HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow the established transfer policy for patients transferred to a higher level of care for four of six transfer medical records reviewed (MR8, MR25, MR26 and MR27).

Findings include:

Review on April 23, 2015, of the facility's "Transfer and Transportation of Patient" policy, last revised December 2014, revealed "Purpose: To provide guidelines for patient transfers within SH [Susquehanna Health] (campus to campus) or outside of SH. To assure medical stabilization within the capabilities of the facility prior to the transfer. Continuity of care and necessary supportive measures will be provided for the patient during transfer. ... Process: ... 5. Paperwork A. Physician Medical Necessity Certification (Refer to Scan Physician Med Necessity Cert attachment) 1. For All Non-emergency transfers 2. Not a permanent part of the Health Record, must be given to the transport crew B. Transfer Consent (Refer to Consent Transfer Attachment) 1. For transfer of patients experiencing an emergency medical condition or for transfer of patients due to unavailability of equipment, space and/or beds. 2. Physician completes the top portion indicating that based on the information available the transfer is appropriate and medically necessary. 3. Regardless of whether the physician is recommending the transfer or the patient is refusing the transfer, the risk and benefits of the transfer must be listed on the patient consent. 4. Check boxes indicating what records were sent with the patient. ..."

1) Review of MR8 on April 21, 2015, revealed the facility transferred this patient to an acute care hospital outside the SH system. Further review revealed no documentation the facility obtained consent from the patient or responsible party for transfer or provided the risks and benefits regarding MR8's transfer.

Interview with EMP2 and EMP4 on April 21, 2015, at approximately 2:15 PM confirmed the facility transferred MR8 to an acute care hospital outside the SH system; there was no documentation the facility obtained consent from the patient or responsible party for transfer; and the facility provided the risks and benefits to the patient or responsible party regarding MR8's transfer.

2) Review of MR25 on April 22, 2015, revealed the facility transferred this patient to an acute care hospital outside the SH system. Further review revealed no documentation indicating what part of MR25's medical record was sent to the receiving hospital to ensure continuity of care.

Interview with EMP3 and EMP4 on April 22, 2015, at approximately 1:15 PM confirmed the facility transferred MR25 to an acute care hospital outside the SH system; and there was no documentation indicating what part of MR25's medical record was sent to the receiving hospital to ensure continuity of care.

3) Review of MR26 and MR27 on April 22, 2015, revealed the facility transferred the patients to acute care hospitals outside the SH system. Further review revealed no documentation the facility obtained consent for transfer from MR26 and MR27 or the patients' responsible party. There was no documentation the facility provided the risks and benefits regarding the transfer or notified the receiving facility regarding the patients' transfers. There was no documentation what parts of the medical records were sent to the receiving hospitals.

Interview with EMP2, EMP3 and EMP4 on April 22, 2015, at approximately 3:00 PM confirmed the facility transferred MR26 and MR27 to acute care hospitals outside the SH system; there was no documentation the facility obtained consent for transfer from MR26 and MR27 or the patients' responsible party, provided the risks and benefits regarding the transfer, notified the receiving facility regarding the patients' transfers or indicated what part of the medical records were sent to the receiving hospitals.

Review of facility documents and staff interview (EMP), it was determined the facility failed to follow its established policy to ensure hot foods were cooled in a manner to prevent foodborne illness.

Findings include:

Review on April 21, 2015, of the facility's "Cooling Methods" policy, last finalized January 26, 2012, revealed "Cooling Methods Always cool using one of these methods ... Cool To Meet Proper Temperature Within 2 hours, cool all hot foods from 140 degrees F [Fahrenheit] to 70 degrees F (60 degrees C (Celsius) to 21 degrees C). Within 4 hours, continue cooling from 70 degrees F to 41 degrees F (21 degrees C to 5 degrees C). Do not exceed 6 hours of total cooling time. Do not place hot foods into a refrigerator or freezer until they have reached 70 degrees F (21 degrees C). ..."

1) Review on April 22, 2015, of the facility's "Cooling Temperature Log" for April 14, 2015, revealed leftover meatloaf. Further review revealed the facility recorded a temperature of 179 degrees Fahrenheit at 8:15 PM and 69 degrees Fahrenheit at 10:30 PM. Continued review revealed no documentation the facility cooled this meatloaf to 41 degrees Fahrenheit within 4 hours before placing in the freezer. This meatloaf was served in the café the next day.

2) Review on April 22, 2105, of the facility's "Cooling Temperature Log" for January 14, 2015, revealed leftover Spanish rice. Further review revealed no documentation the facility cooled this leftover to 70 degrees Fahrenheit in 2 hours or 41 degrees Fahrenheit within four hours. This Spanish rice was served in the café the next day.

3) Review on April 22, 2015, of the facility's "Cooling Temperature Log" for January 11, 2015, revealed leftover chicken and gravy. Further review revealed the facility recorded a temperature of 120 degrees Fahrenheit at 1:40 PM. Continued review revealed no documentation the facility cooled this meatloaf to 70 degrees Fahrenheit in 2 hours or 41 degrees Fahrenheit within 4 hours before placing in the freezer. This meatloaf was served in the café the next day.

4) Review on April 22, 2105, of the facility's "Cooling Temperature Log" for December 22, 2014, revealed leftover hamburgers. Further review revealed the facility recorded a temperature of 169 degrees Fahrenheit at 1:30 PM and 70 degrees Fahrenheit at 3:30 PM. Continued review revealed no documentation the facility cooled these hamburgers to 41 degrees Fahrenheit within 4 hours.

Interview with EMP10 on April 23, 2015, at approximately 9:15 AM confirmed dietary staff did not record the cool down temperatures for these foods at 2 hours and 4 hours before placing them in the freezer. Further interview confirmed the facility did not follow its established policy to ensure hot foods were cooled in a manner to prevent foodborne illness.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure physicians completed the Medicare Certification and Recertification for Swing Bed form when admitting patients to swing bed status for nine of 13 swing bed medical records reviewed (MR42, MR44, MR45, MR46, MR47, MR48, MR50, MR51, MR52).

Findings include:

Review on April 23, 2015, of the facility's "Bylaws of the Medical, Dental, and Podiatric Staff of Muncy Valley Hospital," last reviewed April 2014, revealed no documentation indicating the role the medical staff have in regard to the facility's Swing Bed Program.

Review on April 23, 2015, of the facility's "Swing Bed Program - MVH [Muncy Valley Hospital]", policy, last revised August 2013, revealed "Purpose: To provide skilled nursing care on II Main to provide continuity of care as residents transition from acute care to discharge, either to home or Long Term Care (LTC) Facility. ... 4. Procedure for Transfer from Acute Care to a Swing Bed Program ... D. Attending Physician ... 3. Complete Medicare certification/recertification (must be done on admission and on or before the 14th, 44th, 74th days) ..."

1) Review of MR42 on April 22, 2015, revealed the patient was admitted to the facility's Swing Bed Program on December 19, 2014, and discharged on February 3, 2015. There was no documentation of the Medicare Certification and Recertification for Swing Bed form in MR42.

2) Review of MR44 on April 22, 2015, revealed the patient was admitted to the facility's Swing Bed Program on December 19, 2014, and discharged on February 3, 2015. There was no documentation of the Medicare Certification and Recertification for Swing Bed form in MR44.

3) Review of MR48 on April 23, 2015, revealed the patient was admitted to the facility's Swing Bed Program on March 26, 2015, and discharged on April 5, 2015. There was no documentation of the Medicare Certification and Recertification for Swing Bed form in MR48.

Interview with EMP2 on April 23, 2015, at approximately 9:30 AM confirmed MR42, MR44 and MR48 were admitted to the facility's Swing Bed Program. Further interview confirmed there were no Medicare Certification and Recertification forms for Swing Bed status in MR42, MR44 and MR48's medical record.

4) Review of MR45 on April 22, 2015, revealed the patient was admitted to the facility's Swing Bed Program on March 21, 2015. Further review revealed the physician did not sign and date the patient's certification requiring inpatient swing bed services. Continued review revealed the physician did not sign the recertification form requiring continued inpatient swing bed services before the required 14th day.

Interview with EMP2 on April 22, 2015, at approximately 1:45 PM confirmed MR45 was admitted to the facility's Swing Bed Program; the physician did not sign and date the certification requiring inpatient swing bed services; and the physician did not sign the recertification form requiring continued inpatient swing bed services before the required 14th day.

5) Review of MR46 on April 22, 2015, revealed the patient was admitted to the facility's Swing Bed Program on June 25, 2014, and discharged on July 2, 2014. Further review revealed the physician signed the certification and recertification form on July 23, 2014, after MR46 was discharged from the facility. Continued review revealed no documentation of the condition requiring MR46's skilled nursing care in the facility's Swing Bed Program.

Interview with EMP2 on April 22, 2015, at approximately 1:00 PM confirmed MR46's admission to the facility's Swing Bed Program; the physician signed the certification and recertification form after MR46 was discharged from the facility; and there was no documentation of the condition requiring MR46's skilled nursing care in the facility's Swing Bed Program.

6) Review of MR47 on April 23, 2015, revealed the patient was admitted to the facility's Swing Bed Program on July 2, 2014, and discharged on July 16, 2014. Further review revealed the physician did not sign and date the patient's certification requiring inpatient swing bed services.

7) Review of MR50 on April 22, 2015, revealed the patient was admitted to the facility's Swing Bed Program on April 9, 2015. Further review revealed the physician did not sign and date the patient's certification requiring inpatient swing bed services.

Interview with EMP2 on April 23, 2015, at approximately 10:45 PM confirmed MR47 and MR50 were admitted to the facility's Swing Bed Program, and the physicians did not sign and date MR47 and MR50's certification requiring inpatient swing bed services.

8) Review of MR51 on April 23, 2015, revealed the patient was admitted to the facility's Swing Bed Program on April 28, 2014, and discharged on June 20, 2014. Further review revealed the physician did not sign and date the patient's certification requiring inpatient swing bed services.

9) Review of MR52 on April 23, 2015, revealed the patient was admitted to the facility's Swing Bed Program on May 12, 2014, and discharged on June 16, 2014. Further review revealed the physician did not sign and date the patient's certification requiring inpatient swing bed services.

Interview with EMP3 on April 23, 2015, at approximately 10:45 AM confirmed MR51 and MR52 were admitted to the facility's Swing Bed Program, and the physicians did not sign and date the certification requiring inpatient swing bed services.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to inform patients on swing bed status of their right to participate in planning care and treatment or changes in care and treatment for 13 of 13 swing bed patient medical records reviewed (MR42, MR43, MR44 MR45, MR46, MR47, MR48, MR49, MR50, MR51, MR52, MR53 and MR54).

Findings include:

Review on April 23, 2015, of facility policy "Patient Rights - Swing Beds - MVH [Muncy Valley Hospital]," last reviewed January 2015, revealed "Purpose To protect and promote each patient's rights, in particular the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The social service worker is committed to ensuring that patient's rights are upheld and protected. The patient has the right to exercise his/her rights as patient of this facility and a citizen of the United States. 'Exercising rights' means patients have autonomy and choice as to how they wish to live their lives and about the care they receive. Process A. Each patient and/or representative (sponsor) is informed during the admission process of the patient's rights and responsibilities. These rights and responsibilities are written and explained in a manner and language that the patient can understand. B. Should the patient's attending physician determine the patient is medically incapable of understanding his/her rights and responsibilities in accordance with the State's current laws, regulations and guidelines, the patient's legal guardian or representative (sponsor) will be informed of such rights and then be entitled to act on the patient's behalf. C. Patients and/or their or representative (sponsor) will be asked to sign forms acknowledging the rights, responsibilities and civil rights were orally reviewed and that they understand them as presented. D. A copy of the rights and responsibilities will be given to the patient and /or representative (sponsor). E. The signed forms are placed in the patient's medical record (chart). ... "

Review on April 23, 2015, of facility form "Muncy Valley Hospital Swing Bed Program Resident Rights," last reviewed January 2015, revealed no statement of the patient's right to participate in planning care and treatment or changes in care and treatment.

Review on April 23, 2015 of MR42, MR43, MR44 MR45, MR46, MR47, MR48, MR49, MR50, MR51, MR52, MR53 and MR54 MR11 revealed no documentation the facility informed the patients on swing bed status of their right to participate in planning care and treatment or changes in care and treatment.

Interview of EMP5 at 8:45 AM on April 23, 2015, confirmed the facility's "Swing Bed Program Resident Rights," form did not include the swing bed patient's right to participate in planning care and treatment or changes in care and treatment.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to inform patients on swing bed status of their transfer and discharge rights for 13 of 13 swing bed patient medical records reviewed (MR42, MR43, MR44 MR45, MR46, MR47, MR48, MR49, MR50, MR51, MR52, MR53 and MR54).

Findings include:

Review on April 23, 2015, of facility policy "Patient Rights - Swing Beds - MVH [Muncy Valley Hospital]," last reviewed January 2015, revealed "Purpose To protect and promote each patient's rights, in particular the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The social service worker is committed to ensuring that patient's rights are upheld and protected. The patient has the right to exercise his/her rights as patient of this facility and a citizen of the United States. "Exercising rights" means patients have autonomy and choice as to how they wish to live their lives and about the care they receive. Process A. Each patient and/or representative (sponsor) is informed during the admission process of the patient's rights and responsibilities. These rights and responsibilities are written and explained in a manner and language that the patient can understand. B. Should the patient's attending physician determine the patient is medically incapable of understanding his/her rights and responsibilities in accordance with the State's current laws, regulations and guidelines, the patient's legal guardian or representative (sponsor) will be informed of such rights and then be entitled to act on the patient's behalf. C. Patients and/or their or representative (sponsor) will be asked to sign forms acknowledging the rights, responsibilities and civil rights were orally reviewed and that they understand them as presented. D. A copy of the rights and responsibilities will be given to the patient and /or representative (sponsor). E. The signed forms are placed in the patient's medical record (chart). ... "

Review on April 23, 2015, of facility form "Muncy Valley Hospital Swing Bed Program Resident Rights," last reviewed January 2015, revealed no statement of the patient's transfer and discharge rights.

Review on April 23, 2015, of facility policy "Swing Bed Program - MVH [Muncy Valley Hospital]," last revised August 2013, revealed "Purpose To provide skilled nursing care on II Main to provide continuity of care as residents transition from acute care to discharge, either to home or Long Term Care (LTC) Facility. 1. Admission Criteria: ..." Further review revealed this policy did not address the patient's right to not be transferred or discharged from the facility without a 30 day notice unless the patient met the circumstances listed in 483.12 (a)(2) (i) through (v).

Review on April 23, 2015 of MR42, MR43, MR44 MR45, MR46, MR47, MR48, MR49, MR50, MR51, MR52, MR53 and MR54 MR11 revealed no documentation the facility informed these patients on swing bed status of their transfer and discharge rights.

Interview with EMP5 at 8:45 AM on April 23, 2015, confirmed the facility's "Swing Bed Program Resident Rights," form did not include the swing bed patient's transfer and discharge rights. Further interview of EMP5 confirmed the facility Swing Bed Program Policy did not address the Swing Bed patient's transfer and discharge rights.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a transfer form was completed for residents transferred from the facility's Swing Bed Program to a higher level of care for three of four swing bed medical records reviewed (MR42, MR48 and MR51).

Findings include:

Review on April 23, 2015, of the facility's "Transfer and Transportation of Patient" policy, last revised December 2014, revealed "Purpose: To provide guidelines for patient transfers within SH [Susquehanna Health] (campus to campus) or outside of SH. To assure medical stabilization within the capabilities of the facility prior to the transfer. Continuity of care and necessary supportive measures will be provided for the patient during transfer. ... Process: ... 5. Paperwork A. Physician Medical Necessity Certification (Refer to Scan Physician Med Necessity Cert attachment) 1. For All Non-emergency transfers 2. Not a permanent part of the Health Record, must be given to the transport crew B. Transfer Consent (Refer to Consent Transfer Attachment) 1. For transfer of patients experiencing an emergency medical condition or for transfer of patients due to unavailability of equipment, space and/or beds. 2. Physician completes the top portion indicating that based on the information available the transfer is appropriate and medically necessary. 3. Regardless of whether the physician is recommending the transfer or the patient is refusing the transfer, the risk and benefits of the transfer must be listed on the patient consent. 4. Check boxes indicating what records were sent with the patient. ..."

Review of MR42, MR48 and MR51 on April 23, 2015, revealed these residents were in the facility's Swing Bed Program. Further review revealed the facility transferred MR42, MR48 and MR51 to acute care hospitals outside the SH system. Continued review of MR42, MR48 and MR51 revealed no documentation the facility completed the required transfer form, obtained consent, discussed the risks and benefits of the transfer or indicated what part of the medical record was sent to the receiving acute care hospital.

Interview with EMP2, EMP3 and EMP4 on April 23, 2015, at approximately 10:15 AM confirmed MR42, MR48 and MR51 were residents in the facility's Swing Bed Program; the facility transferred these patients to acute care hospitals outside the SH system; and there was no documentation the facility completed the required transfer form, obtained consent, discussed the risks and benefits of the transfer or indicated what part of the medical record was sent to the receiving acute care hospital.