff interview with RN (Registered Nurse)-A, Medical Surgical Clinical Manager, on 6/19/12 at 2:30 PM revealed the facility does not have a policy requiring a physician to perform/document the evaluation. RN-A stated the facility was under the impression the CRNA (Certified Registered Nurse Anesthetist) pre-op evaluation was adequate.

Based on record review of 5 of 5 Swing Bed patient records (Patients 31, 32, 33, 34 and 35), interview with the AD (Activities Director), and review of facility policy, the facility failed to have an activity program that offered activities to meet the individual needs of patients. The total Swing Bed sample was 5. The Swing Bed Census during survey was 0. Findings are:

A. Record review of the medical records for the following patients failed to have an activities plan of care developed after the Activities Assessment, failed to have documentation of activities offered specific to the interests of the patients and/or documentation of refusal to participate in activities:
- Patient 31 in Swing Bed from 4/3/12-4/12/12, Activities Assessment completed on 4/5/12;
- Patient 32 in Swing Bed from 1/9/12-1/20/12, Activities Assessment completed on 1/11/12;
- Patient 33 in Swing Bed from 4/12-4/17/12, Activities Assessment completed on 4/13/12;
- Patient 34 in Swing Bed from 3/19-3/26/12, Activities Assessment completed on 3/22/12; and
- Patient 35 in Swing Bed from 3/2/12-2/8/12, Activities Assessment completed on 2/3/12.

B. Staff interview with the AD on 6/20/12 at 11:10 AM revealed the facility "electronic medical record does not include activity care plan interventions for individual patients." The AD confirmed the facility "makes no documentation of activities offered, participated in, or refused."

C. Record review of the facility policy titled "Skilled Care Activity Program" last revised 9/11 states "Activities specific to the individual patient will be included in the plan of care" and "Activities will be provided on a group or individual basis, to allow the patient the opportunity to engage in continuing life experience."

Based on record review, staff interview and review of facility policy, the facility failed to ensure 1 of 5 Swing Bed patients (Patient 34) had a discharge summary that included a recapitulation of the patient's stay. Total Swing Bed sample was 5. Swing Bed census during survey was 0. Findings are:

A. Record review revealed Patient 34 was in a Swing Bed from 3/19/12 - 3/26/12. The record failed to document a discharge summary by staff to recapitulate the patient's stay as required.

B. Staff interview with RN (Registered Nurse)-A, Medical Surgical Clinical Manager, on 6/19/12 at 10:55 AM confirmed Patient 34's record did not have the required Swing Bed discharge summary. RN-A verified the Discharge Summary is to be done on every skilled patient by nursing at discharge.

C. Record review of facility policy titled "Discharge of Patient" last revised 5/11 states a "SC [Skilled Care] Discharge Summary is also required for all Skilled Care Patients dismissed and all patients dismissed to a nursing home or assisted living."