HospitalInspections.org

Based on medical record review, document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the pharmacy did not use sample medications for inpatients according to state law. A problem was identified for 5 of 6 inpatients identified on the sample medication log to receive sample medications. The Diabetes Education Coordinator reported samples provided for approximately 10 inpatients in 2019. Failure to ensure the CAH staff did not utilize sample medications for the CAH's inpatients could potentially result in the CAH staff utilizing non-formulary medications the CAH's pharmacy had not verified the CAH staff correctly stored the medication and ensured the CAH's medical staff had full knowledge of how the medication worked prior to CAH staff administering the medication to the patient, thus potentially resulting in the patient developing unexpected side-effects from the medication.


657 - 7.8(7) Samples. The use of drug samples within the institution shall be eliminated to the extent possible. Sample use is prohibited for hospital inpatient use.

Findings include:

1. Observation of the Diabetes Education Program refrigerator on 11/5/19, at 2:15 p.m., with the Diabetes Education Coordinator, revealed the refrigerator stored sample diabetes injectable medications.

2. During an interview, at the time of the observation, the Diabetes Education Coordinator reported the samples are utilized for outpatients and inpatients. She reported the samples are medications not stocked in the pharmacy and are used for inpatients to assist a patient in remaining on their home regimen. She reported the pharmacist keeps a list of the samples and would identify an inpatient admitted with any of the sample medications, as part of their home regimen, and the ordered medication would be obtained from the diabetes education refrigerator and administered to the patient as ordered, with no charge. The Diabetes Education Coordinator reported she maintains a log to identify the patients who receive sample medications, and provided copies of the logs.

3. Review of the logs dated from 6/20/19 through 10/15/19 revealed 6 documented entries of samples given to inpatients. Medical record review revealed the following:

a. Patient #10 admitted on 10/23/2019 and the medication administration record (MAR) showed Tresiba ordered on 10/23/19 and administered twice. A notation on the MAR noted the medication supplied from Diabetes Education.

b. Patient #11 admitted on 7/13/2019 and the medication administration record (MAR) showed Toujeo Solostar ordered on 7/18/19 and administered 6 times. A notation on the MAR noted the medication supplied from Diabetes Education.

c. Patient #11 admitted on 8/9/2019 and the medication administration record (MAR) showed Toujeo Solostar ordered on 8/10/19 and administered 14 times. A notation on the MAR noted the medication supplied from Diabetes Education.

d. Patient #11 admitted on 9/29/2019 and the medication administration record (MAR) showed Toujeo Solostar ordered on 9/29/19 and administered twice. A notation on the MAR noted the medication supplied from Diabetes Education.

e. Patient #12 admitted on 7/25/19 and the medication administration record (MAR) showed Victoza ordered on 7/25/19 and administered once. The medical record lacked any notation to reference it had been supplied from Diabetes Education, however, the sample medication log confirmed the list contained Patient #12's name and date the diabetic education staff logged the medication out for Patient #12's inpatient stay.

f. Patient #13 admitted on 7/29/19 and the medication administration record (MAR) showed Lantus Solostar ordered on 7/29/2019 and administered 4 times. The medical record lacked any notation to reference it had been supplied from Diabetes Education, however, the sample medication log confirmed the list contained Patient #13's name and date the diabetic education staff logged the medication out for Patient #13's inpatient stay.

g. Patient #14 admitted on 6/21/19 and the medication administration record (MAR) showed Tresiba ordered on 6/21/09 and administered 21 times. The medical record lacked any notation to reference it had been supplied from Diabetes Education, however, the sample medication log confirmed the list contained Patient #14's name and date the diabetic education staff logged the medication out for Patient #14's inpatient stay.


4. During an interview on 11/6/19, at 1:30 PM, the Director of Pharmacy confirmed the use of sample injectable diabetes medications for inpatients when the nursing staff identified a non-formulary injectable diabetic medication as a home medication. She reported the samples utilized included uncommon ones and/or expensive one which are not part of the CAH's formulary. The Director of Pharmacy acknowledged the language in the drug sample policy stated drug samples are not used, but reported she had not thought of the injectables as samples. She confirmed when the medication is ordered, the sample is obtained from the diabetes education refrigerator and administered by nursing without charge to the patient.

5. Review of the pharmacy policy "Drug Sample," reviewed 5/2016, revealed in part "Drug samples shall not be utilized at this facility ..."

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing. The CAH staff reported 4 active, 52 courtesy/consulting, 7 associate, and 22 allied health professional medical staff members. Failure to ensure the Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing, could potentially result in the facility's Medical Staff and Board of Directors failure to credential all medical staff members per the facility's policy.

Findings include:

1. Review of the Network Agreement, dated 6/1/05, revealed in part, ". . . [the Network Hospital's name] shall bi-annually review the forms, process and credentialing process and credentialing criteria for physicians requesting both initial and reappointment privileges at VMH [Veterans Memorial Hospital]. Bi-annual reappointment shall be accomplished by a representative of [the Network Hospital's name] reviewing information gathered by VMH based upon forms, process and criteria mutually agreed upon by the Parties. This may be accomplished by phone conferences. Initial appointments shall be performed based upon criteria developed by both Parties...."

Further document review revealed the lack of documentation the Network Hospital bi-annually reviewed the above stated documents in accordance with the Network Agreement.

2. During an interview on 11/6/2019 at 3:55 PM, the Quality Assurance Director acknowledged the lack of documentation the Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing.

Based on review of documents and staff interview, the Critical Access Hospital (CAH) Governing Board failed to ensure the CAH Bylaws were reviewed by the CAH Governing Board at least annually as required in the CAH Governing Board Bylaws. The CAH administrative staff identified a census of 8 inpatients at the beginning of the survey. Failure to review the CAH Governing Board bylaws at least annually may result in the inability of the Governing Board to carry out their oversight of CAH operations.

Findings include:

1. Review of "Veterans Memorial Hospital Bylaws," dated March 10, 2010, revealed in part, "...The Board of Trustees shall review and when necessary revise the Governing Body Bylaws at least annually...."

2. Review of Governing Board meeting minutes from January 23, 2018 through October 22, 2019 lacked evidence the Governing Board were reviewed by the CAH Governing Board at least annually as required in the CAH Governing Board Bylaws.

3. During an interview on 11/6/2019 at 9:10 AM, the Quality Assurance (QA) Director acknowledged the lack of documentation the Governing Board reviewed or revised the CAH Bylaws at least annually as required in the bylaws. The QA Director further acknowledged documentation of the last revised CAH Bylaws by the governing board was March 10, 2010.

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 11 of 17 patient care departments (Administration, Emergency Services, Nutrition Services, Housekeeping, Respiratory Therapy, Diabetes Education, Cardiac Rehabilitation, Pharmacy, Surgery, Maintenance, and Infection Control). The CAH administrative staff identified a census of 10 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 "Critical Access," revised 2/2010, revealed in part, "...The CAH Steering Committee will include at least the following members ... one member of the Medical Staff one midlevel provider ... will conduct a periodic evaluation of the total CAH program at least annually. This review will include at least the following ... CAH healthcare policies review and approval ...."

2. Review of Critical Access Advisory Committee Meeting minutes, dated December 4, 2018, revealed in part, Approve annual policies Administration, Emergency Services, Nutrition Services, Housekeeping, Respiratory Therapy, and Diabetes Education. The meeting minutes lacked documentation a physician and a midlevel provider attended the meeting to approve the stated policy manuals.

Review of Critical Access Advisory Committee Meeting minutes, dated from December 4, 2018, to July 30, 2019 revealed the meeting minutes lacked documentation of annual review of Cardiac Rehabilitation, Pharmacy, Surgery, Maintenance, and Infection Control policies by the required group of professionals that included a physician and a midlevel provider.

3. During an interview on 11/6/2019 at 3:20 AM, the Director Site Administrator confirmed the lack of annual policy review for Administration, Emergency Services, Nutrition Services, Housekeeping, Respiratory Therapy, Diabetes Education, Cardiac Rehabilitation, Pharmacy, Surgery, Maintenance, and Infection Control by the required group of professionals that included a physician and a midlevel provider.

I. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) staff failed to store 1 of 2 succinylcholine vials (medication used to relax muscles during surgery) 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 of 682 surgical procedures per year.

Findings include:

1. Observations on 11/05/19 at 8:00 am in the OR/endoscopy room revealed the anesthesia cart contained a 10 milliliter vial of succinylcholine (200 milligrams/milliliter), unopened, dated 11/06/2019.

2. During an interview at the time of the observation, Certified Registered Nurse Anesthetist (CRNA) A stated the CAH practice was to store succinylcholine 28 days outside the the refrigerator. CRNA A stated that the succinylcholine dated 11/06/19 would be out of the refrigerator for a total of 28 days on 11/06/2019 so CRNA A would dispose of the medication on that day.

3. Review of manufacturer's recommendations for the storage of succinylcholine revealed, in part: "Refrigeration of the undiluted agent will assure full potency until expiration date...Store in refrigerator 2 degrees - 8 degrees C [Celsius]. The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

4. During an interview on 11/05/19 at 12:30 PM, the Pharmacist confirmed the CAH practice was to store succinylcholine outside the refrigerator for up to 28 days. The Pharmacist also acknowledged the manufacturer recommended succinylcholine be stored outside the refrigerator for up to 14 days.



II. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the staff monitored the temperature for 2 of 3 refrigerators located in the pharmacy department and the Diabetic Educator's office. Failure to ensure staff monitored the temperature of the refrigerators could potentially result in the staff failing to detect if the refrigerators went out of an acceptable temperature range, and potentially could result in the medications lacking the expected potency, potentially resulting in the medication not providing the expected effect for the patient. The CAH pharmacy had two refrigerators for mediation storage and the Diabetic Educator had 1 refrigerator for medication storage.

Findings include:

1. Observation on 11/04/19 at approximately 4:00 PM, during a tour of the Pharmacy, revealed a refrigerator stocked with approximately 150 medications.

2. Review of refrigerator temperatures for September through November 4th revealed the Pharmacist failed to document refrigerator temperatures on 17 out of 65 days.

3. During an interview at the time of the tour, the Pharmacist acknowledged the medication refrigerators contained multiple medications which required storage between 2 and 8 degrees Celsius. The Pharmacist acknowledged that the temperatures were not monitored when the pharmacy was closed on the weekends, and if the temperature went outside the desired range during a time when the Pharmacist was not present, the pharmacist would not know the refrigerator had gone outside the desired temperature range or if the temperature returned to the desired range prior to the Pharmacist returning to the pharmacy.

4. Observation on 11/05/19 at 2:15 PM revealed a refrigerator located in the Diabetes Education Coordinator's office stocked with 49 diabetes injectable medications.

5. During an interview at the time of the observation, the Diabetes Education Coordinator reported the refrigerator temperature was monitored and recorded each day the Diabetes Education Coordinator worked at the CAH. The Diabetes Educator confirmed she worked part time and acknowledged she would not know if the temperature went outside the desired range during a time when the Diabetes Educator was not present. The Diabetes Education Coordinator provided copies of the temperature records for review and confirmed she failed to check the temperature of the refrigerator daily.

6. Review of documents titled "Temperature Record," dated July - November 2019, revealed the Diabetes Education coordinator lacked documentation of the refrigerator temperature 66 out of 127 days when the Diabetes Education Coordinator was not at work.

7. During an interview on 11/06/19, at 1:30 PM, the Pharmacy Director confirmed the temperature of the refrigerator, used to store the diabetes injectable medications, should be checked at least daily.

8. Review of the policies revealed the CAH lacked a policy related to monitoring medication refrigerator temperatures.


42197


III. 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 in the nursing department and outdated medications were not available for patient care use in the cardiac/pulmonary rehab department. Failure to remove outdated medications from the CAH's supplies for patient use, could potentially result in staff using expired medications after the manufacturer's expiration date which could result in potential harm to the patient. The hospital's census upon entry was 10 patients.

Findings included:

1. Observations on 11/04/2019, during a tour of the nursing department medication room, revealed:

Heparin 10,000 units, Open date 9/13/2019 Exp. 10/10/2019, 1 of 3 vials,

Xylocaine 2% 1000 mg/mL, Open date 8/05/2019 Exp. 09/02/2019 , 1 of 2 vials,

Simethicone, Exp. 10/10/2019, 1 of 2 bottles,

Oxytocin 1 mL 10 USP/mL, Exp. 10/2019, 1 of 3 vials,

Budesonide inhalation, 0.5 mg/2 mL, Exp. 10/31/2019 per manufacturer, 1 of 4 inhalers.

2. During an interview on 11/04/2019, at the time of the tour, the Nurse Manager revealed it is the responsibility of all nurses to monitor for outdated medication in the medication room. The Nurse Manager verified the medications were expired and should not be used.

3. During an interview on 11/05/2019, the Pharmacist revealed that multi-use vials should generally be used as single use and should be disposed of after use and vials used as multi-dose vials should be disposed of within 28 days of opening.

4. Review of CAH policy "Multi-dose Vials, Outdated and Disposable Medications," revised 02/2015, revealed in part, "multi-dose vials ...discard 28 days after opening.

5. Review of the CAH policy "Expiration dates and lot numbers of Drugs & Biologicals," revised 05/2016, revealed in part, expiration dates should be "recorded on unit dose ... per USP 797". USP 797 included in part, the beyond use date "after initially entering or opening (e.g., needle-punctured) multiple-dose containers is 28 days."

6. Observations during a tour of the cardiac/pulmonary rehabilitation department on 11/06/2019 at 3:00 PM, with Registered Nurse B (RN), revealed the following expired items in the department's emergency medication/supply code cart:

a. 2 of 2 vials Dopamine (medication for low blood pressure) 10 ml/400 mg, expired 08/01/2018
b. 1 of 1 vial Sodium bicarbonate (cardiac arrest medication) 8.4%, 50 mEq, expired 09/01/2019
c. 1 of 1 bag Magnesium Sulfate (cardiac arrest medication) 4 grams in 50 ml, expired 05/01/2015
d. 1 of 1 1000 ml bag Lactated Ringers (intravenous solution), expired 08/2019
e. 1 of 1 500 ml bag Normal Saline (intravenous solution), expired 05/2019
f. 1 of 1 500 ml bag Lactated Ringers (intravenous solution), expired 06/2019

6. During an interview at the time of the tour, RN B confirmed the expired medications in the emergency code cart. RN B revealed at least one of the expired medications was on back-order and that is why they kept the supply.

7. During a telephone interview on 11/07/2019, the Pharmacy Director revealed RN B brings outdated emergency code cart medications to the pharmacy for re-supply. The Pharmacy Director revealed they were unaware of any back ordered medications or medications which could currently be used beyond their expiration dates in the facility.



30076


IV. Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to follow their policy for sample medications and ensure pharmacy oversight of sample medications in 1 of 1 Diabetes Education Program. The CAH reported the Diabetes Education Program provided services to 188 patients in 2018. The Diabetes Education Coordinator confirmed 49 sample injectable diabetes medications stored in the department.

Failure of pharmacy oversight in the dispensing of sample medications could result in outdated, recalled, or otherwise unusable medications being available to provide to patients, as well as the potential for theft of medications by unauthorized persons.

Findings include:

1. Review of the pharmacy policy "Drug Samples," reviewed 5/2016, revealed in part "Drug samples shall not be utilized at this facility ...".

2. Observation of the Diabetes Education Program refrigerator on 11/5/19 at 2:15 p.m.,with the Diabetes Education Coordinator, revealed the refrigerator stored multiple diabetes sample injectable medications.

3. During an interview, at the time of the observation, the Diabetes Education Coordinator reported a physician signs for the receipt of the sample medications and she maintains the supply in a refrigerator in her office. She reported the Director of Pharmacy maintains a list of the samples medications on hand but does not have any other oversight of their management. The Diabetes Education Coordinator reported she maintains a log of patients the samples are given to, and provided copies of the logs.

4. Review of the logs dated from 6/20/19 through 10/15/19 revealed 22 documented entries of samples given to 13 patients.

5. During an interview on 11/6/19, at 1:30 PM, the Director of Pharmacy acknowledged the pharmacy policy titled "Drug Samples" identified drug samples should not be utilized in the facility but reported the development of the policy resulted in relation to pharmaceutical representativeness leaving oral medications and she had not thought of the insulin injectables as samples. She reported she had a list of sample injectable diabetes medications, stored by the Diabetes Education coordinator but did not participate in any oversight of the receipt, storage or dispensing of the sample medication. She acknowledged the process for samples medications should include an accounting of the medications received and dispensed and an accurate inventory. The Director of Pharmacy confirmed the pharmacy policy identified drug samples should not be utilized in the CAH and she did not participate in oversight of the receipt, storage and dispensing of the medications.

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to ensure the nursing staff notified the physician for 5 of 20 medication errors (Patient #3, Patient #5, Patient #6, Patient #8, and Patient #9), or failed to ensure the physician was notified in a timely manner for 4 of 20 medication errors (Patient #1, Patient #2, Patient #4, Patient #7). Failure of nursing staff to notify the physician, or 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 10 patients on entrance, and an average daily census of 7.

Findings include:

1. Review of the policy "Medication Errors," last revised 07/19/2017, revealed in part, "Notification of Provider: When it is noticed that a medication error may have occurred, the provider is to be notified immediately."

2. Review of the policy "Medication Administration/Narcotic Count/Variance Reports," last revised 05/2019, revealed in part, "Notify the attending provider as soon as possible of the error, if the attending provider is not available, the 'on call' or 'back-up' provider will be notified of the error."

3. Review of medication errors for Patient #3, Patient #5, Patient #6, Patient #8, and Patient #9, revealed the following:

a. On 12/25/2018 at 10:29 PM, the nursing staff discovered they administered an incorrect dose of Fentanyl (a medication used for pain) to Patient #3. The medication error record lacked documentation of the date or time the nursing staff notified Patient #3's physician of the medication error.

b. On 01/25/2019 at 2:00 PM, the nursing staff documented Patient #5 received 2 incorrect doses of Coumadin (a medication used to thin the blood). The medication error record lacked documentation of the date or time the nursing staff notified Patient #5's physician of the medication error.

c. On 02/04/2019 at 9:30 PM, the nursing staff documented Patient #6 did not received an ordered dose of Azithromycin (antibiotic). The medication error record lacked documentation of the date or time the nursing staff notified Patient #6's physician of the medication error.

d. On 07/11/2019 at 10:31 AM, the nursing staff documented Patient #8 received the wrong type of intravenous solution. The medication error record lacked documentation of the date or time the nursing staff notified Patient #8's physician of the medication order.

e. On 10/13/2019 at 12:11 AM, the nursing staff documented Patient #9 was given an incorrect dose of Rocephin (an antibiotic) because the physician order was unclear. The medication error record lacked documentation of the time the nursing staff notified Patient #9's physician of the medication order.


4. Review of medication errors for Patient #1, Patient #2, Patient #4, Patient #7, revealed the following:

a. On 07/09/2019 at 5:50 AM, the nursing staff discovered they had failed to administer an antibiotic that was scheduled at 4:00 AM for Patient #1. The nursing staff notified the physician on 07/09/2019 at 9:00 AM, over 3 hours after the error was identified.

b. On 12/16/2018 at 10:00 AM, the nursing staff documented they discovered Patient #2 had been receiving a medication in error. The nursing staff notified the physician on 12/16/2018 at 6:00 PM, over 8 hours after the error was identified.

c. On 01/05/2019 at 10:00 PM, the nursing staff discovered they administered an incorrect dose of Gabapentin (a medication used to treat nerve pain caused by the singles virus) to Patient #4. The nursing staff notified the physician on 01/06/2019 at 7:00 AM, over 9 hours after the error was identified.

d. On 06/17/2019 at 8:10 AM, the nursing staff documented Patient #7 received eye drops in the wrong eye. The nursing staff notified the physician on 06/17/2019 at 9:45 AM, over 1 1/2 hours after the error was identified.


5. During an interview on 11/06/2019 at approximately 12:00 PM, Quality Assurance Director acknowledged inconsistent policies and stated that the provider should be notified of a medication error as soon as possible after ensuring the patient is safe. Quality Director confirmed the CAH staff did not document notification of the physician, or notification of physician as soon as possible for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9.

Based on review of the Quality Assessment and Improvement Program, Quality Assessment Committee Meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate 1 of 3 contracted patient care services (Pharmacy). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of the "Quality Assessment and Improvement Program," dated 4/2010, revealed in part, "...The scope of the Quality Assessment and Improvement Program is comprehensive, including all Veterans Memorial Hospital's departments, services, disciplines and practitioners...."

2. Review of the Quality Assessment and Improvement Meeting minutes from November 21, 2018 through October 16, 2019 revealed the minutes lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve performance improvement for Pharmacy.

3. During an interview on 11/6/2019 at 3:25 PAM, the Quality Assurance Director acknowledged the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve performance improvement for Pharmacy for the past 12 months.

Based on document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure activity personnel developed and implemented an ongoing activity program that included an activities care plan for 1 of 4 open swing bed patients (Patients #15) and 2 of 3 closed swing bed patients (Patients #17, and Patient #18). 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. The CAH administrative staff identified a census of 2 swing patient at the time of the survey and an average of 116 swing bed patients per year.

Findings include:

1. Review of the policy, "Swing Bed Program - Patient Activities," revised 3/2000, revealed in part, " An individual activity plan will be developed...with each patient by the activity coordinator and other members of the health team... The activity plan...is part of the total plan of care..."

2. Review of 1 of 4 open swing bed patient medical records and 2 of 3 closed swing bed patient medical records revealed the following information:

a. A physician ordered swing bed services for Patient #15 on 10/22/19. Patient #15's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

b. A physician ordered swing bed services for Patient #17 on 8/22/19 and was discharged on 8/30/19. Patient #17's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

c. A physician ordered swing bed services for Patient #18 on 8/7/19 and was discharged on 8/27/19. Patient #18's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.


3. During an interview on 11/06/19 at 10:15 AM, the Activities Coordinator acknowledged she was responsible for completing a comprehensive activity assessment and providing an activity program for swing bed patients. The Activity Coordinator revealed that, in addition to activity calendars, there were a variety of activities available for swing bed patients at the hospital. The Activity Coordinator reported she did not develop an ongoing activities program that included an activities care plan for each swing bed patient. The Activity Coordinator reported she did not have access to the care plan and was not aware if other heath team members created an activities care plan for a swing bed patient.

4. During an interview on 11/06/19 at 3:00 PM, the Quality Director verified the lack of an activities care plan for Patient #15, Patient #17, and Patient #18's swing bed admission. The Quality Director acknowledged the CAH staff failed to follow their policy.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 1 of 4 open swing bed patients (Patient #16) and 2 of 3 reviewed closed swing bed patient (Patients #18, Patient #19). Failure to ensure a physician ordered specialized rehabilitation 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 2 swing bed patients upon entrance and provided swing bed services to approximately 116 swing bed patients in fiscal year 2019.

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 #16's open medical record revealed the CAH staff admitted Patient #16 for swing bed level care on 11/03/19. Physician's Assistant (PA) D wrote an order on 11/03/19/19 at 3:55 PM for the Physical Therapist to evaluate and treat Patient #16 and on 11/03/19 at 3:59 PM wrote an order for the Occupational Therapist to evaluate and treat Patient #16.

Review of Patient #18's closed medical record revealed the CAH staff admitted Patient #18 for swing bed level care on 8/07/19. The CAH staff discharged Patient #18 on 8/27/19. PA D wrote orders on 8/27/19 at 4:37 PM for the Physical Therapist to evaluate and treat Patient #18 and for the Occupational Therapist to evaluate and treat Patient #18.

Review of Patient #19's closed medical record revealed the CAH staff admitted Patient #19 for swing bed level care on 7/11/19. The CAH staff discharged Patient #19 on 7/15/19. ARNP (Advanced Registered Nurse Practitioner) E wrote orders on 7/11/19 at 9:55 AM for the Physical Therapist to evaluate and treat Patient #19 and for the Occupational Therapist to evaluate and treat Patient #19.


3. During an interview on 11/6/2019 at 3:00 PM, the Quality Director acknowledged that PA D wrote the therapy orders for Patients #16 and Patient #18, and ARNP E wrote the therapy orders for Patient #19, when the patients received swing bed services. The Director of Patient Care Services acknowledged a physician did not write the therapy orders for Patient #16 , Patient #18 and Patient #19. The Quality Director acknowledged the CAH administrative staff was not aware that specialized rehab services must be provided under the order of a physician and the CAH did not have a policy reflecting that requirement.