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Based on observation, document review and interview, the hospital failed to meet the requirements for the Condition of Participation for Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101, 2012 edition. The hospital failed to ensure that the facility's medical gas warning alarm system equipment is maintained and inspected in accordance with NFPA. The hospital's failure to comply could adversely affect all patients in all 8 smoke zones using or receiving piped in medical gases from the bulk medical system throughout, which includes the OR (operating room), ED (emergency department) and all patient areas. This deficient practice of not maintaining the medical gas warning alarm system has a direct impact on the day to day operations of the medical gas system and allow undetected variances in the medical gases to occur without immediate alarm notification. There were 18 surgeries, 6 emergency and 5 inpatients between August 12, 2020 through September 1, 2020. The facility has a capacity of 25 with a census of 6 at the time of the survey.

Findings Include:

1. The annual medical gas systems report completed on 8/12/20 showed the CO (carbon monoxide) sensors in the following locations were bad and had not been fixed: Room 352 on the compressor, Room 350 on the Master alarm panel 1, and in the Emergency Room Corridor on the master alarm panel 2.

Refer to C-930 and Life Safety Code Survey ASPEN # DDNC21; K-908 for further details.

Based on observation, document review and interview, the hospital failed to meet the requirements for participation at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101, 2012 edition when they failed to ensure that the facility's medical gas warning alarm system equipment is maintained and inspected in accordance with NFPA. The hospital's failure to comply could adversely affect all patients in all 8 smoke zones using or receiving piped in medical gases from the bulk medical system throughout, which includes the OR (operating room), ED (emergency departments) and all patient areas. This deficient practice of not maintaining the medical gas warning alarm system has a direct impact on the day to day operations of the medical gas system and allow undetected variances in the medical gases to occur without immediate alarm notification. There were 18 surgeries, 6 emergency and 5 inpatients between August 12, 2020 through September 1, 2020. The facility has a capacity of 25 with a census of 6 at the time of the survey.

Findings Include:

Review of records on September 3, 2020 at 8:51 AM showed the following:

The annual medical gas systems report was completed on 8/12/20 by Medical Technology Associates, Inc. and had the following remarks noted. The CO (carbon monoxide) sensors in the following locations are bad and have not been fixed: located in room 352 on the compressor, on the Master alarm panel 1 in room 350, and on the master alarm panel 2 located in the ER corridor. The Chief Executive Officer stated that he was unaware of the deficiencies found by Medical Technology Associates, Inc. during the 8/12/2020 inspection. The master alarm panel 1 in room 350 was observed; it was working with no alarms or trouble signals. The Chief Executive Officer stated that he was going to make some calls to the contractor and figure out how to fix the sensors. It was observed the maintenance staff checked the sensor in room 352 and master alarm panel 2 in the ER corridor. No alarms or trouble signals where observed at either location.

The facility was notified that this deficient practice represents an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) at 12:13 PM on 9/24/20. The Chief Executive Office acknowledged that the facility had received the IJ template. The facility sent the plan to remove the IJ at 2:20 PM on 9/24/20.

Observation during an onsite survey on September 25, 2020 at 9:40 AM showed the following:

The Immediate Jeopardy for K-908 for the Gas and Vacuum Piped Systems was removed on September 25, 2020 at 12:02 PM while the surveyor was in the building when the medical gas vendor was on location to replace all the CO sensors that were identified in the vendors report dated August 12, 2020.

Refer to the Life Safety Code Survey ASPEN #DDNC21; K-908 for further details.

Based on observations, policy reviews, document reviews, and interviews, the hospital failed to meet the requirement of the Condition of Participation for Surgical Services. The hospital failed to verify the surgeon scheduled to operate on patients had surgical privileges to perform the surgery. This failure to comply placed all patients presenting to the hospital at risk for having surgery by an unqualified practitioner.

Findings Include:

1. The hospital did not provide a current roster listing each practitioner's specific surgical privileges. The surgery manager did not have access to the surgeon's privileges and did not know how to obtain a current roster. (Refer to C-1140)

Based on policy review, document review, and interview, the hospital failed to ensure the surgery department had a current roster listing each practitioner's specific surgical privileges available in the surgical suite. The deficient practice had the potential to have surgeries performed for which the practitioner was not privileged and had the potential to affect all surgeries performed in the hospital's surgical suite.

Findings Include:

Review of the "Hospital/Critical Access Hospital (CAH) Database Worksheet", updated on 09/04/2020 by the hospital, showed "Services Provided by the Facility" included: Anesthesia Services, Operating Rooms, Post-Operative Recovery Rooms, Inpatient Surgical Services, and Outpatient Surgical Services.

Review of the policy titled, "Surgeon's Privileges," revised September 2010, showed that surgeon's privilege lists are maintained in the Surgical Services Department and are updated periodically by the Medical Staff Office. Further review showed that before a case is finalized on the schedule, the surgeon's privileges must be verified.

A request was made on 09/02/20 at 10:55 AM, during a tour of the surgical department of Staff L, Surgery Manager, to review the current roster listing each practitioner's specific surgical privileges. Staff L did not provide a current roster of surgeons with their listed surgical privileges.

During an interview on 09/02/20 at 10:55 AM, Staff L, Surgery Manager stated that she didn't have access to the surgeon's privileges and didn't know how to obtain the current roster.

Based on observations, policy reviews, document reviews, and interviews, the hospital failed to meet the requirement of the Condition of Participation for Infection Prevention and Control and failed to properly implement critical elements to prevent the spread of COVID-19. This failure to comply placed the 5 inpatients, all patients presenting to the hospital, and the employees currently working in the hospital at risk for COVID-19.

On 09/04/20 at 9:05 AM, Staff A Chief Executive Officer (CEO) was notified that that an Immediate Jeopardy (IJ - a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) existed at C-1200 due to failure to screen staff before the beginning of their shift for signs and symptoms of COVID-19, lack of signage at entrances with instructions related to requirements for COVID-19, improper cleaning of re-usable medical equipment, and not ensuring that staff were following hospital policies and procedures related to infection control.

On 09/04/20 at 4:30 PM, Staff A, CEO, presented a removal plan for the IJ. The removal plan included the following:

1. Additional signage placed at the front entrance and emergency department entrance to the building in a larger printed format with additional information related to COVID-19 visitation restrictions and screening requirements. The signage added the current requirement to wear a face mask.

2. The hospital will screen all staff at the beginning of their shift for fever and signs and symptoms of COVID-19. Each employee will enter through the middle employee entrance, take their temperature, document the temperature, and check off that no signs or symptoms are present with a hospital employee assigned to monitor the employee entrance at all times to ensure all staff are complying with the screening procedures.

3. The COVID-19 Screening Policy was updated to include a process for cleaning of reusable equipment (temperature probe) between visitor use.

4. Staff will be provided training on the policies and procedures and acceptable standards of practice for hand hygiene prior to the next shift worked, and training will continue until all staff has been trained. No employee will report to work until training has occurred.

5. Update of Policies and procedures and acceptable standards of practice for glove use and wearing of face masks.

6. Training on glove use and proper wearing of face masks will be provided to all staff before their next shift.

7. Update of Policies and procedures and acceptable standards of practice for environmental cleaning to include glove use. All staff will review and attest to comply with the updated procedures prior to their next shift.

The hospital submitted a credible plan of removal on 09/04/20 at 5:00 PM. Validation of the removal plan implementation by the on-site surveyor was completed on 09/04/20 at 5:20 PM and Staff A, CEO was informed that the plan for removal was accepted.

Findings Include:

1. The hospital did not have signage posted at the hospital's main entrance on 09/02/20 at 8:15 AM with information about visitation restrictions and screening procedures. The hospital did not have signage posted at the main entrance with instructions to individuals seeking medical care with symptoms of respiratory infection to immediately put on a mask and keep it on during their assessment, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions. (Refer to C-1231)

2. The hospital did not screen any staff at the beginning of their shift for fever and signs and symptoms of illness related to COVID-19 and failed to document the absence of symptoms. (Refer to C-1231)

3. Staff did not clean reusable equipment (a temperature probe that requires skin contact) between visitor use. (Refer to C-1231)

4. Staff did not follow policies and procedures and acceptable standards of practice for hand hygiene and glove. (Refer to C-1231)

5. Staff did not follow policies and procedures and acceptable standards of practice for wearing of masks. (Refer to C-1231)

6. Staff did not follow policies and procedures and acceptable standards of practice for environmental cleaning. (Refer to C-1231)

Based on observations, policy reviews, document review, and interviews, the hospital failed to develop and implement facility-wide infection surveillance, prevention, and control policies and procedures that adhere to current nationally recognized guidelines and standards of practice. The deficient practices presented a potential for the spread of COVID-19 to the 5 current inpatients, all patients presenting to hospital, and to the employees.

Findings Include:

1. Observation on 09/02/20 at 8:15 AM showed no signage posted at the front entrance related to COVID-19 with instructions to individuals seeking medical care, with symptoms of respiratory infection, to immediately put on a mask and keep it on during their assessment, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions.

During an interview on 09/02/20 at 9:02 AM, Staff G, Certified Nursing Assistant (CNA), stated that there was no signage at the front entrance of the hospital used by patients, visitors, and rural health clinic patients related to COVID-19.

2. Review of the hospital policy titled, "Patient Services - Infection Control Policy and Procedure Manual," revised June 2020, showed that "self-screening prior to coming to work is recommended."

Observation on 09/03/20 at 6:25 AM showed Staff D, Director of Nursing-emergency room (DON-ER) entered the hospital. Continuous observation for five minutes showed Staff D, DON- ER, did not check her temperature and was not screened by staff for any symptoms of COVID-19.

Observation on 09/03/20 at 6:45 AM showed Staff E, Registered Nurse - Infection Control (RN-IC) entered the hospital and was observed to begin making rounds on patients without taking her temperature and being screened by staff for any symptoms of COVID-19.

Review of the Centers for Medicare & Medicaid Services(CMS) memo titled, "Quality, Safety, and Oversight Group (QSO)-20-20-All" dated 03/23/2020, showed the "COVID-19 Focused Infection Control Survey: Acute and Continuing Care. This survey tool provides a focused review of the critical elements associated with the transmission of COVID-19...Are facilities actively screening visitors (The Centers for Disease Control and Prevention (CDC) currently recommends staff are checking for fever and signs and/or symptoms of respiratory infection, and other criteria such as travel or exposure to COVID-19)?...Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?"

Review of the CMS memo titled, "QSO-20-13-Hospitals-CAHs", dated 03/30/20, with the subject of "Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs)...showed that "the same screening performed for visitors should be performed for hospital, psychiatric hospital, and CAH staff". Further review showed visitor screening included asking if the visitor/patient had signs or symptoms of a respiratory infection, such as a fever, cough, or difficulty breathing; had been in contact with a person who is positive for COVID-19 or with someone who is considered a PUI (person under investigation) or someone who is ill with respiratory illness; had traveled within the last 14 days to areas with widespread or ongoing COVID-19 community spread; and if resided in or worked in a community where community-based spread of COVID-19 is occurring.

Review of the CDC document titled, "Management of Visitors to Healthcare Facilities in the Context of COVID-19," updated on June 28,2020, showed, "Visitors to healthcare facilities should be limited in the context of the COVID-19 pandemic, regardless of known community transmission. If visitors are allowed: Facilities should designate an entrance that visitors can use to access the healthcare facility. Visitors who are noted by healthcare facility staff to have fever or other symptoms of acute respiratory illness (e.g., cough or shortness of breath) should be instructed to leave the facility and seek care if needed".

Review of an email dated 05/22/20 to the nursing staff and department heads from Staff P, Rural Health Clinic Administrator (RHCA), showed that employees will be responsible for taking their own temperature upon entrance to the hospital, and the temperature readings do not need to be logged.

During an interview on 09/02/20 at 2:35 PM, at the staff entrance near the operating room/emergency department/radiology department, Staff N, Nursing Assistant (NSA) stated that it was Staff N, NSA's understanding they had quit doing employee screening. Staff N, NSA stated employees were all coming in one entrance with staff there to do temperature checks and screening, but they had stopped doing that for about one month now.

During an interview on 09/02/20 at 2:40 PM, Staff O, NSA stated that the employees do self-monitoring and aren't required to document the screening now.

During an interview on 09/02/20 at 5:10 PM, Staff C, DON, stated that there is no documented evidence to show that all employees currently working in the hospital had screened for COVID-19.

During an interview on 09/03/20 at 6:50 AM, Staff D, DON-ER stated that she checked her temperature at home. Staff D, DON-ER further stated staff are supposed to check their temperature at home, and if they haven't done so, they are to check it when they arrive at the hospital.

During an interview on 09/03/20 at 7:10 AM, Staff E, RN-IC stated that she checked her temperature at home before coming to work.

During an interview on 09/03/20 at 7:15 AM, Staff D, DON-ER and Staff E, RN-IC, presented guidance from Centers for Disease Control and Prevention (CDC) titled "General Business Frequently Asked Questions (FAQs) for Businesses," updated 07/11/20, that showed "screening employees is an optional strategy that employees may use." When informed by the surveyor that the guidance was related to general businesses and not healthcare facilities, Staff D, DON-ER stated she would look for further guidance.

During interviews with the Chief of Staff and Medical Director on 09/03/20 at 12:15 PM, the two physicians stated that they were aware of the hospital's change in the staff screening policy, and they relied on guidance received from the clinical managers for policy development. Staff F, Chief of Staff, stated "I'm chief of staff, but I don't make decisions of whose screened or not."

During an interview on 09/03/20 at 2:45 PM, Staff A, Chief Executive Officer (CEO) stated that he was aware the staff screening policy had been changed. Staff A, CEO, stated the Kansas Department of Health and Environment has stated the CDC guidelines are recommendations and not mandates, and it's left up to the local and state for interpretation. Staff A, CEO did not provide anything in writing from the Kansas Department of Health and Environment to confirm this.

3. Observation on 09/02/20 at 8:15 AM showed Staff G, CNA checking a male visitor's temperature upon entering the front entrance of the hospital. Staff G, CNA, then checked the temperature of the female visitor (who entered with the male visitor) without cleaning the temperature probe between use (the probe had touched the forehead, temple, and below the ear of the male visitor).

Review of the infection control policies presented by Staff B, Chief Operating Officer (COO), revealed no documented evidence of the procedure for cleaning/disinfecting reusable patient equipment. The policies presented included "Infection Control Guidelines for Hand Hygiene & (and) Surgical Scrub," effective June 2020; "Cleaning Patient Room - Discharge/Transfer," effective 07/22/19; "Glove Use Guidelines," effective June 2020; "Infection Prevention Plan," effective May 2020; and "COVID-19 Screening Tool," issued 04/01/20.

During an interview on 09/02/20 at 9:02 AM, Staff G, CNA, stated that she doesn't clean/disinfect the thermometer probe between family members who enter the hospital together.

4. Review of the policy titled "Glove Use Guidelines," effective date June 2020, showed that gloves were to be worn for contact with "moist body substances" such as blood, wound drainage, oral secretions, feces, urine, and open skin and mucous membranes. Further review showed gloves were not required for activities that do not typically involve contact with moist body substances, such as changing bed linens, passing medication, and transporting patients. Further review showed gloves should never be worn after completing the specific task for which they were put on to prevent contaminating environmental surfaces.

Review of the policy titled, "Infection Control Guidelines for Hand Hygiene & Surgical Scrub," effective June 2020, showed hands should be washed thoroughly for at least 15 seconds when they are visibly soiled. Examples included after contact of patient's blood, body fluids, mucous membranes and/or secretions, or articles of soiled linens and clothes of the patients; after care of an infected patient or one who is colonized with microorganisms; after handling devices, equipment, specimens, or linen contaminated with body substances; after using the toilet or blowing the nose; when moving from a contaminated body site to a clean site during patient care; and when leaving one patient room before entering another patient room. Further review showed if hands are not visibly soiled, an alcohol-based waterless antiseptic agent may be used.

Observation in the Computerized Tomography (CT) Room on 09/02/20 at 11:05 AM showed Staff K, Radiography Tech/CT, cleaning the room after completing a procedure. Staff K, Radiography Tech/CT, removed the pillow case from the pillow and the sheet that was on the CT table and went to the station counter, picked up a roll of tape used on the former patient, opened the drawer, and placed the tape in the drawer without performing hand hygiene. Staff K, Radiography Tech/CT, then removed syringes from the injector and donned gloves (to clean/disinfect the CT table) without performing hand hygiene.

During an interview on 09/02/20 at 11:05 AM, Staff K, Radiography Tech/CT, confirmed that the observations documented above were breaches in hand hygiene and glove use.

Observation on 09/02/20 at 1:40 PM showed Staff I, Housekeeper cleaning Patient 1's room (Room 105). Observation showed Staff I, Housekeeper was gloved and cleaned the rim of the bedside commode chairs in the bathroom and then cleaned the handrails at the side of the toilet with the same contaminated cloth. Staff I, Housekeeper did not change gloves and perform hand hygiene when moving from a dirty environmental surface (commode seats) to a clean site used by patients (hand rails).Staff I, Housekeeper, then placed the contaminated cloth in a plastic bag. With contaminated gloved hands, Staff I, Housekeeper took keys from her pocket and unlocked the housekeeping cart, took cleaner to pour in the toilet, and replaced the cleaner in the cabinet and locked it, all while wearing contaminated gloves.

During an interview on 09/02/20 at 1:50 PM, Staff I, Housekeeper, stated that she wasn't told gloves had to be changed between tasks.

5. Review of an email sent by Staff T, Marketing Director, on 04/30/20 at 10:31 AM to department heads showed that department heads were to share the information included in the email with staff. Further review of the email showed that effective 04/30/20 all staff were to wear a mask in "public places" such as hallways, waiting areas, and screening areas and when providing patient care.

Review of CDC, "How to Select, Wear, and Clean Your Mask," updated August 27, 2020, showed that face masks are to be worn over the nose and mouth and secured under the chin.

Observation on 09/02/20 at 8:20 AM, during the entrance conference conducted in the conference room, showed Staff A, Chief Executive Officer (CEO), was wearing the face mask with the nose exposed.

Observation on 09/02/20 at 10:15 AM in the hall outside the lab area showed Staff A, CEO, was wearing the face mask with the nose and mouth exposed.

Observation on 09/03/20 at 7:45 AM in the hall outside Staff A, CEO's office showed Staff A, CEO was wearing the face mask with the nose exposed.

During an interview on 09/02/20 at 2:00 PM, Staff A, CEO, offered no explanation when informed of the observations made on 09/02/20 at 8:20 AM and 10:15 AM.

6. Review of the policy titled "Cleaning Patient Room - Occupied," revised 07/22/19, showed all patient rooms will be cleaned on a daily basis. Further review showed all fixtures, ledges, and surfaces in the room and bathroom above shoulder height were to be dusted. Damp dust overbed table, bedside tables, telephone, chairs, stools, ledges, light switches, lamps, and spots on walls or cabinets with a hospital-approved germicidal solution. There was no documented evidence the policy addressed the cleaning of the patient bed that included the headboard and side rails.

Observation on 09/02/20 at 1:40 PM showed Staff I, Housekeeper cleaning Patient 1's room. Staff I, Housekeeper failed to clean the patient's bed rails and headboard.

During an interview on 09/02/20 at 1:40 PM, Staff I, Housekeeper, stated that she didn't wipe Patient 1's bed when cleaning the room. Staff I, Housekeeper stated, "I don't know to be honest" when asked if she was supposed to clean the patient's bed when performing daily cleaning of the room.

Based on policy review, record reviews, and interviews, the hospital failed to ensure a discharge planning evaluation was conducted for each patient as required by hospital policy. The deficient practice had the potential to prevent appropriate arrangements for post-critical access hospital care to be made before discharge, potentially causing unnecessary delays in discharge for 10 (Patient 2, Patient 3, Patient 5, Patient 12, Patient 14, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20) of 15 patient records reviewed for discharge planning.

Findings Include:

Review of the policy titled, "Discharge Planning Policy," revised on 09/02/16, showed that all acute and swing bed admissions were to be interviewed. Further review showed that Discharge Planner/Case Manager was responsible for the following functions:
1. Explaining acute care and swing bed programs to all patients and families;
2. Documenting such interviews and teaching in patient charts;
3. Assessing and planning goals and objectives for a satisfactory discharge and documenting in patient charts;
4. Evaluating self-care or the possibility of the patient being cared for in the environment from which he or she entered the hospital;
5. Coordinating continuity of care for discharge with outside health, social, and financial agencies;
6. Monitoring, consulting, and screening all acute care and swing bed admissions with physicians, Director of Nursing, Chief Executive Officer, and Health Information Department;
7. Making frequent patient visits to assess progress towards discharge and documenting updates to the plan;
8. Providing the patient with information regarding the availability of post-hospital care services and ensuring the patient has the freedom to choose among appropriate providers of post hospital care.

Review of patient electronic medical records (EMR), with the assistance of Staff S, Registered Nurse (RN), navigating the EMRs, on 09/04/20 showed the following:

1. Review of Patient 2's "Face Sheet," (commonly used term referring to a one-page summary of important information about the patient) showed Patient 2 was admitted on 08/31/20 and discharged on 09/03/20. Review of the "Diagnoses/Problems" tab showed diagnoses of enteritis (inflammation of the small intestine), hypomagnesemia, hypokalemia (low potassium level), and abdominal pain. There was no documented evidence that a discharge evaluation had been conducted.

2. Review of Patient 3's "Face Sheet," showed Patient 3 was admitted on 08/24/20 and discharged on 08/26/20. Review of the "Diagnoses/Problems" tab showed diagnoses of dehydration, right lower lobe pneumonia, and anemia. There was no documented evidence that a discharge evaluation had been conducted.

3. Review of Patient 5's "Face Sheet," showed Patient 5 was admitted on 08/02/20 and discharged on 08/04/20. Review of the "Diagnoses/Problems" tab showed diagnoses of gastroenteritis, sepsis (inflammation throughout the body), and dehydration. Review of the "Orders/Plan of Care" tab showed a physician's order to consult case management. There was no documented evidence that Case Management had conducted a discharge evaluation.

4. Review of Patient 12's "Face Sheet," showed Patient 12 was admitted on 06/29/20 and discharged on 07/02/20. Review of the "Diagnoses/Problems" tab showed diagnoses of cellulitis (bacterial skin infection) of right lower extremity and at risk of venous thrombo-embolus (blood clot in a vein.) There was no documented evidence that a discharge evaluation had been conducted.

5. Review of Patient 14's "Face Sheet," showed Patient 14 was admitted on 06/28/20 and discharged on 07/02/20. Review of the "Diagnoses/Problems" tab showed diagnoses of acute hyponatremia (sodium in blood is too low), lethargy, and hypomagnesemia. There was no documented evidence that a discharge evaluation had been conducted.

6. Review of Patient 16's "Face Sheet," showed Patient 16 was admitted on 07/19/20 and discharged on 07/22/20. Review of the "Diagnoses/Problems" tab showed diagnoses of heat stroke, hypernatremia, and diabetes. There was no documented evidence that a discharge evaluation had been conducted.

7. Review of Patient 17's "Face Sheet," showed Patient 17 was admitted on 08/04/20 and discharged on 08/06/20. Review of the "Diagnoses/Problems" tab showed diagnoses of congestive heart failure (CHF) (heart doesn't pump blood as well as it should) exacerbation, hyperglycemia (high blood sugar levels), and chronic kidney disease. There was no documented evidence that a discharge evaluation had been conducted.

8. Review of Patient 18's "Face Sheet," showed Patient 18 was admitted on 08/11/20 and discharged on 08/16/20. Review of the "Diagnoses/Problems" tab showed diagnoses of hyponatremia, anemia, and chronic CHF. There was no documented evidence that a discharge evaluation had been conducted.

9. Review of Patient 19's "Face Sheet," showed Patient 19 was admitted on 08/19/20 and discharged on 08/24/20. Review of the "Diagnoses/Problems" tab showed diagnoses of CHF, chronic systolic heart failure, and atrial fibrillation (irregular, often rapid heart rate.) There was no documented evidence that a discharge evaluation had been conducted.

10. Review of Patient 20's "Face Sheet," showed Patient 20 was admitted on 08/25/20 and discharged on 08/27/20. Review of the "Diagnoses/Problems" tab showed diagnoses of elevated liver function tests and gastroesophageal reflux disease. There was no documented evidence that a discharge evaluation had been conducted.

During an interview on 09/03/20 at 9:55 AM, Staff Q, Case Manager, stated that if there is no case management consult ordered by the physician for discharge planning or no needs are identified by the provider or nurse, Staff Q, Case Manager, doesn't see the patient to conduct a discharge evaluation. When shown the policy titled "Discharge Planning Policy," that showed that an evaluation is to be done on all patients, Staff Q, Case Manager, stated she thought if there was no need identified or patients/family didn't have questions, Staff Q, Case Manager, didn't think the patient had to be seen for discharge planning.

During an interview on 09/04/20 at 9:30 AM, Staff S, RN verified that the above-listed patients did not have discharge planning evaluations.

Based on policy reviews, document review, record reviews, and interview, the hospital failed to ensure a comprehensive assessment was conducted and a care plan was developed for activity pursuit. The hospital failed to ensure activities were provided that met the needs of patients on the swing bed unit. The deficient practice affected 3 (Patient 4, Patient 15, Patient 21) of 3 swing bed patients reviewed.

Findings Include:

Review of the policy titled "Swing Bed (SB) Comprehensive Care Plans," revised 08/15/18, showed that care plans are molded to fit the actual patient they are being used on. Further review showed that care plans will reflect disease control, health management goals, physical goals, mental goals, cognitive goals, psychosocial goals, functional goals, and environmental factors. There was no documented evidence the policy addressed assessing for activity pursuit.

Review of the policy titled "Swing Bed (SBS/SBI) Activities," revised 08/01/18, showed that swing-bed patients will have an activity planned with the activity director that " ... will consist of bingo, outings when planned, card games, arts and crafts, . . ."

Review of the undated "Position Title: Activity Coordinator/Designee," showed that the coordinator's duties included assessing psychosocial and spiritual needs and interests of the resident, assisting the health care team to identify and develop a plan of care incorporating activity goals and interventions, developing and implementing individual and small group activities, maintaining current records of planned activities for residents, and documenting the resident's response to the planned activities.

Review of Patient 4's "Face Sheet," with Staff S, Registered Nurse (RN), navigating the electronic medical record (EMR), showed Patient 4 was admitted to a swing bed on 08/31/20. Review of the "Diagnosis/Problems" tab showed Patient 4's diagnoses included post procedural intra-abdominal abscess and history of bowel resection and chronic obstructive pulmonary disease. Review of Patient 4's EMR under the assessment tab showed no documented evidence that a comprehensive assessment was conducted that included an assessment of activity pursuit and a plan of care incorporating activity goals and interventions for the psychosocial and spiritual needs and interests of Patient 4. Review of Patient 4's "Activities Progress Notes," dated 09/01/20, 09/02/20, and 09/03/20 and documented by Staff G, certified nursing assistant (CNA), who is also the hospital's activity coordinator, showed Staff G, CNA talked with patients, but there was no documented evidence that activities were conducted with Patient 4. There was no documented evidence that activities had been refused by Patient 4.

Review of Patient 15's "Face Sheet," tab in the EMR showed Patient 15 was admitted to a swing bed on 08/29/20 and discharged 09/03/20 with diagnoses of acute on chronic respiratory failure and pulmonary emboli. Review of Patient 15's EMR under the assessment tab showed no documented evidence that a comprehensive assessment was conducted that included an assessment of activity pursuit and a plan of care incorporating activity goals and interventions for the psychosocial and spiritual needs and interests of Patient 15. Review of Patient 15's "Activities Progress Notes" dated 08/31/20, 09/01/20, 09/02/20, and 09/03/20, and documented by Staff G, CNA showed no documented evidence that activities were conducted with Patient 15. There was no documented evidence that activities had been refused by Patient 15.

Review of Patient 21's "Face Sheet," tab in the EMR showed Patient 21 was admitted to a swing bed on 08/28/20 with a diagnosis of acute hypoxemia with respiratory failure. Review of Patient 21's EMR under the assessment tab showed no documented evidence that a comprehensive assessment was conducted that included an assessment of activity pursuit and a plan of care incorporating activity goals and interventions for the psychosocial and spiritual needs and interests of Patient 21. Review of Patient 21's "Activities Progress Notes" dated 08/31/20 and 09/01/20, and documented by Staff G, CNA showed no documented evidence that activities were conducted with Patient 21. There was no documented evidence that activities had been refused by Patient 21.

During an interview on 09/04/20 at 9:30 AM in the conference room, Staff S, RN stated that the "Activities Progress Notes" presented for the above-listed patients were the only documentation related to activities. Staff S, RN stated there was no assessment related to activity pursuit in the EMR of Patient 4, Patient 15, and Patient 21.

During an interview on 09/04/20 at 3:40 PM, with Staff C, Director of Nursing (DON), and Staff D, Director of Nursing Emergency Room (DON-ER), Staff C, DON stated that Staff G, CNA, was certified as the activity coordinator, but Staff G, CNA, was not available to be interviewed. Staff C, DON, stated some of the patient activities had been decreased due to COVID-19, but the activities could have been individualized and performed in the patient's room.