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I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) acute care nursing staff failed to monitor defibrillator operation checks for 1 of 1 defibrillator located on the acute care nursing unit. The Patient Care Coordinator identified an average of 4 patient cardiac emergency cases yearly.

Failure to test the defibrillator could potentially result in the defibrillator failing to shock a patient when a cardiac emergency occurs resulting in patient harm or even patient death.

Findings include:

1. Observation during tour of the acute care nursing unit on 10/22/11 at 2:00 PM revealed 1 of 1 Zoll-M defibrillator.

2. During an interview, at the time of the tour, Staff B, Patient Care Coordinator stated the acute care nurses on the evening shift are responsible for completion of daily defibrillator safety checks. Staff B reported when the checks were completed the nurses documented the information on the crash cart documentation checklist. Staff B stated, "The nurses would initial the checklist, if there's blank spaces you would not be able to verify whether the checks were completed. We have a memo book that would remind all nurses to do the checks and to document when they are completed. This would be hospital policy and they are aware of this."

3. Review of Crash Cart Documentation Checklist sheets revealed:

a. Key definitions including but not limited to MWB - Monitor/Defib works on battery if applicable. Signature and OK in findings on the checklist.

b. Crash Cart Documentation Checklist dated June 2011 lacked initials for 6/6/11 and 6/27/11.

c. Crash Cart Documentation Checklist dated July 2011 lacked initials for 7/5/11, 7/14/11 and 7/15/11.
d. Crash Cart Documentation Checklist dated August 2011 lacked initials for 8/8/11 and 8/14/11.

4. Review of policy "Crash Carts: Supplies, Equipment, Location" dated 7/11/11, revealed in part,..."The monitor/defibrillator operation and power supply is checked daily...by designated personnel on the unit...Documentation on the crash cart documentation checks list includes date, findings per key on checklist and signature of personnel."

During a follow up interview on 8/25/11 at 8:30 AM, Staff B stated defibrillator checks "will be added to our Quality Improvement process as a quality indicator." She continued, "I've educated nurses now on the acute nursing regarding the importance of this."

II. Based on observation, document review and staff interview the Critical Access Hospital (CAH) acute care nursing staff failed to maintain the microwave in the patient kitchenette a sanitary condition. Additionally, dietary and acute care nursing staff failed to appropriately date and store food available for patient use in the patient kitchenette, in accordance with the facilities policies and procedures. The CAH identified an average daily census of 3 acute care patients and 3 same day surgical patients.

Failure to maintain sanitary conditions of patient care equipment and safety practices for dating and disposal of food products could potentially result in an outbreak of a food borne illness and the integrity/palatability of food products.

1. Observation on 8/22/11 at 11:27 AM, during the initial tour of the acute care nursing unit, accompanied by Staff K, Certified Nursing Assistant (CNA) revealed a patient kitchenette located adjacent to the nurses station. An Amana microwave oven, located on the counter revealed a large amount of dried, brown food debris inside the microwave including the glass plate and all surfaces inside the microwave cabinet and window. Staff N acknowledged the findings and stated, "This [microwave] is suppose to be clean after each use. I agree there's a large build up of dried food and obvious food spills. All of us [nursing staff] are responsible for cleaning it. The microwave is used for patient food products."

During an interview on 8/22/11 at 4:55 PM, Staff M, Registered Nurse (RN) "Some staff don't clean it [microwave] after they use, it would be an important infection control measure because it's for the patients."

During an interview on 8/23/11 at 7:30 AM, Staff Q, RN stated, "I did note on Monday morning [8/22/11] that it [microwave] was dirty and I was going to come back to clean it, I did not get back to do it and I should have."

During an interview on 8/24/11 at 7:35 AM, Staff L, Dietary Supervisor, verified the importance of cleaning microwaves. Staff L stated bacteria may be present when dried food spatters and debris are left on surfaces inside the microwave, "it's an infection control issue."

During an interview on 8/24/11 at 8:35, Staff E, Resource Nurse stated. "I did some education with nurses this morning about checking the microwave and cleaning it up after they [nurses] use it."

Review of policy "Nourishments" dated 1/10/11 revealed in part,..."Each nursing unit is responsible for daily cleaning of the kitchen."

2. Observation on 8/22/11 at 11:27 AM, during the initial tour of the acute care nursing unit, accompanied by Staff K, CNA revealed a patient kitchenette located adjacent to the nurses station. 4 of 5 covered bowls of dried cereal lacked dates and 1 of 1 covered bowl of dried cereal dated 7/12/11 in a cabinet above the microwave oven. Staff K acknowledged the cereal bowls lacked dates and stated, "The kitchen delivers the cereal, they [cereal bowls] should be dated."

During an interview on 8/23/11 at 7:35 AM, Staff L stated dietary staff are trained to date dried cereal before delivering to the acute care nursing unit. Staff L stated, "It [dried cereal] is considered a patient product and the shelf life is approximately 2 weeks and then it would be discarded because it could get dried out or soggy because of the way it is packaged."

During an interview on 8/24/11 at 8:40 AM, Staff E stated dietary staff was responsible for dating dried food products and the dietary supervisor "will be double checking this."

3. Continued observation of the patient kitchenette on 8/22/11 at 1:42 PM, revealed 5 of 5, 21 ounce containers of Strawberry/Raspberry jello cups expired July 20, 2011 in the refrigerator. The jello package lacked one container. Staff K acknowledged the expired jello cups at the time of the observation. Staff K verified nursing staff monitored for expired food products monthly and documented findings on an outdate checklist. Staff K stated the 8/15/11 checklist, "did not indicate any expired food products and hospital policy would direct nursing staff to pitch them if expired."

During an interview on 8/22/11 at 4:55 PM, Staff I, CNA stated, "I ordered jello last night, we knew we were having a lot of same day surgeries today. That jello had to come this morning because there wasn't any jello in the refrigerator last night."

During an interview on 8/23/11 at 8:35 AM, Staff M, RN stated physicians order an advance as tolerated diet after same day surgical procedures. Staff M stated, "Nurses would start out with liquids and then if the patient is tolerating liquids we would give them jello perhaps." Staff M verified nursing staff was responsible for monitoring for expired food items and stated, "We are trained to throw away expired food."

During a telephone interview on 8/23/11 at 3:15 AM, Staff N, Dietary Assistant verified delivery of the 6 Strawberry/Raspberry jello cups to the acute care kitchenette from the kitchen on 8/21/11. Staff N stated, "I delivered the jello cups to the acute unit kitchenette refrigerator around 6:40 PM last night [8/22/11]. I did not check the expiration date, I guess I just assumed it was fine."

During an interview on 8/24/11 at 8:40 AM, Staff E stated administrative staff spoke with the dietary supervisor regarding rotating food stock to avoid delivery of expired food to the nursing units. Staff E stated, "Nurses are responsible for checking for expiration dates prior to giving them to the patient."

Review of policy "Nourishments" dated 1/10/11 revealed in part,..."Each nursing unit is responsible for daily refrigerator checks and disposal of outdated food items."

I. Based on document review and staff interview, the Critical Access Hospital (CAH) medical staff failed to provide required monitoring for 1 of 1 provisional practitioner's (Practitioner F), and failed to ensure the Practitioner served on one hospital committee, and attended required medical staff meetings.

Failure to provide appropriate monitoring could potentially result in the provisional practitioner providing substandard care, to patients or the practitioner not meeting the medical staff ' s requirements for ethical and moral conduct.

Failure to serve on CAH committees and attend required medical staff meetings could potential result in the provisional practitioner ' s failure to integrate into the hospital culture appropriately.

Findings include:
1. Review of Medical Staff Bylaws, dated April 2005, revealed in part:
"i...Members of the Medical Staff will serve a provisional status for a minimum of 12 months to allow sufficient time for evaluation...During this provisional period their professional competence and ethical and moral conduct will be observed by the President of the Medical Staff or designee. At the end of the 12 month provisional period, the President of the Medical Staff will submit a written report to the Medical Staff Executive Committee indicating whether the practitioner is recommended for full staff status in the appropriate department or whether the provisional periods should be extended, indicating a recommended period of time."
"ii...During the provisional period the practitioner: will serve on at least one hospital committee as assigned; must attend assigned medical staff or committee meetings, but is not eligible to vote."

2. Review of Practitioner F's credential file revealed the Board of Trustees approved the initial appointment to active medical staff as provisional for 12 months, on 11/17/09.

3. Practitioner F's credential file lacked documented evidence of a written report from the President of the Medical Staff.

4. Practitioner F's credential filed lacked documented evidence that showed Practitioner F had served on at least one hospital committee as assigned or attended medical staff or committee meetings.

During an interview on 8/25/11 at 7:35 AM, Staff R, Credential File Director, stated Practitioner F received advancement for full privileges at the May 26, 2011 Medical Board Meeting. Staff R verified Practitioner F ' s credential file lacked evidence of a written report from the President of the Medical Staff. Staff R stated, " I was unable to locate a written report to the Medical staff indicating whether [Practitioner F] was recommended to full staff status in the appropriate period of time." Additionally, Staff R reported she had been unable to locate evidence "that [Practitioner F] served on a hospital committee or attended a medical staff or committee meeting, unfortunately."

During an interview on 8/25/11 at 8:15 AM, Staff E, Resource Nurse stated, "I can't find anywhere that [Practitioner F] attended any med staff committee meeting or served on a hospital committee. I've looked everywhere."

II. Based on review of the Critical Access Hospital (CAH) Administrative manual and staff interviews the CAH administration failed to follow their operational responsibility policy during the absence of the CAH director. The administrative staff reported an average daily census of 3.

Failure to follow the policy for operational responsibility in absence of the CAH's Director could potentially result in the lack of a key person responsible to make immediate and critical decisions.

Findings include:

1. Review of the policy, "Operational Responsibility in Absence of Director", dated 1/2005 revealed in part, "...Purpose: To designate the management responsibility for Mercy Medical Center . To make known whom to call when decision need to be made or information conveyed or in event of a disaster...The director is responsible for all operations of Mercy Medical Center-Dyersville...The Vice President (VP) of Patient Care Services, [network hospital] is responsible in the absence of the Director..."

2. During an interview on 8/22/11 at 1:00 PM, Staff E, Registered Nurse, (RN) Resource Nurse for the CAH, stated the Director of the CAH had not been able to perform the Director responsibilities since 7/21/11 due to illness. Staff E stated Staff B, RN Patient Care Coordinator, had taken over the Director's responsibilities since then. Staff E stated Staff B reported to him/her and as the Recourse Nurse, he/she reported to the VP of Patient Care Services at the network hospital.

During an interview on 8/24/11 at 4:30 PM, the VP of Patient Care Services confirmed Staff B assumed the role responsibilities of the Director with the assistance of Staff E. The VP of Patient Care Services confirmed according to the policy if the Director could not perform his duties, the VP of Patient Care Services assumed these responsibilities.

Based on review of the Critical Access Hospital (CAH) Administrative manual and staff interviews, the CAH administration failed to report a change in Administrative staff during the absence of the CAH director. The administrative staff reported an average daily census of 3.

Failure to report a change in absence of the Director of the CAH could potentially result in the lack of knowledge of the key person to notify in case of natural and/or security events affecting the operation of the CAH.

Findings include:

1. Review of the policy, "Operational Responsibility in Absence of Director", dated 1/2005 revealed in part, "...Purpose: To designate the management responsibility for Mercy Medical Center . To make known whom to call when decision need to be made or information conveyed or in event of a disaster...The director is responsible for all operations of Mercy Medical Center-Dyersville...The Vice President (VP) of Patient Care Services, [network hospital] is responsible in the absence of the Director..."

2. During an interview on 8/23/11 at 3:00 PM, Staff E, Registered Nurse, (RN) Resource Nurse for the CAH, stated, Staff F, VP of Patient Care Services, took on the responsibility and e-mailed the state agency (on 8/23/11) of the changes in the administrative duties.

During an interview on 8/23/11 at 3:00 PM, Staff F stated he/she did not notify the state office until 8/23/11 because the administrative staff were not aware how long the Director would be unavailable to perform his/her duties. Staff F provided an e-mail sent 8/23/11 to the Program Coordinator for Hospitals at the State Office. Staff F confirmed the Director had not been able to attend to his/her duties since July 21, 2011.

During an interview on 8/25/11 at 9:00 AM, Staff E confirmed the CAH lacked a policy or procedure designating a responsible person to notify the state agency when there were administrative changes.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to develop and implement policies and procedures specific to the CAHs services, staff, and capabilities.

Written policies and procedures provide guidance and consistency among staff and serve as a resource for staff in the provision of care. Failure to ensure the required group reviewed and approved all policies and procedures to assure they provided staff with necessary guidance, expected practices, and performances in the provision of patient care specific to the CAH's patient population, staff, and their capabilities could potentially result in CAH patients receiving less than optimal care and/or failure to provide patients' with the care and services needed.

The CAH administrative staff reported an average daily census of approximately 3 patients.

Findings include:

1. Observation, during initial tour, of the acute care nursing unit on 8/22/11 at approximately 11:30 AM revealed 25 of 25 patient beds lacked evidence of electrical safety checks. Staff B, Patient Care Coordinator confirmed patient care beds lacked evidence of electrical safety checks at the time of the observation.

2. During an interview on 8/22/11 at noon, Staff O, Plant Engineer stated Mercy Medical Center Dyersville maintenance staff completed the electric bed inspection checks on 8/15/11 by and Trinity Health Clinical Engineering (Bio-Meds) completed the annual preventive maintenance electrical safety checks for patient beds. Staff O stated, in addition to patient beds, Trinity Health Bio-Med staff completed annual PMI safety checks for all electrical medical equipment.

3. During an interview on 8/23/11 at 10:45 AM, the supervisor of the Health Information Maintenance (HIM) department stated Trinity Health Information Services were responsible for policy and procedure development and maintenance of computer security and privacy of confidential patient information.

During an telephone interview on 8/23/11 at 1:25 PM, Staff P, Director of HIM services at Mercy Dubuque confirmed Mercy Medical Center Dyersville lacked policies and procedures for computer security, Staff P stated, Basically it would reference or say that Dyersville has adopted all Trinity Corporation's, from Michigan, privacy and security standards.

During an interview on 8/23/11 at 1:55 PM, Staff O confirmed Mercy Medical Center Dyersville lacked policies and procedures for clinical engineering. Staff O stated, "Policies would cover the whole Trinity Network and Dyersville Mercy would not have any policies separate from Trinity Health clinical engineering policies that I'm aware of."

3. Review of documentation presented by Staff O and the Clinical Resource Nurse to the survey team on 8/21/11 at 2:45 PM, revealed in part, ..."Contracted Services at Mercy Medical Center Dyersville: Trinity Health Clinical Engineering (Bio-Med)...Trinity Health Information Services."
Staff O stated, "They [Trinity Health Clinical Engineering and Trinity Health Information Services] have their own policies and procedures not approved by Dyersville, but they are available from directors of these departments in Mercy Dubuque and approved through the hospital where they [Trinity Health Clinical Engineering and Trinity Health Information Services] originated."

During an interview on 8/21/11 at 3:55 PM, the Clinical Resource Nurse stated, "Contracted Services for bio-med and computer information is part of a purchased management services agreement with Mercy Dubuque which is the network hospital."

During a follow up interview on 8/24/11 at 2:45 PM, Staff O stated, "You can pull [policies and procedures from Mercy Dubuque/Trinity Health] off the Intranet for use a Mercy Dyersville but we do not currently have all clinical engineering and information services policies and procedures in the Dyersville Policy and Procedure Manuals."

Review of documents titled "Policy Development and Manuals" dated 10/4/10 revealed in part, "...To identify and delineate responsibility for development and communication of Mercy Medical Center policies...Mercy Medical Center staff is responsible for initiating and developing policies and obtaining the necessary approvals....The Director is responsible for initiating, developing, and recommending appropriate policies to the Board...The Board is responsible for initiating, reviewing, and approving Board policies as well as reviewing and approving all other policies specific by regulatory agencies as requiring board approval."

Based on document review and staff interview the Critical Access Hospital (CAH) nursing staff failed to notify physicians of medication errors for 2 of 6 medication errors reviewed (Patient # 1 and #10), in accordance with facility policy and procedure.

The CAH administrative staff reported an average daily census of approximately 3 patients.

Failure to notify the physician of medication errors could potentially result in life threatening or other related health conditions that could lead to serious harm.

Findings included:

1. Review of medication error reports revealed:

a. A medication error report dated 1/7/11 documented an omission of routine Zyprexa on 1/5/11 at 9:00 PM for Patient #1. Nursing staff failed to notify the physician of the medication error.

b. A medication error report dated 2/12/11 documented an omission of Flagyl on 2/12/11 at midnight for Patient #10. Nursing staff failed to notify the physician of the medication error.

2. During an interview on 8/24/11 at 12:30 PM Staff B, Patient Care Coordinator verified nursing staff failed to notify the physicians of the medication errors. Staff B stated both Patient #1 and #10's medical record lacked evidence of physician notification. Staff B reported hospital policy "instructs" nursing staff to "contact" the physician when a medication error occurs and nurses are "educated" regarding this policy.

During a follow up interview on 8/25/11 at 8:10 AM, Staff B stated monitoring of physician notification of medication errors "will be added to our Quality Improvement projects."

3. Review of policy "Medication Errors" dated 3/11, revealed in part,..."When a medication error occurs the following should occur in this order: Notify the physician immediately (within 30 minutes)...Document in the patient's medical record a factual statement of the occurrence. Record notification of physician in the medical record with any actions taken including resultant orders, chemical interventions, etc."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals conducted an annual review of all CAH policies.

The required group failed to review the written policies and procedures developed and provided by the network hospital and Trinity Health Systems for patients admitted to Mercy Medical Center Dyersville that addressed, provision of Clinical Engineering and Health Information Systems.

The CAH administrative staff reported an average daily census of approximately 3 patients.

Findings include:

1. Review of documentation presented by Staff O and the Clinical Resource Nurse to the survey team on 8/21/11 at 2:45 PM, revealed in part, ..."Contracted Services at Mercy Medical Center Dyersville: Trinity Health Clinical Engineering (Bio-Med)...Trinity Health Information Services."
Staff O stated, "They [Trinity Health Clinical Engineering and Trinity Health Information Services] have their own policies and procedures not approved by Dyersville, but they are available from directors of these departments in Mercy Dubuque and approved through the hospital where they [Trinity Health Clinical Engineering and Trinity Health Information Services] originated."

Review of documents titled "Policy Development and Manuals" dated 10/4/10 revealed in part, "...To identify and delineate responsibility for development and communication of Mercy Medical Center policies...Mercy Medical Center staff is responsible for initiating and developing policies and obtaining the necessary approvals....The Director is responsible for initiating, developing, and recommending appropriate policies to the Board...The Board is responsible for initiating, reviewing, and approving Board policies as well as reviewing and approving all other policies specific by regulatory agencies as requiring board approval."

2. During an interview on 8/23/11 at 10:45 AM, the supervisor of the Health Information Maintenance (HIM) department stated Trinity Health Information Services were responsible for policy and procedure development and maintenance of computer security and privacy of confidential patient information.

a. During an telephone interview on 8/23/11 at 1:25 PM, Staff P, Director of HIM services at Mercy Dubuque confirmed Mercy Medical Center Dyersville lacked policies and procedures for computer security, Staff P stated, Basically it would reference or say that Dyersville has adopted all Trinity Corporation's, from Michigan, privacy and security standards.

b. During an interview on 8/23/11 at 1:55 PM, Staff O confirmed Mercy Medical Center Dyersville lacked policies and procedures for clinical engineering. Staff O stated, "Policies would cover the whole Trinity Network and Dyersville Mercy would not have any policies separate from Trinity Health clinical engineering policies that I'm aware of."

c. During an interview on 8/21/11 at 3:55 PM, the Clinical Resource Nurse stated, "Contracted Services for bio-med and computer information is part of a purchased management services agreement with Mercy Dubuque which is the network hospital."

d. During a follow up interview on 8/24/11 at 2:45 PM, Staff O stated, "You can pull [policies and procedures from Mercy Dubuque/Trinity Health] off the Intranet for use a Mercy Dyersville but we do not currently have all clinical engineering and information services policies and procedures in the Dyersville Policy and Procedure Manuals."

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interview, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for Ultra Sound and Diabetes Education. The CAH administrative staff reported a weekly average of 4 Ultra Sound procedures and a yearly average of 5 patients for Diabetes Education.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substandard care.

Findings include:

1. Review of the "Quality Improvement Plan FY 2011-2012" revealed in part, "...all departments and services including those furnished under contract or arrangement are monitored and evaluated. Each department or service addresses issues related to services provided...each service/department monitors, evaluates and reports at least quarterly..."

2. The Quality Improvement Committee Meeting minutes from July 2010 through July 2011 lacked documentation that showed the Quality Improvement staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for the following areas: Diabetes Education and Ultra Sound.

3. During an interview on 8/24/2011 at 1:30 PM, Staff F, Registered Nurse (RN), Resource Nurse for the CAH, acknowledged that Diabetes Education and Ultra Sound staff failed to participate in the Quality Program through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance in accordance with the CAH's Quality Improvement Plan.

During an interview on 8/24/2011 at 1:45 PM, the Dietician stated the volume of patients averaged approximately 4-5 a year. The dietitian stated the dietary staff did not complete a Quality Assurance project due to low volume of patients requiring this service.

During an interview on 8/24/2011 at 1:50 PM, Staff G, Radiology Technician, stated he/she was unaware of any QA projects submitted to the QA meetings. Staff F stated, since Ultra Sound was from the network hospital, the CAH staff did not collect any data related to Ultra Sound services provided to patients of the CAH. According to Staff F, the Network Hospital collected QA data and sent reports, based on the data they collected, to the CAH and they accepted and used the information provided.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 5 of 16 medical staff members selected for review received external peer review from an equivalent peer. The CAH administrative staff identified 42 members of the medical staff.

The CAH administrative staff identified 105 Colonoscope yearly, 8 ENT procedures yearly, 40 opthmalogy procedures yearly, and 15 podiatry procedures yearly.
Failure to ensure all medical staff members received external peer review from a true peer could potentially expose patients to inappropriate medical care.
Findings include:
1. Review of credential Files on 8/24/11 at 10:15 AM revealed:
a. Family Practice Physician A's credential file lacked documented evidence of external peer review by a family practice physician.
b. Doctor of Podiatry B's credential file lacked documented evidence of external peer review by a doctor of podiatry.
c. Doctor of Podiatry C's credential file lacked documented evidence of external peer review by a doctor of podiatry.
d. Doctor of Ophthalmology D's credential file lacked documented evidence of external peer review by a doctor of opthmalogy.
e. ENT Physician E's credential file lacked documented evidence of external peer review by a ENT physician.
2. Review of the policy "Medical Staff Quality Improvement and Peer Review", dated 1/10/11 revealed in part,..."Each physician on the Medical Staff at Mercy Medical Center - Dyersville will have an external peer review annually." The policy failed to address medical staff members selected for review received external peer review from an equivalent peer.
3. During an interview at the time of the credential file review, Staff R, Credential files coordinator stated they sent medical records to their network hospital. The outside network hospital had the medical records reviewed by an Orthopedic surgeon. The outside network did not have physicians with a Osteopathic, Podiatry, Ophthalmology and an ENT specialist, review medical records of patients that received care from Practitioner A, B, C, D, and E. Staff R acknowledged that they failed to ensure the physician reviewer for Practitioner A, B, C, D, and E had enough knowledge to appropriately evaluate the medical records presented. Staff R stated, "I wasn't aware that the external peer review needed to be completed by a physician from a respective department. It won't be difficult to change this process."
4. During a follow up interview on 8/25/11 at 8:30 AM, Staff R stated, "We did not find any additional information."

Based on medical record review, policy review, and staff interviews, the Critical Access Hospital (CAH) nursing and activity staff failed to to document individual or group activities provided to swing bed patients in 2 of 2 inpatients (Patient #1 and #2) and 5 of 5 closed swing bed patients (Patients #3, #4, #5, #6 and #7). The CAH identified an average daily census of approximately 3 swing bed patients.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient could potentially impede the patient 's progression for attaining or maintaining the highest practicable level of well being.

Findings include:

1. Review of the medical record for Patient #1 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

2. Review of the medical record for Patient #2 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

3. Review of the medical record for Patient #3 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

4. Review of the medical record for Patient #4 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

5. Review of the medical record for Patient #5 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

6. Review of the medical record for Patient #6 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

7. Review of the medical record for Patient #7 lacked documentation the patient participated in the activity program. Clinical staff failed to document patient participation in the nurse's notes or the activity notes.

Review of the CAH policy titled Assessment Process for Swing Bed Patients revealed in part "... A. Each patient assessment/screening includes information regarding physical, psychological, social, environmental, functional, nutritional and educational and discharge planning factors to determine the need for care or treatment, the type of care or treatment to be provided and the need for any further assessment. C. Documentation of the reassessment includes the patient's response to nursing interventions and any significant change in the patient condition. D. The results of the assessment are used to develop, review and revise the comprehensive care plan of care."

During an interview on 8/23/11 at 1:45 PM, Staff C (Activities Coordinator) said staff were not documenting patient participation in the activities program in the patient's medical records. Staff had not documented patient activities in the medical record for 2.5 months.

Based on review of policies, skilled clinical record review and staff interviews, the Critical Access Hospital (CAH) activity staff failed to ensure skilled patient's activity care plans were individualized to meet the patient's mental and psychosocial needs gathered from the activity comprehensive assessment for 2 of 2 inpatients (Patient #1 and #2) and 5 of 5 closed records (Patient #3, #4, #5, #6 and 7. The CAH administrative staff reported an average daily census of 3 skilled patients.

The activity assessment determines the content of the care plan. All skilled 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 skilled patients could potentially neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

Findings include:

1. Review of the medical record for Patient #1 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

2. Review of the medical record for Patient #2 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

3. Review of the medical record for Patient #3 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

4. Review of the medical record for Patient #4 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

5. Review of the medical record for Patient #5 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

6. Review of the medical record for Patient #6 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

7. Review of the medical record for Patient #7 revealed he/she received skilled care treatment while in the CAH. However, the medical records lacked an activity care plan with individual activity-related interventions during the skilled patient's hospital stay.

Review of the CAH policy titled Assessment Process for Swing Bed Patients revealed in part "... A. Each patient assessment/screening includes information regarding physical, psychological, social, environmental, functional, nutritional and educational and discharge planning factors to determine the need for care or treatment, the type of care or treatment to be provided and the need for any further assessment. D. The results of the assessment are used to develop, review and revise the comprehensive care plan of care."

During an interview on 8/23/11 at 1:45 PM, Staff C (Activity Coordinator), said if the medical record lacked activity documentation in the care plan, it did not get completed.

During an interview on 8/24/11 at 2:20 PM, Staff B (Patient Care Coordinator), said the activity department does not have access to Cerner (electronic medical record) care plan. If the activity care plans were not documented in the medical records, they were not completed.

Based on policy review, policy review and staff interviews, the Critical Access Hospital (CAH) failed to provide 1 of 2, (Patient #1), inpatients weekly care conferences. The CAH administrative staff reported an average weekly census of 3 skilled patients.

Failure to provide weekly care conferences for skilled patients could result in patients not receiving adequate care during hospitalization.

Findings include:

Review of the medical record for Patient #1 revealed, patient admitted on 5/20/11 and qualified for skilled nursing care at the CAH. Review of the Interdisciplinary Rounds showed CAH staff provided the patient Care Conferences on 5/24, 6/28, 7/26 and 8/11/11. The hospital staff failed to provide the patient with weekly Care Conferences since his/her admit to the hospital.

Review of the CAH brochure, given to all skilled patients, titled Mercy Dyersville- Skilled Unit Rehabilitation Services revealed in part "... There is a weekly Care Conference for review of the patient's continuing care. Family participation in the care conferences is highly recommended to establish/update patient-centered goals, discuss patient's progress, level of care and discharge planning needs as far as appropriate discharge setting and/or need for assistance. If you are unable to attend the weekly care conferences, please call the Rehabilitation Services Department to discuss these issues with staff therapists.

During an interview on 8/24/11 at 2:20 PM, Staff B (Patient Care Coordinator) said the patient did qualify for skilled nursing services and should have received the care conferences weekly. The medical record lacked documentation the patient received the weekly care conferences.