HospitalInspections.org

Surveyor: 29354
Based on record review, interview, and policy review, the provider failed to ensure two of four sampled surgical patients (22 and 24) had a history and physical (H and P) report documented prior to surgery and two of five sampled swing bed patients (27 and 28) had a H and P completed within 48 hours of admission. Findings include:

1. Review of the medical records for patients 22 and 24 revealed:
*Patient 22's surgical procedure was on 6/25/14, and there was no history and physical report completed.
*Patient 22's surgical procedure was on 6/25/14, and there was no history and physical report found in the medical record.
*Patient 24's surgical procedure was on 12/12/13, and the history and physical report documented in the medical record had been signed on 10/22/13.

Interview on 12/17/14 at 1:15 p.m. with the director of patient care services (DPCS) confirmed the history and physical for patient 22 could not be found in the medical record. The DPCS confirmed there was not a current history and physical report for patient 24 prior to her surgical procedure nor an update note for the 10/13/13 H and P report. Patient 24's history and physical report had been dictated on 10/17/13 and signed by the physician on 10/22/13.

Review of the provider's October 2014 Medical Record Chart Completion policy revealed "A completed H&P is required prior to a surgical procedure being performed. The procedure will be cancelled if an H&P is not in the chart prior to the procedure unless the practitioner states in writing that such a delay would be harmful to the patient."




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2. Review of the medical records for patients 27 and 28 revealed:
*Patient 27:
-Had been admitted on 12/9/14.
-Had been discharged on 12/15/14.
*Patient 28:
-Had been admitted on 12/12/14.
-Had been discharged on 12/15/14.
*Neither patient had a history and physical report in their medical record.

Interview with the DPCS on 12/16/14 at 11:00 a.m. revealed she would not have expected the history and physicals to be in the medical records. The physicians had needed to dictate the reports, and they had not been transcribed yet.

The transcribed history and physicals were handed to this surveyor on 12/16/14 at 11:15 a.m.

Review of the provider's October 2014 Medical Record Chart Completion policy revealed "A complete history and physical examination shall be recorded within 48 hours of admission and no more than 7 days before admission."

Based on record review, interview, contract review, swing bed resident information booklet review, and policy review, the provider failed to:
*Clearly identify who was overseeing the activity program for the swing bed patients.
*Identify the occupational therapist (OT) activity program duties in the Occupational Therapy Services contract agreement.
*Have documentation of OT consultation swing bed activity reports.
*Document activity invitations or activity provided for five of five sampled swing bed patients (26, 27, 28, 29, and 30).
Findings include:

1. Interview on 12/16/14 at 9:15 a.m. with registered nurse (RN) B during a review of the swing bed program revealed:
*The admitting nurse documented an activity assessment when each patient was admitted indicating what activity each patient would have preferred.
*OT C was the swing bed activity program consultant.
*The entire nursing department assisted with the activities.
*The nursing department oversaw the activities. There was not one specific person to oversee it.

Interview on 12/17/14 at 8:50 a.m. with the director of patient care services regarding the swing bed activities revealed:
*OT C approved an activity calendar each month.
*Activities normally included card games, movies, coffee, and some board games.
*The patient-care technicians, nurses, or OT C would help with activities.
*The staff could have documented activities in the electronic medical record.

2. Review of the 8/1/10 Occupational Therapy Services Agreement revealed the OT duties had not included consultant of the swing bed patient activities.

3. Interview on 12/16/17 at 8:50 a.m. with the director of patient care services revealed OT C had not provided consultation reports for the activity services.

4. Review of the medical records for patients 26, 27, 28, 29, and 30 revealed:
*Each patient had an initial activity assessment completed on admission.
*No individual documentation in the medical record that the patients had been invited to participate in activities, or that activities had occurred.

Interview on 12/17/14 at 1:05 p.m. with the administrator revealed:
*The OT consultant duties were not spelled out in the OT contract.
*No activity consultant reports had been documented.
*No one was specifically over-seeing the swing bed activities.
*Staff inviting patients to participate or performing activities with the patients should have documented them in the electronic medical record.

Review of the provider's undated Swing Bed Resident Information Book revealed "Activities are individualized based on an assessment. An ongoing program is available to meet the interest, physical, mental and psychosocial well being of each Swing Bed patient."

Review of the provider's February 2010 Swing Bed Activities policy revealed the activities program should, at a minimum:
*Be directed by a qualified person.
*Reflect the schedule, choices, and rights of the residents.
*Reflect the cultural and religious interests of the residents.
*Appeal to men and women of all age groups.
*A calendar would be placed on each patient's chart - labeled with the patient's name, signed by the OT personnel, and kept as a permanent record left in their charts.