HospitalInspections.org

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Based on interview, review of the hospital's quality and performance improvement program, and review of the hospital's plan of correction dated 12/16/19, the Critical Access Hospital failed to implement action plans and monitor for successful correction of deficiencies found during a federal and state complaint investigation in November 2019.

Failure to systematically identify problems, implement corrective action plans, and monitor for improvement limits the hospital's ability to provide high quality patient care and improve patient outcomes.

Reference: 485.641(b) "The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes."

Findings included:

1. Staff education had not been completed for new policies and procedures for adverse event reporting and investigation, and patient falls follow-up activities.

2. Evidence of completion of orientation was not present in the personnel file of a registered nurse who had been hired in September 2019. Personnel files audits had not been performed and reported monthly to the hospital's quality program.

3. Comprehensive Care Plans for long-term care patients did not include interventions and goals for meeting all of the patient's health care needs for 3 of 3 patients reviewed. Care plan audits had not been performed and reported monthly to the hospital's quality program.

4. Participation in activities for long-term care patients were not recorded in the patient's record for 3 of 3 patients reviewed. Activity participation audits had not been performed and reported monthly to the hospital's quality program.

Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring was NOT MET.

Cross Reference: C-0336, C-1620
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Based on interview, review of the hospital's quality and performance improvement program, and review of the hospital's plan of correction dated 12/16/19, the Critical Access Hospital failed to implement action plans and monitor for successful correction of deficiencies found during a federal and state complaint investigation in November 2019.

Failure to systematically identify problems, implement corrective action plans, and monitor for improvement limits the hospital's ability to provide high quality patient care and improve patient outcomes.

Findings included:

1. Review of the hospital's Quality Improvement Plan dated 01/20 showed the hospital's quality assurance/quality improvement program included analyzing all "state-cited deficiencies", and developing and monitoring action plans to show improvement and correction of the deficiencies.

2. On 03/04/20 at 1:15 PM, the investigator interviewed the hospital's quality program coordinator (Staff #5) and the Chief Nursing Officer (Staff #3) and reviewed the hospital's quality program. The interview and review showed that the hospital had not implemented its corrective action plan for deficiencies cited during a state and federal complaint investigation that was conducted in November 2019:

a. STAFF EDUCATION:

1) In November 2019, the investigator cited deficiencies related to reporting and investigating patient abuse and adverse patient healthcare events. The hospital stated in its plan of correction that it had created an abuse reporting policy and procedure and that staff education had been completed. The plan of correction also stated that the hospital had created an adverse event investigation and reporting policy and that hospital staff would be educated regarding this policy by 01/15/20.

2) On 03/04/20 at 2:40 PM during an interview with the investigator, the Chief Nursing Officer (Staff #3) stated that all staff were expected to review the new policies and procedures as part of the education plan. Review of reports titled "Policy Acknowledgement Detail for Reporting Abuse" and "Policy Acknowledgement Detail for Reporting Adverse Events Policy" showed the policies had been assigned to hospital staff members on 12/06/19. The reports showed 20 hospital staff members had not read the policies.

b. STAFF ORIENTATION:

1) In November 2019, the investigator cited deficiencies related to staff orientation and competencies. The hospital stated in its plan of correction that the hospital would audit personnel files to ensure they contained evidence of staff orientation and competencies. The correction was to have been completed by 01/25/20.

2) On 03/04/20 at 2:10 PM the investigator reviewed the personnel files of five hospital staff members with the assistance of the hospital's Human Resources Manager (Staff #1). The file review included the personnel file for a registered nurse who had provided care for the hospital's three long-term care patients on 03/03/20 (Staff #2). The file review and interview showed the nurse had been hired on 09/12/19. There was no evidence in the nurse's personnel file that she had been oriented to nursing duties and responsibilities when caring for long-term care patients.

3) The quality program interview showed that personnel files audits had not been performed and reported monthly to the hospital's quality program as stated in the hospital's plan of correction.

c. COMPREHENSIVE CARE PLANS:

1) In November 2019, the investigator cited deficiencies related to comprehensive care planning and activities for long-term care patients. The hospital stated in its plan of correction that care plans would be updated weekly by social services, nursing, physical therapy, dietary, and the patient's health care provider during team "huddles". Care plans and participation in hospital activities would be audited and reported monthly to the hospital's quality program. The correction was to have been completed by 01/25/20.

2) On 03/03/20, the investigator reviewed the comprehensive care plans for three long-term care "swing bed" patients currently receiving care at the hospital. The review showed that 3 of 3 care plans did not include interventions and goals for meeting all of the patients' health care needs. Participation in activities were not recorded in the patient's record for 3 of 3 long-term care patients reviewed.

3) The quality interview showed that care plan and activity participation audits had not been performed and reported monthly to the hospital's quality program as stated in the hospital's plan of correction.

Cross Reference: C1620
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to 1) ensure that hospital staff developed and implemented comprehensive care plans for long-term care ("swing bed") patients in accordance with the resident's comprehensive assessment, and 2) provide evidence that staff members developed and implemented an individualized, ongoing activity program in accordance with interests identified in the patient's activities assessment for 3 of 3 long-term care patients reviewed (Patients #2, #3, #4).

Failure to develop and implement a comprehensive plan of care based on an assessment of the long-term care resident's needs risks deterioration of the resident's health and adverse healthcare outcomes.

Findings included:

1. COMPREHENSIVE CARE PLANS

a. Review of the hospital's policy and procedure titled "Swing Bed Care Plans and Care Conference," Policy #6434122 revised 12/19, showed a temporary plan for care would be developed for each swing bed patient within 24 hours of admission. A personalized comprehensive plan for care would be developed within 14 days of admission. The policy stated the plan for care would be reviewed and revised according to changes in the patient's condition.

b. Review of three long-term care "swing bed" patients currently receiving care at the hospital (Patients #2, #3, #4) showed the following:

1) Patient #2 was an 88 year-old patient who had been admitted to the hospital's swing bed program on 10/01/16. The patient's medical records showed the patient had experienced a progressive decline in her health status since admission. The patient developed a stage 4 pressure ulcer in August 2019, had lost weight, and was experiencing pain. According to a care conference note in the patient's record dated 11/08/19, the patient had been diagnosed with failure to thrive and had been placed on end of life "comfort care". The note stated that care of the pressure ulcer would continue and that pain management would be a primary goal. Review of the patient's care plan showed the patient's pressure ulcer had not been identified as a problem. No interventions had been identified on the patient's care plan for wound care and pain management.

2) Patient #3 was 68 year-old patient with a history of Parkinson's Disease who had been admitted to the hospital's swing bed program on 01/30/20. The patient's medical records showed the patient had bilateral leg edema. The records included an order written by the patient's health care provider on 02/27/20 for nursing staff to wrap both of the patient's legs daily and to check the patient's skin integrity daily. Review of the patient's care plan showed edema and risk for impaired skin integrity had not been identified as a problem.

3) Patient #4 was a 90 year old patient with dementia related to Alzheimer's Disease who had been admitted to the hospital's swing bed program on 01/01/20. The patient had a indwelling urinary catheter. Review of the patient's plan for care showed urinary incontinenace had not been identified as a problem, and no interventions had been identified for care of the catheter. The patient's records showed he fell on 01/30/20. The patient's care plan had not been updated to include interventions to prevent future falls. The care plan showed the patient had been started on a functional maintenance program on 01/15/20. On 03/04/20 at 11:20 AM during an interview with the investigator, the hospital's occupational therapist (Staff #6) stated when patients completed physical therapy, the physical therapist would initiate a Functional Maintenance Flow Sheet with interventions for maintaining physical mobility. Nursing staff would document functional maintenance care on this form. Review of the patient's medical records showed a Functional Maintenance Flow Sheet was not present.

c. On 03/03/20 between 1:00 PM and 1:30 PM during an interview with the investigator, the Chief Nursing Officer (Staff #3) confirmed the hospital's care planning policy and procedure had not been followed for Patients #2, #3, and #4.

2. ACTIVITY PROGRAM

a. Review of the hospital's policy and procedure titled "Activities and Activity Program, SB," Policy #7069129 revised 03/18, showed the hospital would provide for an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of each swing bed patient in accordance with their comprehensive assessment. A variety of activities would be offered to facilitate the patient's physical, social, and mental well-being. A record of participation in activities would be kept in the patient's chart and documented daily in the patient's electronic medical record.

b. Review of the medical records of three swing bed patients currently hospitalized under the hospital's long-term care "swing bed" program showed that a hospital staff member had performed an assessment of each patient's activity interests and developed activity plans. There was no evidence in the records that the patient's had been offered activity choices and whether they had participated in the activities.

c. On 03/04/20 at 1:00 PM during an interview with the investigator, the Chief Nursing Officer (CNO) (Staff #3) stated that patient care staff members had been instructed to record patient participation in activities on a form titled "East Adams Rural Healthcare: Activities Log." The CNO confirmed the logs had not been completed for Patients #2, #3, and #4.
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