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Based on observation, review of documents and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure development, implementation and annual review of written policies and procedures that addressed the provision of Sleep Lab services provided by the network hospital for patients admitted to Mercy Medical Centerville Hospital.


Written policies and procedures provide guidance and consistency among staff and serves as a resource for staff in the provision of care. Failure to maintain policies and procedures for staff reference failed to provide staff with guidance for the expected practices and performances in the provision of patient care. The lack of policies and procedures in the provision of patient care could potentially result in the patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm, illness, or even patient death.

The CAH administrative staff reported Sleep Study inpatient census of approximately 3 patients weekly.

Findings include:

Observation on 8/9/11 at 7:45 AM revealed two sleep study patient rooms [Room A and B] located in the east hallway of the main level. During an interview at the time of the observation the Chief Nursing Officer (CNO) verified the CAH lacked policies and procedures approved by the CAH committeed and board of directors. The CNO stated, "I suppose it should be included in our annual review of policies. We would follow the network hospital's policies for sleep lab dated 10/10."

Review of documentation presented by the CNO to the survey team on 8/9/11 at 11:00 AM revealed in part, ..."The sleep lab at Mercy Medical Center - Centerville is an extension of the Mercy - Des Moines Sleep Lab..."

Review of document titled "Provision of Services" dated 7/11 revealed in part, "...To assure services, whether provided directly by Mercy Medical Center - Centerville or by arrangement, are available to ensure safe and efficient operations...Sleep Services A = Services provided by arrangement."

Review of document titled "Policy and Procedure Development and Review" dated 7/6/11, revealed in part, "...All policies and procedures will be presented to the CAH advisory Committee for annual review and approval."


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Review of the CAH Board of Directors Meeting Minutes lacked documentation for reviewing and approving sleep study policies and procedures since 1/30/2009.

Review of the CAH Quality Improvement Meeting Minutes, 1/1 to 6/30/2011 revealed active participation from the sleep study department in the overall quality improvement program.

Based on review of policies, medical records and staff interviews the Critical Access Hospital (CAH) nursing staff failed to ensure the accuracy of the documentation for narcotics given per Patient Controlled Analgesic (PCA) pump.

The CAH administrative staff reported a census of 10 in-patients with a daily average of 12 in-patients. The administrative staff could not provide the average patient use of a PCA pump.

Patient-controlled analgesia (PCA) is a means for the patient to self-administer pain medications intravenously by using a computerized pump, which introduces specific doses into the vein. The purpose of PCA is improved pain control. The patient receives immediate delivery of pain medication without the need for a nurse to administer it. The patient controls when the medication is given. Failure to ensure documented accuracy of a narcotic could potentially lead to a lack of consistent care, the inability to evaluate the effectiveness of the pain therapy and potential medication theft.

Findings for 1 of 1 in-patient's PCA record, (Patient #16) and 1 of 1 closed patient's PCA record, (Patient #19) reviewed include:

1. Review of "Patient Controlled Analgesia (PCA) management Protocol", effective dates 1/11 and 8/11 revealed in part, "...validate correct medication/concentration and pump setting with initial setup, with syringe/bag change, and with any change in medication or settings. This must be documented by two nurses, one of which must be a R.N. [Registered Nurse]. Pump setting must also be validated by two nurses immediately upon transfer to a new unit...
Validate the following every shift with patients using a PCA pump:...
correct settings,
loading dose if applicable
basal/continuous dose, if applicable...
Documentation:...
record PCA medication infusion on the PCA Flowsheet when started...
enter credit on PCA Flowsheet at end of each shift...
upon discontinuing PCA, WASTE remainder of opioid with 2 nurses and document waste in the Omnicell and on the PCA Flow sheet as appropriate..."

2. During an interview on 8/10/11 at 4:00 PM, Staff J, RN Medical/Surgical unit manager, stated, the statements, "with syringe/bag change, and with any change in medication or settings. Pump setting must also be validated by two nurses immediately upon transfer to a new unit," in the PCA management protocol were not included in the 1/11 policy, they were added in the updated 8/11 policy after the inaccurate documentation for the PCA pumps was brought to his/her attention.

3. Review of "Medication" effective 8/11 revealed in part, "...Medication and mediation administration techniques that are high alert or problem prone, must be checked and verified by two licensed medical professionals prior to administration. Both professionals initialing the med entry on the chart will indicate documentation of this process...
processes include...Analgesics given by PCA pump (drug, drug concentration, pump setting and dosages)...
if a Class II drug...is wasted; it must be verified and witnessed by another Licensed Nurse in the Omnicell..."

4. Review of Patient #16's medical record revealed the patient received narcotic pain analgesics per a PCA from 8/3/11 to 8/9/11. Patient #16's PCA Flowsheet revealed an order for Morphine 1 mg/ml-30 ml PCA syringe with PCA dose of 1 mg each 10 minutes up to 24 mg per 4 hours.

Nursing staff failed to accurately calculate and document the morphine used in the PCA pump.

a. Patient #16's PCA Flowsheet for Morphine revealed:

8/3/11 at 1:30 PM, 12 mg of morphine left in the PCA syringe.

8/4/11 at 12:15 AM, no morphine given, no morphine left in pump and a new 30 mg syringe placed in PCA. The PCA Flowsheet lacked documented evidence that staff wasted or what happened to the 12 mg of morphine.

8/4/11 at 5:50 AM, 5 mg of morphine given but 29 mg of morphine left in the 30 mg syringe. The PCA Flowsheet lacked documentation that showed why 29 mg of morphine was left when 5 mg had been used (5 mg from 30 mg should leave 25 mg).

8/5/11 at 12:10 AM, 6 mg of morphine in syringe at beginning of shift, 5.3 mg used and a new syringe of 30 mg placed. The PCA Flowsheet lacked documentation that showed nursing staff wasted the remaining 0.7 mg of morphine.

8/5/11 at 3:00 PM, 7 mg of morphine used out of the 30 mg syringe with 25 mg left. The PCA Flowsheet lacked documentation that showed why 25 mg of morphine was left in the syringe when 7 mg had been used (7 mg from 30 mg should leave 23 mg).

8/6/11 at 5:35 AM, 16 mg of morphine remained in syringe at the end of shift.

8/6/11 no time noted, 12 mg of morphine used with 3 left in syringe. The PCA Flowsheet lacked documentation that showed why 3 mg of morphine was left when 12 mg had been used (12 mg from 16 mg should leave 4 mg).

8/6/11 at 7:00 PM, 3 mg used and new 30 mg morphine syringe placed.

8/6/11 at 8:47 PM, 2 mg used and 30 mg left in syringe. The PCA Flowsheet lacked documentation that showed why 30 mg of morphine was left when 2 mg had been used (2 mg from 30 mg should leave 28 mg).

8/8/11 at 4:30 AM, 25 mg of morphine left in syringe of PCA pump.

8/8/11 at 1:30 PM, 14 mg given and 13 mg left in syringe. The PCA Flowsheet lacked documentation that showed why 13 mg of morphine left when 14 mg had been removed (14 mg from 25 mg should leave 11 mg).

8/9/11 not timed, 1 mg used and a line drawn through the box of mg left in syringe (1 mg from 11 mg should leave 10 mg).

8/9/11 not timed, 3.7 mg used, 0 left in syringe and order discontinued (3.7 mg from 10 mg should leave 6.3 mg).

b. During an interview on 8/8/11 at 9:30 AM, Staff J, acknowledged the inaccurate documentation of the PCA Flowsheet. Staff J acknowledged the inaccurate documentation represented approximately 30 mg of morphine that was unaccounted for. Staff J stated, the nurses have a lot of work to do, the nurses need to check the syringe and log for accuracy.

c. During a follow up interview on 8/10/11 at 4:00 PM, Staff J stated, after speaking with some of the nurses I discovered that some nurses read the syringe and some read the pump, this may have lead to the discrepancy.

d. Review of an incident report dated 8/10/11, revealed in part, "[Patient]/family notified: no-patient was not overdosed only had to do with documentation...
possible cont [contributing] factor: some nurses read the vial and some read the pump. the pump reads out in tenths and to the eye a nurse may see 4 when it is really 3.7 or vice versa. This may have led to the discrepancy documented..."

3. Review of Patient #19's medical record revealed the patient received narcotic pain analgesics per a PCA from 1/9/11 to 1/12/11. A physician's order dated 1/9/11 revealed a PCA order for Meperidine 10 mg per 1 ml every 10 minutes with 6 ml per hour.

Nursing staff failed to accurately calculate and document the Meperidine used in the PCA pump.

a. Patient #19's PCA Flowsheet for Meperidine revealed:

The PCA Flowsheet lacked documentation that showed nursing staff placed the initial Meperidine syringe on 1/9/11 at Noon. Additionally, the PCA Flowsheet lacked end of shift documentation that reflected the amount of Meperidine used and/or the amount of Meperidine left in the syringe at the end of each shift.

1/9/11 at 9:00 PM, the patient used 20 mg of Meperidine and 26 ml remained in the syringe at end of shift. The PCA Flowsheet lacked documentation that showed why 26 ml of Meperidine was left when 20 mg had been removed (10 mg per 1 ml would be 2 ml removed),

1/11/11 not timed, 20 mg used and 24 ml left at end of shift,

1/11/11 not timed, none used, 24 ml left end of shift,

1/12/11 time, amount used and amount remaining boxes were empty.

b. Review of the physician's order showed the physician had discontinued the Meperidine PCA.

c. Record of waste on PCA Flowsheet lacked documented evidence of the wastage for 24 ml of Meperidine

d. During an interview on 8/11/11 at 8:45 AM, Staff J stated nursing staff should have entered the initial syringe on the PCA Flowsheet then documented a separate entry when the next shift came on. Staff J acknowledged that nursing staff had inaccurately documented the Meperidine administration on the PCA Flowsheet, as well as, failed to document wasting the remaining 24 ml of Meperidine when they discontinued the PCA.

4. During an interview on 8/10/11 at 3:30 PM, Staff N, Pharmacist, stated PCA medication could not be wasted in the Omni Cell, the syringe could have been removed days prior and the Omnicell would not be able to go back to retrieve that information. Staff N stated, the policy needed to be updated to reflect this. Staff N stated the nurses needed to document the waste on the PCA Flowsheet.

5. Staff N reviewed the PCA Flowsheets and stated the nursing staff need to be more attentive to their documentation. Staff N stated, "I'm not sure where the nurses are getting these numbers for the mg given and mg left, the machine or the syringe. I don't understand where the numbers came from." Staff N acknowledged the PCA Flowsheets lacked accurate documentation.

6. On 8/11/11 at 9:00 AM, Staff J provided a document titled, "Care Conference" dated 8/10/11. The document stated Staff J held discussions on the importance of accuracy with documentation on the PCA pump Flowsheet. The staff verbalized understanding and acknowledged the updated PCA record and policy.

7. During a follow up interview on 811/11 at 10:30 AM, Staff J acknowledged the lack of consistency of the PCA pump documentation. Staff J acknowledged the discrepancies and the missing medications due to this inaccurate documentation of the PCA pump medications. Staff J reviewed the PCA Flowsheets then stated, the PCA Flowsheet and policies needed to be updated to ensure the accuracy in the calculations of the medications. Staff J indicated the nursing staff will have meetings regarding the PCA pumps and documenting accurately so missing medications are not due to a lack of inadequate documentation.

I. Based on review of policies, documents, clinical records, and observation, the Critical Access Hospital (CAH) staff failed to follow physician's orders for diets documented in 2 of 10 patient's medical records, (Patient #1 and #2). The CAH administrative staff reported a census of 10 patients, with an average daily census of 12.

Failure to follow the physician's order for a diet could potentially result in patient complications including in part, high or low blood sugar, missed tests and/or delayed surgical procedures, and potential malnutrition.

Findings include:

Review of the nursing service CAH policy titled "Physician's Orders", reviewed and approved in 7/11, revealed in part "... 1. ... Orders must be noted with date and time and signature of RN or LPN ... who is then legally responsible for the implementation and accuracy of the orders. ... 2. Verbal or telephone orders may be accepted by an RN, LPN or paramedic and must be written on the Physician's Order Sheet."

Review of the nutritional services CAH policy titled "Confirmation of Verbal Diet Orders", reviewed and approved in 7/11, revealed in part "... The verbal orders given by the physician for the patient's diet and recorded by Nursing or the Dietitian have to be read back and verified to the physician. It is the responsibility of the Nurse or Dietitian to ensure this is confirmed/recorded/signed. ... All orders for diets must be documented on the physician's order sheet in the patient's medical record."

Review of the nutritional services CAH policy titled "Diet Orders", reviewed and approved in 7/11, revealed in part "... A written order signed by the attending physician is necessary to initiate, change or renew any diet."

Review of the nutritional services CAH policy titled "Diet Manual and Nutritional Evaluation", reviewed and approved in 7/11, revealed in part "... Confirmation of the patient's diet order is the responsibility of the unit secretary and/or nursing staff."

Review of the document titled "Diet Census Report" revealed a diet order for Soft/Surgical Soft, ordered at 11:54 AM on 8/9/11 for Patient #1. Previous diet orders included clear liquid ordered at 3:47 PM on 8/8/11 and NPO (nothing by mouth) ordered at 3:44 PM.

Review of the document titled "Diet Census Report" revealed a diet order for full liquids ordered at 9:14 AM on 8/8/11 for Patient #1. A previous diet order included NPO ordered at 2:40 AM on 8/7/11.

Review of Patient #1's clinical record, in the presence of Staff J, Med/Surg Unit Manager, revealed admission orders including a diet order of NPO, ordered on 8/8/11. Review of the subsequent physician's orders revealed no written order for a clear liquid diet or Soft/Surgical Soft diet, as indicated on the document titled "Diet Census Report." The clinical record document titled "Acute Daily Assessment Sheet" included an entry, on 8/8/11 at 5:30 PM, stating a clear liquid diet served and tolerated well. An additional entry, on 8/9/11 at 8:00 AM, noted the patient took 100% of surgical soft diet and tolerated well. Staff J concurred the diet order on the clinical record did not match the current diet order on the Diet Census Report.

Review of Patient #2's clinical record, in the presence of Staff J, revealed the admission orders included a diet order of ADA 2000 calories. Review of the subsequent physician's orders revealed no written order for NPO or full liquid as listed on the document titled "Diet Census Report". Staff J concurred the diet order on the clinical record did not match the current diet order on the Diet Census Report.

Observation of meal service on 8/10/11 at 11:10 AM, revealed the dietary cardex and tray card for Patient #1 listed a diet order of Surgical Soft. The patient received a Surgical soft meal. The dietary cardex and tray card for Patient #2 listed a diet order of full liquid. The patient received a full liquid diet.

During an interview on 8/10/11 at 8:00 AM, Staff A, Nutritional Services Manager, reported dietary staff require a computer generated diet order before a meal tray is served.

During an interview on 8/10/11 at 1:30 PM, Staff B, Director of Nutritional Services/Dietitian, reported he/she had noted, diet orders on the clinical record do not always match the diet order on the nursing cardex. He/she further reported the diet order on the nursing cardex failed to match the diet order communicated to the kitchen.

During an interview on 8/10/11 at 9:10 AM Staff J reported the lack of a documented diet order changes may have occurred if a verbal order was taken from the physician and the RN failed to document the order on the clinical record, as required.

During an interview on 8/10/11 at 3:00 PM with Staff J and Staff C, Ward Clerk, Staff J reported confirmation, with Patient #1's physician, that diet advancement was ordered on 8/8 to clear liquid and to further advance to surgical soft, if clear liquids tolerated. Staff J reported the RN directed the ward clerk to enter the diet order into the computer and change on the diet order nursing cardex, but failed to document the verbal order in the clinical record. Staff C confirmed the details of the occurrence and reported the usual procedure for any physician order begins with the written order, which generated the computer entry and nursing cardex entry. The RN then noted the order in the clinical record and verified staff made the appropriate changes.

II. Based on review of policies, documents, observation, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure availability of the approved CAH diet manual to medical and nursing staff in 2 of 2 patient care areas. The CAH administrative staff reported a census of 10 patients, with an average daily census of 12. The Director of Nutritional Services and Nutritional Services Manager reported an average of 5 therapeutic diets served daily.

Failure to ensure availability of a diet manual to medical and nursing staff could potentially result in foods served to patients that are inappropriate and/or harmful to their medical condition.

Findings include:

Review of the CAH's nutritional services policy titled "Diet Manual and Nutritional Evaluation," reviewed and approved in 7/11, revealed in part, "Policy: The Nutritional Services Diet Manual shall serve as an effective resource to provide education and direction for appropriate nutritional care to the patient population. The Diet Manual will be located on each patient care unit. ... A copy of the Diet Manual is kept at each nursing station, clinical dietitian's desk, diet clerk's desk, dietary manager's office and the medical library."

During an interview on 8/10/11 at 8:00 AM, Staff A reported uncertainty as to the location of the CAH diet manual on the patient care units. Staff A referred the surveyor to Staff B.

During an interview on 8/10/11 at 9:05 AM, Staff B reported uncertainty as to the location of the CAH diet manual on the patient care units. Staff B referred the surveyor to staff J.

During an interview on 8/10/11 at 9:10 AM, Staff J verified the lack of a CAH diet manual on patient care units. Staff J further reported patient care units had previously stored diet information, but the information became outdated and discarded. Staff J relayed nursing and medical staff may utilize e-clinical reference (an on-line computer site), as needed, for diet-related questions.

During an interview on 8/10/11 at 1:30 PM, Staff B confirmed the lack of availability of the CAH diet manual on patient care units. He/she concurred the lack of a diet reference could result in the inability of nursing staff to provide patients with food and/or beverages appropriate for their specific therapeutic diet, when dietary staff and the facility dietitian are not available.

Based on review of contracts/agreements, documents and policies, the Critical Access Hospital (CAH) administrative staff failed to ensure a contract/agreement was in place with the entity that provided sleep lab services to the inpatients of the CAH.

Mercy Medical Center Centerville is a CAH with sleep study services provided under the hospital license. The CAH must have an agreement/contract with an entity that provides services to the CAH patients, such as sleep studies, to ensure the safe and effective provision of care to the CAH patients. Contracts provide for consistency in care and services and delineate responsibilities and accountabilities between the contracted entity and CAH for the provision of patient care. Failure to ensure a contract was in place between the CAH and the Mercy Medical Center Des Moines sleep technicians providing care to the CAH ' s sleep study inpatients could potentially result in lack of communication regarding the patient ' s condition, sleep study results, and follow up professional services, as well as, the lack of coordination of patient care which could result in poor patient outcomes.

The CAH administrative staff reported Sleep Study inpatient census of approximately 3 patients weekly.

Findings include:

1. The CAH administrative staff provided a list of contracts upon entrance. The list failed to acknowledge a Sleep Study Contract.

2. Review of documentation presented by the Chief Operating Officer (COO) to the survey team on 8/10/11, titled "Summary of Services related to Sleep Lab", revealed in part, "...Our sleep lab department was started in October 2008...Our MBO Mercy Medical Center Des Moines sleep technicians travel to Mercy Centerville to perform the technical studies..Beyond that, we are unique from other CAH hospitals in Iowa as Catholic Health Initiatives (CHI) and Mercy Des Moines is our parent company...We are unique in that we don't have a separate management contract for our sleep lab services with an independent company...We have access to staffing throughout Mercy and based on need we have had to utilize Des Moines staffing, etc to support our local services."

3. Review of CAH policy, "Review of Contract Services" dated 7/11 revealed in part, "...When the hospital does not employ a qualified professional person to render specific service to be provided by the hospital, arrangements shall be made for such a service through a written agreement with an outside source. The responsibilities, functions, objectives and terms of agreement, including financial arrangements and charges of each outside resource, shall all be delineated in writing and signed by an authorized representative of the hospital and the person or the agency providing the service. The agreement shall specify that the hospital retain professional and administrative responsibility for the services rendered."

I. Based on review of policies, job description, medical records and staff interviews, the Critical Access Hospital (CAH) staff (Administrative, Patient Registration and Information Clerk) failed to ensure the CAH patients signed an informed consent prior to treatments and services in the skilled care unit, Special Care Unit (SCU) Rehab Therapies unit and Sleep Study Unit.

The CAH administrative staff reported a skilled in-patient census of 3 with a daily average of 4 skilled in-patients. The CAH administrative staff reported no special care unit patients at the time of the survey, but reported a weekly average of 5 patients.

The Rehab Director reported a monthly inpatient census of approximately 5 Occupational Therapy (OT) patients and 2 Speech Therapy (ST) patients.

The Sleep Study Clinical Supervisor reported a weekly inpatient census of approximately 3 Sleep Study patients.

Informed consent means the CAH gave the patient or patient's representative the information, explanations, consequences, and options needed in order to consent to a procedure or treatment. Informed consent forms containing required information provide written evidence the CAH informed the patient or the patient's representative of the information, explanations, consequences, and options and that the patient or patient representative consented to the procedure or treatment. Failure to provide the patient with information needed to make an informed decision could potentially result in the patient receiving a treatment or procedure which the patient did not want or agree to which could cause the patient adverse physical and/or mental outcomes.

Findings for:
4 of 5 closed skilled care medical records reviewed (Patients #11, #12, #13 and #14)
2 of 5 SCU patients (Patients #20 and #21)
1 of 6 closed inpatient OT medical records reviewed (Patient #31)
1 of 3 closed outpatient ST medical records reviewed (Patient #32)
5 of 5 inpatient sleep study patients (Patients #33, #34, #35, #36 and #37)

1. The CAH staff use job descriptions and policies and procedures to provide guidance for consistent and continuity of patient care. Review of these policies and procedure revealed the following information:

a. Review of the job description, "Case Manager"dated 6/10, revealed the following in part, "...Assists in obtaining patient admission information and signatures..."

b. Review of the job description, "Information Clerk "revealed the following in part, "...Registers/Admits all inpatients..."

c. Review of the job description, "Patient Account Rep/Registration Clerk" revealed the following in part, "...Registers patients in the patient accounting system..."

d. Review of CAH policy, "Documentation in the Medical Record" dated 7/11, revealed the following in part, "...The completed medical record must contain...consent to treat...Informed consent - The medical record must reflect evidence of properly executed informed consents ...informed consent is a legal and ethical precondition for medical treatments..."

2. Review of Patient #31's inpatient medial record revealed an admission date of 5/26/11 and a physicians order for inpatient OT services dated 6/1/11. Patient #31's medical record lacked a dated and signed informed consent for admission and inpatient OT services.

During an interview on 8/10/11 at 4:10 PM, Staff L verified the medical records lacked a dated and signed informed consent sheet. Staff L stated nursing staff were responsible for ensuring patients signed and dated the informed consent sheet before receiving OT services.

3. Review of Patient #32's outpatient medical record revealed a physicians order for outpatient ST treatment dated 1/13/11. Patient #32's medical record lacked dated and signed informed consent for admission and inpatient ST services.

During an interview on 8/10/11 at 4:10 PM, Staff L verified the medical records lacked a dated and signed informed consent sheet. Staff L stated nursing staff were responsible for ensuring the medical records contained dated and signed informed consent sheet for the ST services.

4. Review of Patients #33, #34, #35, #36, and #37's medical records revealed Patients #33, #34, #35, #36 and #37 received sleep study treatment while in the CAH. However, the medical records lacked a dated and signed informed consent sheet for sleep study treatment.

During an interview on 8/10/11 at 3:40 PM, Staff L stated sleep study patients register at the switchboard operator's desk. Staff L verified the medical records lacked dated and signed informed consent sheets and stated, switchboard personnel were responsible for ensuring patients signed the consents before admission to the CAH for treatment. Staff L stated, "The registration and switchboard staffs are trained on the processes for registration including consents for treatments."



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5. Review of Patients #11, #12, #13 and #14 skilled medical records revealed Patients #11, #12, #13 and #14 received skilled care treatment while in the CAH. However, the medical records lacked a dated and signed informed consent form for the skilled care treatment.

a. Patient #11's medical record showed Patient #11 had a skilled care admission date of 9/28/10 and discharged on 10/4/10 due to Respiratory distress. Review of documentation from 9/28/10 to 10/4/10 in the CAH medical record showed Patient #11 received Intravenous (IV) fluids and PT during this time.

Patient #11's medical record lacked a dated and signed informed consent for the skilled treatment received.

b. Patient #12's medical record showed Patient #12 had a skilled care admission date of 1/13/11 and discharged on 1/15/11 due to lower lobe Pneumonia. Review of documentation from 1/13/11 to 1/15/11 in the CAH medical record showed Patient #12 received IV medications during this time.

Patient #12's medical record lacked a dated and signed informed consent for the skilled treatment received.

c. Patient #13's medical record showed Patient #13 had a skilled care admission date of 11/17/10 and discharged on 11/22/10 due to recovery from surgery of a fractured right hip. Review of documentation from 11/17/10 to 11/22/10 in the CAH medical record showed Patient #11 received PT, Occupational Therapy (OT) and IV medications during this time.

Patient #13's medical record lacked a dated and signed informed consent for the skilled treatment received.

d. Patient #14's medical record showed Patient #14 had a skilled care admission date of 4/15/11 and discharged on 4/19/11 due to left knee prothesis displaced. Review of documentation from 4/15/11 to 4/19/11 in the CAH medical record showed Patient #14 received PT and OT during this time.

Patient #14's medical record lacked a dated and signed informed consent for the skilled treatment received.

6. During an interview on 8/10/11 at 1:35 PM, Staff M, RN-Case Manager, stated when the patient moves from acute care to skilled care the patient should sign another informed consent. Staff M stated, it was the responsibility of the case managers to ensure the patient signed the informed consent and when the case managers were not working it would be the responsibility of the admitting nurse.

a. During an interview on 8/10/11 at 4:00 PM, Staff J confirmed it was the case managers and/or the admitting nurse ' s responsibility to obtain the patient's signature for the informed consent. Staff J stated the process when a patient moves from acute care to skilled care was; the business office generates another demographic sheet with a new informed consent form for the patient to sign. Staff J reviewed skilled care Patients #11, #12, #13 and #14's medical records and acknowledged the informed consent forms lacked patient signatures.

b. During an interview on 8/10/11 at 4:10 PM, Staff L, Vice President of Staff Communication, stated the business office generated a new demographic sheet with a new consent for patients discharged from acute care, admitted to skilled care, and was the responsibility of nursing staff to ensure the patient signed the informed consent.

7. Review of Patients #20 and #21's SCU medical records revealed Patients #19 and #20 received care on the special care unit of the CAH. However, the medical records lacked a dated and signed informed consent form for the special care treatment.

a. Patient #20's medical record showed Patient #20 admitted to the special care unit on 1/23/11 and discharged on 1/23/11. Review of documentation on 1/23/11 in the CAH medical record showed Patient #20 received treatment in the special care unit for acute coronary syndrome with unstable angina prior to transfer to an acute hospital.

Patient #20's medical record lacked a dated and signed informed consent for the skilled treatment received.

b. Patient #21's medical record showed Patient #21 admitted to the special care unit on 11/20/10 and discharged on 11/20/10. Review of documentation on 11/20/10 in the CAH medical record showed Patient #21 received treatment in special care unit for chest pain prior to transfer to an acute hospital.

Patient #21's medical record lacked a dated and signed informed consent for the skilled treatment received.

During an interview on 8/10/11 at 10:30 AM, Staff J, Registered Nurse (RN) Medical/Surgical unit manager, stated the SCU nursing staff should have ensured patients signed the informed consents. Staff J stated the patient usually signed the informed consent at the registration office, but the staff nurses should make sure the patient signed the informed consent during their admission assessments. Staff J reviewed SCU Patient #19 and #20's medical records and acknowledged the informed consents forms lacked patient signatures.

II. Based on review of policies, job descriptions, medical records, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician completed the skilled certification and recertification form prior to treatments and services in the skilled care unit

The CAH administrative staff reported a skilled in-patient census of 3 with a daily average of 4 skilled in-patients.

Certification and recertification for Skilled Care Services must clearly indicate that post hospital skilled care services are required on an inpatient basis because of the individual's need for skilled care. The patient's need of skilled care on a continuing basis for any of the conditions for which he/she was receiving inpatient hospital services, including services of an emergency hospital prior to transfer to the Skilled unit. Staff needs to obtain certifications at the time of admission. The routine admission procedure followed by a physician would not be sufficient certification of the necessity for post hospital skilled care services for purposes of the Medicare program.

Failure to obtain the completed certification and recertification statements could potentially result in non-payment by Medicare for the services provided.

Findings in 3 of 3 skilled in-patients (Patient #16, 17, and 18) medical records and 5 of 7 closed skilled patients (Patient #11, 13, 14, 15, 30, and 31) medical records reviewed include:

1. The CAH staff use job descriptions to provide guidance for consistent and continuity of patient care. A review of the "Case Manager"dated 6/10, revealed the following in part, "...Assists in obtaining patient admission information and signatures..."

2. Review of Patient #11, 13, 14, 15, 16, 17, 18, 30, and 30's medical records revealed Patient #11, 13, 14, 15, 16, 17, 18, 30, and 31 received skilled cares while in the CAH. However, the medical records for Patients Patient #11, 13, 15, 18, 30 and 31 lacked a completed skilled certification and recertification form for skilled care and Patients # 14, 16, and 17's medical record lacked a Physician signed and dated skilled certification and recertification form.

a. Patient #11's skilled medical record revealed Patient 11's admission to the skilled care unit, due to respiratory distress, from 9/28/10 to 10/4/10 for PT and IV fluids. However, the physician failed to check the "yes" box indicating the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #11's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care.

b. Patient #13's skilled medical record revealed Patient 13's admission to the skilled care unit, due to right hip fracture, from 11/17/10 to 11/22/10 for PT, OT, and IV medication. However, the physician failed to check the "yes" box indicating the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #13's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care.

c. Patient #15's skilled medical record revealed Patient 15 received skilled care, due to right hip fracture, from 10/14/10 to 10/25/10 for PT and OT. However, the physician failed to check the "yes" box indicating the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #15's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care.

d. Patient #18's skilled medical record revealed Patient 18's admission to the skilled care unit, due to increased weakness, on 8/3/11 for IV (Intravenous) medications and PT. However, the physician failed to check the "yes" box indicating the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #18's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care.

e. Patient #30's skilled medical record revealed Patient #30's admission date to the skilled care unit due to status post (S/P) fracture repair of the right leg, on 4/29/11. However, the physician failed to check the "yes" box indicating the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #30's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care.

f. Patient #31's skilled medical record revealed Patient #31's admission date to the skilled care unit due to S/P sepsis, on 5/26/11. However, the physician failed to document if the skilled care was for the same condition for which the patient received in-patient hospital services.

Patient #31's medical record lacked a completed skilled certification and recertification form to attest to the patients need for the extended skilled care

g. Patient #14's skilled medical record revealed Patient 14 received skilled care, due to left knee prosthesis displaced, from 4/15/11 to 4/19/11 for PT and OT. However, the medical record lacked a skilled certification and recertification form signed and dated by the Physician at the time of admission to skilled care.

Patient #14's medical record lacked a Physician signed and dated skilled certification and recertification form at the time of admission to skilled care to attest to the patient's need to receive the extended care.

h. Patient #16's skilled medical record revealed Patient 16's admission to the skilled care unit, due to low back pain, on 8/4/11 for pain control and Physical Therapy (PT). However, the medical record lacked a skilled certification and recertification form signed and dated by the Physician at the time of admission to skilled care.

Patient #16's medical record lacked a Physician signed and dated skilled certification and recertification form at the time of admission to skilled care to attest to the patient's need to receive the extended care.

i. Patient #17's skilled medical record revealed Patient 17's admission to the skilled care unit, due to total knee replacement, on 8/4/11 for PT, Occupational Therapy (OT). However, the medical record lacked a skilled certification and recertification form signed and dated by the Physician at the time of admission to skilled care.

Patient #17's medical record lacked a Physician signed and dated skilled certification and recertification form at the time of admission to skilled care to attest to the patient's need to receive the extended care.

3. During an interview on 8/10/11 at 11:55 AM, Staff Q, Risk Manager, stated the skilled certification box "should be checked yes or no"by the physician.

4. During an interview on 8/11/11 at 11:30 AM, Staff M, Case Manager, stated Physicians completed the skilled certification and recertification form at the time of admission of the skilled patient. Staff M stated the case managers are responsible to ensure the Physician sign and fill out the skilled certification and recertification form. Staff M stated the boxes "Yes, No" should be marked by the Physician. Staff M stated Patient #16 skilled certification and recertification form remained on his/her clipboard for the Physician to sign. Staff M confirmed Patient #16 admission date of 8/4/11, 7 days prior. Staff M looked through their clip board and stated they did not have Patient #14 and Patient #17's skilled certification and recertification forms.

5. During an interview on 8/11/11 at 11:35 AM, Staff R, Case Manager, acknowledged the skilled certification and recertification form needed to be completed at admission of the skilled patient and the "Yes, No" should be marked by the Physician. Staff R looked through their clip board and stated they did not have Patient #14 and Patient #17's skilled certification and recertification forms.

6. During a follow up interview on 8/11/11 at 11:45 AM, Staff Q reviewed Patient #14 and 17's medical records and acknowledged the skilled certification and recertification forms were not on the medical records. Staff Q acknowledged the skilled certification and recertification form needed to be completed at admission of the skilled patient and the "Yes, No" should be marked by the Physician. Staff Q stated, the case managers were responsible to ensure the completion of the skilled certification and recertification form.


22064

Based on review of documents, medical records, and staff interview, the CAH administrative staff failed to ensure all physicians authenticated, dated and timed all orders in the medical record.

The CAH administrative staff reported an average daily census of 4 skilled inpatients and 17 emergency room patients.

Failure to authenticate, date and or time record entries potentially could cause harm to patients by delay in treatments, actions or assessments provided.

Findings included:

1. Findings for 2 of 7 closed Skilled medical records reviewed (Patient #30 and #31) and 6 of 6 closed Emergency Department (ED) medical records reviewed (Patient #22, #23, #24, #25, #26 and #27) include:

a. Review of CAH policy, "Documentation in the Medical Record" dated 7/11 revealed in part, "...All verbal and telephone orders must be signed by the responsible practitioner. The orders need to be signed authenticated and signed by the prescribing practitioner as soon as possible but no later than 30 days post discharge."

b. Review of CAH Rules and Regulations of Medical Staff dated 11/5/10 revealed in part, "...All clinical entries in the patient's medical record shall be accurately dated, timed and signed."

2. Review of Patient #30's skilled medical record revealed an admission date of 4/29/11 for skilled nursing services and a discharge date of 5/6/11.

Patient #30's medical record lacked date and time for 2 of 9 physician's telephone/verbal orders.

3. Review of Patient #31's skilled medical record revealed an admission date of 5/26/11 for skilled nursing services and a discharge date of 6/16/11.

Patient #30's medical record lacked time for 1 of 14 physician's orders and 3 of 4 telephone/verbal orders.

4. Review of Patient #22's ED medical record revealed an admission and discharge date of 6/28/11.

Patient #22's medical record lacked date and time for physician notes and clinical work up order sheets.

5. Review of Patient #23's ED medical record revealed an admission and discharge date of 6/28/11.

Patient #23's medical record lacked date and time for physician notes.

6. Review of Patient #24's ED medical record revealed an admission and discharge date of 6/17/11.

Patient #24's medical record lacked date and time for physician notes and clinical work up order sheets.

7. Review of Patient #25's ED medical record revealed an admission and discharge date of 6/7/11.

Patient #25's medical record lacked date and time for physician notes and clinical work up order sheets.

8. Review of Patient #26's ED medical record revealed an admission and discharge date of 4/24/11.

Patient #26's medical record lacked date and time for physician notes and clinical work up order sheets.

9. Review of Patient #27's ED medical record revealed an admission and discharge date of 4/21/11.

Patient #27's medical record lacked date and time for physician notes and clinical work up order sheets.

During an interview on 8/10/11 at 10:05 AM, Staff Q, Risk Management verified the physician entries in the medical records lacked dates and times when the physician wrote orders. Staff Q stated, "All physician's orders and notes for these records need to be dated and timed."

Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) Health Information (HIM) staff failed to secure all medical records in the medical records department against unauthorized access. The CAH administrative staff reported an average daily census of approximately 12 patients.

Failure to secure medical records against unauthorized access could result in identify theft or unauthorized disclosure of personal medical information.

Findings include:

During an interview on 8/8/11 at 10:35 AM, Staff T, the HIM Manager stated housekeeping services staff cleaned the medical records department in the evening unsupervised. The HIM manager acknowledged that housekeeping services staff could access patient medical records and did not have a need to know the patient's medical information.

Tour of the medical records department on 8/8/11 from 10:00 AM to 11:00 AM, revealed 7 moveable shelving units which contained information including but not limited to patient names, date of birth, medical record number, and copious confidential medical diagnosis etc. During a interview, at the time of the observations, the HIM manager stated the shelving units contained approximately 59,938 closed medical records and housekeeping services staff cleaned the department in the evening unsupervised. The HIM manager acknowledged that housekeeping services staff could access information contained in the shelving units and did not have a need to know the patient's medical information.

During an interview on 8/8/11 at 10:35 AM, the HIM manager acknowledged active patient medical records were located "all over this department." and reported there were approximately "two to three hundred active patient files" located in the department at the time of the interview. The HIM manager acknowledged that housekeeping services staff could access patient medical records and did not have a need to know the patient's medical information.

Review of CAH policy, "Security of Medical Records" dated 7/11, revealed the following in part, "...All medical records will be secured."

I. Based on review of policies, medical records and staff interviews, the Critical Access Hospital (CAH) activity staff failed to complete a comprehensive assessment necessary to develop a care plan, to provide the appropriate and consistent care and services for each patient's individual needs.

Patient comprehensive assessments is used to determine the necessity of the service, the patient's needs, guide treatment, identify the patient's strengths, needs and interest and must be obtained or completed as necessary to be considered current. The comprehensive assessment information is then used for evaluation purposes to give consistent care and to meet the individual needs of the patient. Failure to complete an activity comprehensive assessment could potentially neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 3 swing-bed patients with a daily average of 4 swing-bed in-patients

Findings for 3 of 3 swing-bed patients (Patient #16, #17, and #18 ) medical records and 5 of 5 closed swing-bed patients (Patient # 11, 12, 13, 14 and 15 ) medical records reviewed include:

1. The CAH staff use the policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

a. "Resident Assessments" dated 7/05 revealed in part, "...will conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity...comprehensive assessment of resident's needs will include the following: customary routine, mood and behavior patterns, psychosocial well-being, activity pursuit...assessment process must include...communication with licensed and non-licensed direct care staff..."

b. "Resident Activities" dated 6/09 revealed in part, "...on-going program of activities...in accordance with the comprehensive assessment, the interest and physical, mental and psychosocial well-being of each resident..."

2. Review of Patients #11, 12, 13, 14, 15, 16, 17, and #18's medical records revealed Patients #11, 12, 13, 14, 15, 16, 17, and #18 admission to swing-bed level of care while in the CAH. However, the medical records lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

a. Patient #16's swing-bed medical record revealed Patient #16's admission to swing-bed level of care, due to low back pain, on 8/4/11 for pain control and Physical Therapy (PT). Patient #16's medical record revealed a Physician order dated 8/4/11 for an "activity Coord [coordinator] Consult". The medical record revealed an unsigned activity note dated 8/5/11 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #16's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

b. Patient #17's swing-bed medical record revealed Patient #17's admission to swing-bed level of care, due to total knee replacement, on 8/4/11 for PT, Occupational Therapy (OT). Patient #17's medical record revealed a Physician order dated 8/4/11 for a "Consult activity Coord." The medical record revealed an activity note dated 8/5/11 and 8/8/11 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #17's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

c. Patient #18's swing-bed medical record revealed Patient #18's admission to swing-bed level of care, due to increased weakness, on 8/3/11 for IV (Intravenous) medications and PT. Patient #18's medical record revealed a Physician order dated 8/3/11 for a "Consult activity Coord." The medical record revealed an activity note dated 8/3/11 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #18's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

d. Patient #11's swing-bed medical record revealed Patient #11's admission to swing-bed level of care, due to respiratory distress, from 9/28/10 to 10/4/10 for PT and IV fluids. Patient #11's medical record revealed a Physician order dated 9/28/10 for a "Consult activity Coord." The medical record revealed an activity note dated 9/27/10 and 10/1/10 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #11's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

e. Patient #12's swing-bed medical record revealed Patient #12's admission to swing-bed level of care, due to right lower lobe pneumonia, from 1/13/11 to 1/15/11 for IV medication. Patient #12's medical record revealed a Physician order dated 1/13/11 for an "activity Coordinator Consult". The medical record revealed an activity note dated 1/13/11 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #12's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

f. Patient #13's swing-bed medical record revealed Patient #13's admission to swing-bed level of care, due to right hip fracture, from 11/17/10 to 11/22/10 for PT, OT and IV medication. Patient #13's medical record revealed a Physician order dated 11/17/10 for an "activity Coordinator Consult". The medical record revealed an activity note dated 11/17/10 and 11/22/10 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #13's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

g. Patient #14's swing-bed medical record revealed Patient #14 received swing-bed level of care, due to left knee prosthesis displaced, from 4/15/11 to 4/19/11 for PT and OT. Patient #14's medical record revealed a Physician order dated 4/15/11 for an "activity Coordinator Consult". The medical record revealed an activity note dated 4/18/11 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #14's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

h. Patient #15's swing-bed medical record revealed Patient #15 received swing-bed level of care, due to right hip fracture, from 10/14/10 to 10/25/10 for PT and OT. Patient #15's medical record revealed a Physician order dated 10/14/10 for an "activity Coordinator Consult." The medical record revealed an activity note dated 10/15/10, 10/20/10 and 10/22/10 but lacked a comprehensive assessment that included the activity interests of the patient.

Patient #14's medical record lacked a comprehensive activity assessment during the patient's admission to swing-bed level of care.

3. Although the activity Coordinator was not present at the time of the survey, the staff member taking on the responsibility of Activity Coordinator and the Medical Surgical unit manager were available for interview.

a. During an interview on 8/8/11 at 2:45 PM, Staff I, Registered Nurse (RN)-Long Term Care (LTC) Director of Nursing (DON), stated since the Activity Coordinator was a patient in the hospital, Staff I took on these responsibilities. Staff I stated the initial visit would be the start of the patient's activity assessment. Staff I stated the activity assessment completed at the initial visit consisted of introduction of the Activity Coordinator and providing a calendar for scheduled activities. Staff I stated all documentation for Activities would be in the medical record under the interdisciplinary progress notes.

b. During an interview on 8/9/11 at 10:45 AM, Staff J, RN Medical/Surgical unit manager, stated the Activity Coordinator needed to complete a comprehensive assessment of the swing-bed patient not just introduce themselves and give the patient a calendar. Staff J stated without a comprehensive assessment, the Activity Coordinator would not be aware of activity interest the patient may have.

c. During an interview on 8/10/11 at 1:10 PM, Staff K, DON reviewed the medical records for Patients #11, 12, 13, 14, 15, 16, 17, and #18 and acknowledged the activity assessment needed to be a more comprehensive assessment to reflect the patient activity interest.

II. Based on review of policies, medical records and staff interviews, the Critical Access Hospital (CAH) Social Worker failed to complete a comprehensive assessment necessary to develop a care plan, to provide the appropriate and consistent care and services for each patient's individual needs.

Patient comprehensive assessment is used to determine the necessity of the service, the patient's needs, guide treatment, identify the patient's strengths, needs and interest and must be obtained or completed as necessary to be considered current. The comprehensive assessment information is then used for evaluation purposes to give consistent care and to meet the individual needs of the patient. The Social Workers failure to complete a comprehensive assessment could potentially neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 3 swing-bed patients with a daily average of 4 swing-bed patients.

Findings for 3 of 3 swing-bed patient's (Patient #16, #17, and #18 ) medical records reviewed include:

1. The CAH staff use the policies and procedures to provide guidance to the staff for consistent and continuity of care. Review of these policies and procedure revealed:

a. "Resident Assessments" dated 7/05 revealed in part, "...will conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity...comprehensive assessment of resident's needs will include the following: customary routine, mood and behavior patterns, psychosocial well-being, activity pursuit...
assessment process must include...communication with licensed and non-licensed direct care staff..."

b. "Social Services" dated 7/05 revealed in part, "...all residents admitted to skilled care will have a social services assessment implemented..."

2. Review of Patients #16, 17, and 18's medical records revealed Patients #16, 17, and 18 received swing-bed level of care while in the CAH. However, the medical records lacked a comprehensive assessment by the Social Worker during the patient's admission in swing-bed level of care.

a. Patient #16's skilled medical record revealed Patient #16's admission to swing-bed level of care, due to low back pain, on 8/4/11 for pain control and Physical Therapy (PT). The medical record revealed an undated form "Patient Assessment and discharge Plan" signed by the Social Worker. The Patient Assessment and Discharge Plan revealed, "Plan discussed with family" dated 8/2/11, 2 days prior to admission to swing-bed level of care.

Patient # 16's medical record lacked a comprehensive assessment by the Social Worker during the patient's stay in swing-bed level of care.

b. Patient #17's swing-bed medical record revealed Patient #17's admission to swing-bed level of care, due to total knee replacement, on 8/4/11 for PT, Occupational Therapy (OT). The medical record revealed an undated form "Patient Assessment and discharge Plan" signed by the Social Worker. The Patient Assessment and Discharge Plan revealed, "Plan discussed with family" dated 8/1/11, 3 days prior to admission to swing-bed level of care.

Patient #17's medical record lacked a comprehensive assessment by the Social Worker during the patient's stay in swing-bed level of care.

c. Patient #18's swing-bed medical record revealed Patient #18's admission to swing-bed level of care, due to increased weakness, on 8/3/11 for IV (Intravenous) medications and PT. The medical record revealed an undated form "Patient Assessment and discharge Plan" signed by the Social Worker. The Patient Assessment and Discharge Plan revealed, "Plan discussed with family" dated 8/1/11, 2 days prior to admission to swing-bed level of care.

Patient #18's medical record lacked a comprehensive assessment by the Social Worker during the patient's stay in swing-bed level of care.

3. During an interview on 8/9/11 at 10:30 AM, Staff O, Social Worker, stated if the patient's condition does not change when moved from Acute care to Skilled Care, the "Patient Assessment and discharge Plan" form would not be updated nor does he/she document on the patient's record. Staff O stated the CAH policy instructs the Social Worker to visit the patient when they go skilled and to assist with discharge plans. Staff O stated, he/she does visit the patient, but since there is not documentation on the record of these visits, it looks like the Social Worker doesn't visit with the patient. Staff O stated, "I guess it would be good to document these visits."

4. During an interview on 8/9/11 at 10:45 PM, Staff J, Registered Nurse (RN) Medical/Surgical unit Manager, stated the Social Worker needed to complete a comprehensive assessment for all patients admitted to skilled.

5. In a follow up interview on 8/10/11 at 11:50 AM, Staff J stated the Social Worker's charting needed to be more detailed with documentation to show their visits to the patient. Staff J reviewed Patients #16, #17 and #18's medical records and acknowledged the medical records lacked a Social Worker's comprehensive assessment during the patient's admission to the skilled unit.

Based on review of policies, swing-bed clinical records, swing-bed care plans, and staff interviews the Critical Access Hospital (CAH) activity staff failed to ensure swing-bed patient's activity care plans were individualized to meet the patient's mental and psychosocial needs gathered from the activity comprehensive assessment.

The activity assessment determines the content of the care plan. All swing-bed patients should have an activity care plan with individual activity-related interventions gathered from the information in the comprehensive assessment. The individualized care plans sets realistic, measurable goals, patient interventions and should be patient-centered driven. Failure to create individualized activity care plans for swing-bed patients could potentially neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 3 swing-bed patients with a daily average of 4 swing-bed patients

Findings for 3 of 3 swing-bed patients (Patient #16, #17, and #18) medical records and 5 of 5 closed swing-bed patients (Patient # 11, 12, 13, 14 and 15) medical records reviewed include:

1. The CAH staff use the policies and procedures to provide guidance to the staff for consistent and continuity of care. A review of these policies and procedure revealed:

a. "Swing-bed Skilled Comprehensive Care Plans" effective date 6/09 revealed in part, "...comprehensive care plan that includes measurable objectives and timetables to meet a resident's...mental and psychosocial needs that are identified in a comprehensive assessment..."

b. "Resident Activities" effective date 6/09 revealed in part, "...the activities program will be multi-faceted and reflect individual resident's needs on their care plan..."

2. Review of Patients #11, 12, 13, 14, 15, 16, 17, and #18's medical records revealed Patients #11, 12, 13, 14, 15, 16, 17, and #18 received swing-bed level of care while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the swing-bed patient's hospital stay.

a. Patient #16's swing-bed medical record revealed Patient 16's admission to swing-bed level of care, due to low back pain, on 8/4/11 for pain control and Physical Therapy (PT). Patient #16's medical record revealed a Physician order dated 8/4/11 for an "Activity Coord [coordinator] Consult". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #16's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

b. Patient #17's swing-bed medical record revealed Patient 17's admission to swing-bed level of care, due to total knee replacement, on 8/4/11 for PT, Occupational Therapy (OT). Patient #17's medical record revealed a Physician order dated 8/4/11 for a "Consult Activity Coord". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #17's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

c. Patient #18's swing-bed medical record revealed Patient 18's admission to swing-bed level of care, due to increased weakness, on 8/3/11 for IV (Intravenous) medications and PT. Patient #18's medical record revealed a Physician order dated 8/3/11 for a "Consult Activity Coord". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #18's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

d. Patient #11's swing-bed medical record revealed Patient 11's admission to swing-bed level of care, due to respiratory distress, from 9/28/10 to 10/4/10 for PT and IV fluids. Patient #11's medical record revealed a Physician order dated 9/28/10 for a "Consult Activity Coord". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #11's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

e. Patient #12's swing-bed medical record revealed Patient 12's admission to swing-bed level of care, due to right lower lobe pneumonia, from 1/13/11 to 1/15/11 for IV medication. Patient #12's medical record revealed a Physician order dated 1/13/11 for an "Activity Coordinator Consult". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #12's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

f. Patient #13's swing-bed medical record revealed Patient #13's admission to swing-bed level of care, due to right hip fracture, from 11/17/10 to 11/22/10 for PT, OT and IV medication. Patient #13's medical record revealed a Physician order dated 11/17/10 for an "Activity Coordinator Consult". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #13's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

g. Patient #14's swing-bed medical record revealed Patient #14 received swing-bed level of care, due to left knee prosthesis displaced, from 4/15/11 to 4/19/11 for PT and OT. Patient #14's medical record revealed a Physician order dated 4/15/11 for an "Activity Coordinator Consult". However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of care.

Patient #14's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

h. Patient #15's swing-bed medical record revealed Patient #15 received swing-bed level of care, due to right hip fracture, from 10/14/10 to 10/25/10 for PT and OT. Patient #15's medical record revealed a Physician order dated 10/14/10 for an "Activity Coordinator Consult." However, the medical records lacked an individualized activity care plan during the patient's stay in swing-bed level of .

Patient #15's medical record lacked an individualized activity care plan with personal activity-related interventions during the patient's stay in swing-bed level of care.

3. Although the Activity Coordinator was not present at the time of the survey, the staff member taking on the responsibility of Activity Coordinator and the Medical Surgical unit manager were available for interview.

4. During an interview on 8/8/11 at 2:45 PM, Staff I, Registered Nurse (RN)-Long Term Care (LTC) Director of Nursing (DON), stated since the Activity Coordinator was in the hospital, Staff I took on these responsibilities. Staff I stated each patient received the same care plan. Staff I stated the staff does not have individual interventions for the activity care plan.

5. During an interview on 8/9/11 at 10:45 AM, Staff J, RN Medical/Surgical unit manager, stated the Activity Coordinator needed to make certain the activity care plan incorporated the patient activity interest prior to admission to swing-bed level of care. Staff J stated the activity staff needed to individualize the patient's care plan.

6. In a follow up interview on 8/10/11 at 11:50 AM, Staff J reviewed the swing-bed medical records for Patients #11, 12, 13, 14, 15, 16, 17, and #18 and acknowledged the activity care plans were the same for all the patients and did not reflect the patient individualized activity interest.

7. During an interview on 8/10/11 at 1:10 PM, Staff K, DON reviewed the medical records for Patients #11, 12, 13, 14, 15, 16, 17, and #18 and acknowledged the activity care plans needed to be more of an individual care plan and to reflect the patient activity interest.

8. On 8/11/1 at :00 AM Staff J provided a document, Care Conference" dated 8/10/11 that revealed in part, "...Discussion was held re [regarding]: individualizing the patient care plan to reflect the specific are for that patient. We must see the plan of care reflects the care given to that patient..." Staff J stated, the nurses will be working on improving the care plans to reflect the patient care.