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Based on observation, interview and policy review, the facility failed to ensure that infection control practices used by staff minimized the risk of cross contamination for one patient (#15) of five hand hygiene observations and for one patient (#2) of one wound care observation. These failed practices had the potential to increase the risk of infection for all patients. The facility census was seven.

Findings included:

1. Record review of the nationally accepted standards of care for reducing the risks of infection and hand hygiene (hand washing) published by the Centers for Disease Control and Prevention (CDC), reviewed 05/01/14, showed "Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings)."

Record review of the facility's policy titled, "Infection Prevention: Hand Washing," reviewed 03/11, showed no direction for staff to wash their hands between contact with inanimate (equipment, handles, non-living items) objects and a patient, during patient care.

2. Observation on 07/29/14 at 2:40 PM, showed Staff U, Registered Nurse (RN), administered an injection to Patient #15. Staff U touched the patient, then touched surfaces on a computer and computer cart, electronic scanning device (used to document medication administration), and a drawer handle in the facility's nursery, then returned to the patient and administered the injection without performing hand hygiene.

During an interview on 07/29/14 at 3:45 PM, Staff U stated that she did not recognize that she came into contact with contaminated surfaces, before she came into contact with the patient, and therefore failed to recognize the need to perform hand hygiene before she administered the medication to Patient #15.

3. During an interview on 07/29/14 at 3:45 PM, Staff O, Obstetric Director, stated that the computer and computer cart were cleaned once weekly, and not in between patient use.

4. During an interview on 07/30/14 at 9:05 AM, Staff E, Infection Preventionist, stated that staff should wash their hands when moving between inanimate objects and the patient during patient care.

5. Observation on 07/29/14 at 1:30 PM, showed Patient #2 in bed while Staff P, RN, provided wound care to the patient's above the knee left leg amputation surgical site. Staff P opened and assembled clean and sterile wound cleansing and dressing supplies and placed them directly on the surface of the patient's bed sheets. No clean protective barrier (to prevent transmission of unwanted bacteria and viruses directly to the wound) was placed between the wound care supplies and the patient's bed surface.

6. During an interview on 07/30/14 at 10:30 AM, Staff E, stated that she was not aware of a facility policy that provided staff guidance related to the placement of wound care supplies while wound care was conducted. However, she stated that her expectations were that nurses followed nursing standards of infection control practice and place a clean barrier between clean wound care supplies and the patient's bed when providing wound care.




17863

Based on observation, interview and record review the facility failed to ensure one of two Dietary staff was able to demonstrate appropriate hand hygiene/washing when handling foods for patient meal service and failed to ensure Dietary staff was qualified by training and compliant with a county health department requirement for food safety certification. These failures had the potential to cross contaminate patient foods and consequently cause food borne illness. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "Sanitation & Safety - Personal Health & Hygiene," revised 08/08/12, directed Dietary staff to wash their hands with soap and water for twenty seconds after touching face or hair.

2. Record review of Dietary in-service education records dated 01/14/14 showed all staff (including Staff C, Cook) had received food sanitation education including hand hygiene/washing.

3. During an interview on 07/28/14 at 2:26 PM, Staff A, Dietary Manager, stated that she periodically taught in-service sessions to Dietary department staff regarding food sanitation that included hand hygiene/washing to prevent cross contamination of foods.

4. Observation on 07/28/14 at 5:20 PM, in the facility kitchen, showed Staff C, scratched her head and touched her hair (under her hair restraint) then, failed to wash her hands before using a thermometer to check the temperature of a food item for patient tray service.

Observation on 07/28/14 at 5:28 PM, on a patient unit, showed Staff C wiped the back of her hand across her cheek and hair that extended from under her hair restraint then, without using hand hygiene/washing, touched portioned foods assembled for patient bedtime snacks.

During an interview on 07/28/14 at 5:28 PM, Staff C stated that she had been taught to wash her hands after touching her face or hair.

5. Record review of a notice from the county health department, dated 06/11/14, showed the facility Dietary staff (food handlers) were required, by local ordinance, to obtain food handler's certification by undergoing online food sanitation training.

6. During an interview on 07/28/14 at 2:26 PM, Staff A, Dietary Manager, stated that there were ten Dietary staff in the department and none of them had food handler's certification issued by the county health department.

Based on interview, record review and policy review, the facility failed to ensure that their policies were reviewed and revised on an annual basis for eight departments (Emergency, Radiology, Infection Prevention, Medical Surgical Unit, Nursing, Dietary, Surgical/Anesthesia and Swing Bed) of nine departments' policies reviewed. This failed practice had the potential to affect the quality of care for all patients, when policies do not contain current standards of care. There were 14 clinical departments and nine non-clinical departments with department specific policies in the facility. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "Hospital Policy and Procedure Process," reviewed 10/13, showed that all hospital departments will maintain an up-to-date policy manual and that each clinical department policy and procedure manual shall be reviewed on an annual basis and revised as needed. The sponsoring leader will be responsible to coordinate the review of their department policies annually and make necessary revisions.

Record review of facility document titled, "Mercy Hospital Aurora CAH (Critical Access Hospital, a Centers for Medicare & Medicaid Services designation) Program Annual Evaluation July 2013 - June 2014," dated, 7/16/14, showed, "All healthcare policies are reviewed annually by senior leadership and physician leadership with any necessary revisions implemented".
2. During an interview on 07/30/14 at 1:30 PM Staff N, Vice President of Quality Resources, stated that she was the author of that report and meant that all policies that were reviewed were done by the group. Staff N stated that she had not intended to mislead and stated that, "We are very aware that the facility policy review process was way behind".

3. Record review of Emergency Department policies showed the policies were reviewed in 06/14, but were not current as evidenced by:
- Use of the former name of the hospital in the body of the policies;
- A process to copy the patient's medical record when the facility's medical records were electronic;
- Direction to triage (determine how urgent a patient needed to receive medical care) was based on a three level system instead of the nationally recognized five level triage system the department was currently using.

During an interview on 07/30/14 at 3:00 PM, Staff I, Emergency Department Director, stated that the Emergency Department policies had not been revised to include current processes and procedures. Staff I stated that an example of this was that the hospital transitioned to electronic medical records one and one-half to two years ago, but the policy related to copying patient medical records had not been revised with the electronic process.

4. Record review of Imaging Services (Radiology) policies showed the policy titled, "Patient Concerns and Cleaning of Carts, Wheelchairs and IV (Intravenous, in the vein) Poles" (portable poles that are used with IV equipment during medication or fluid infusions) had not been revised since 08/15/12.

During an interview on 07/30/14 at 12:00 PM, Staff T, Radiology Director, stated that she did not have evidence that she reviewed the Radiology Department policies annually.

5. Record review of Infection Prevention policies showed the policies titled, "Healthcare Associate Infections", "Hand Washing", and Guidelines for Infection Prevention" had not been reviewed since 05/11;

During an interview on 07/30/14 at 9:05 AM, Staff E, Infection Preventionist, stated that she did not have evidence of annual review of the infection control policies.

6. Record review of Medical Surgical Unit policies showed the following:
- "Care of the Hemovac" (use of manual suction to remove drainage from a surgical wound) was effective 11/15/03 and had not been reviewed or revised.
- "Hoyer Lift" (machine used to assist in the physical transfer of a patient from a bed to a chair) was effective 11/15/03 and had not been reviewed or revised.
- "Gait Belt Use" (belt used to assist in the physical transfer of a patient from a bed to a chair and during ambulation) was revised 11/03 and had not been reviewed or revised since that time.

7. Record review of Nursing Department policies showed the policy, "Medication Administration" had not been revised since 09/28/11.

During an interview on 07/30/14 at 12:00 PM, Staff L, Chief Nursing Officer, and Staff M, Medical Surgical Director, stated that they realized the policies were outdated.

8. Record review of the facility's Dietary department policy and procedure manual showed the policies were not reviewed annually.

During an interview on 07/28/14 at 2:26 PM, Staff A, Dietary Manager, stated that the department policies and procedures had not routinely been reviewed annually.

9. Record review of Surgical/Anesthesia policies showed:
-Policies titled, "Organization of Department of Anesthesia", "Department Mission", "Scope of Services", and "Scope of Practice", had no effective dates, revision dates of 03/01 and no review dates;
- Policies titled, "Guidelines and Standards for Nurse Anesthesia Practice", "Qualification of Personnel", "Rules and Regulations: Pre Anesthetic Care", "Post Anesthetic Evaluations", and "Position Description CRNA (Certified Registered Nurse Anesthetist)", had effective dates of 03/01, revision dates of 07/11, and no review dates;
- Policy titled, ""Surgeon Credentialing" had an effective date of 01/03 and review/revision dates of 02/11;
- Policy titled, "Holding a Sterile Set Up" had an effective date of 04/04, revision date of 07/11, and no review dates.
During an interview on 07/29/14 at 1:45 PM Staff V, Director of Surgery, stated that she was aware that policy review/revisions were not up to date.
10. Record review of facility policies in the Swing Bed Manual provided by the facility and verified by Staff L, Chief Nursing Officer (CNO), as the current Swing Bed Manual showed policies dated from the year 1997 through the year 2007. No current policies were in the manual.

During an interview on 07/30/14 at 10:30 AM, Staff R, Case Manager, stated that she was responsible for the facility Swing Bed Services. Staff R stated, "The Swing Bed Manual is a disaster and needed to be revised" and "there aren't any policies on the computer, they were deleted years ago." Staff R stated that the policies used for swing bed residents were the same policies used for all patients in the hospital and all patients were treated alike.

11. Record review of the facility annual program evaluation dated June 2014 review showed no review of the Swing Bed Program.
















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Based on interview, record review and facility policy review the facility failed to ensure nursing care plans were developed based on the individual needs of three patients (#4, #5, and #25) of five patients' nursing care plans reviewed. The failure to develop nursing care plans based on the patients' individualized needs with planned interventions and ongoing assessments in response to the interventions, had the potential to contribute to deterioration or not improve the patients' health status. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "Multidisciplinary Patient Care Plan," reviewed 11/07, showed direction for facility staff to provide an individualized, interdisciplinary plan of care for all patients. Further direction included:
- All patients admitted to the facility would receive continuous care based upon needs identified through the nursing assessments, medical diagnosis and would be documented on the multidisciplinary plan of care.
- Care plans would be initiated upon admission, completed within 24 hours, would identify measurable goals for problems, list individual patient specific interventions with ongoing assessment and re-evaluation to ensure patients' met identified goals.
- Care plan documentation was considered incomplete without all components of the nursing process identified and ongoing assessments and evaluations documented in the patient's medical record.
- Every nurse shift report was provided via the Care Plan (written in bold underlined lettering).

2. Record review of Patient #4's Nursing Assessment dated 07/29/14 showed the patient's date of admission was 07/27/14 for hospice (comfort/supportive care for persons with terminal illness nearing end of life) respite care (brief hospitalization to stabilize a condition or provide home caregivers a break from care). Further documentation showed the following assessment findings:
- Sensory perception was slightly limited.
- She wore adult diapers and was incontinent of urine and feces.
- Body movement and control was very limited and was chairfast (unable to leave chair).
- The Braden Score (obtained from the skin assessment to predict the risk for pressure ulcer development) was 17 (if 18 or less a prevention protocol should have been initiated, per facility assessment guidelines).

3. During an interview on 07/28/14 at approximately 3:00 PM, Staff Q, Registered Nurse (RN) assigned to Patient #4, stated that the patient's pain was not an issue because she received pain medication twice daily. Staff Q further reported the patient was blind, could not feed herself, had partial paralysis her left side due to a brain injury, could state her name at times however she was not oriented to time, place or her condition.

4. Record review of Patient #4's Nursing Care Plan on 07/29/14 at 3:30 PM showed no care planning documentation related to individual identified needs/problems related to; pain, risks for pressure ulcer development, the inability to feed herself, her alteration in sensory perception related to blindness and left sided mobility deficits, incontinence of bowel and bladder, unmet communication/socialization needs and end of life care needs.

5. During an interview on 07/28/14 at approximately 3:00 PM, Staff Q, assigned to Patient #5, stated that the patient was admitted on 07/27/14 with an arm fracture. Staff Q further stated that the patient had severe mental, behavioral and mobility limitations to the extent that required a caregiver in his home prior to admission. Staff Q stated that the patient's arm was in a sling and he was uncooperative with care which included; medication administration, assistance with ambulation, and he remained in his soiled clothes since admission from home.

6. Record review of Patient #5's Nursing Care Plan on 07/29/14 at 3:30 PM showed no care planning documentation related to the identified individualized needs of actual or potential pain, severe cognitive and mobility deficits and limitations, communication needs, and care of the fractured arm including use of the sling.

7. During an interview and concurrent reviews of Patient #4 and Patient #5's care plans on 07/29/14 at 3:30 PM, Staff M, Medical Surgical Services Director, stated that nurses just know what to do and document what they actually do when needed in the nurses' notes. Staff M stated that she was responsible for nursing education and nursing documentation in the medical record and that the nurses have done what was expected. She stated that the nurses use the problems built into the "system" and they cannot be changed in anyway by editing, adding interventions or comments. Staff M stated, "The nurses just know what to do and tell each other what's going on with the patients in report" and "Nurses go by whatever the Doctors order". Staff M stated that nurses are expected to complete care plans within eight hours after admission.

8. During an interview on 07/28/14 at approximately 4:20 PM, Staff O, Director of Obstetric Services, stated that Patient #25 was admitted that same day and had a cesarean section (surgical delivery of an infant through an incision in the mother's abdomen and uterus) and was sleeping.

9. Record review of Patient #25's Nursing Care Plan on 07/30/14 (two days after admission), showed no care planning documentation related to individual identified needs related to the patient's post-surgical incision site pain, the abdominal surgical site wound care or actual/potential problems associated with childbirth.

10. During an interview on 07/30/14 at 1:15 PM, Staff L, Chief Nursing Officer, stated that after review of the nursing care plan documentation she agreed the facility nursing care plan documentation failed to identify measurable goals for problems, did not list individual patient specific interventions with ongoing planned assessment and re-evaluation to ensure patients' met identified goals. Staff L stated that good communication at the time of nurse shift report was very important for patient safety and that nurses were expected to give shift report from the care plan documentation to ensure accurate information was reported from shift to shift.

Based on interview and facility record review the facility failed to ensure policies and procedures were developed, written and staff was educated on resident mistreatment, neglect, abuse and misappropriation of resident property. The lack of an effective system developed for prevention and early identification of resident mistreatment has the potential to affect all residents admitted. The facility census was seven of which two were swing bed (a Medicare program with distinct admission and reimbursement criteria) residents.

Findings included:

1. Record review of facility policies showed no policies or procedures that provided written guidance or measures for staff related to prevention or reporting of actual or suspected staff to resident abuse, neglect, mistreatment, or misappropriation property. Even though requested, the facility failed to provide abuse and neglect related policies, procedures or related staff education.

2. During an interview on 07/30/14 at 3:00 PM, Staff L, Chief Nursing Officer, stated that the facility did not have written policies, procedures or education related to staff to resident abuse and neglect prevention, identification or education. Staff L stated "staff just knows what to do" and "we haven't had any problems".

3. During an interview on 07/30/14 at approximately 3:50 PM, Staff N, Vice President of Quality Resources, verified that no policies, procedures or education had been developed or provided for staff.

Based on interview, record review and facility policy review the facility failed to ensure an ongoing activity program was developed to meet the needs of all the residents (#2 and #3) admitted. The failure to develop and implement an activity program designed to prevent deterioration and/or promote the residents' physical, mental, and psychosocial well-being affected all residents admitted. The facility census was seven of which two were swing bed (a Medicare program with distinct admission and reimbursement requirements) residents.

Findings included:

1. Record review of the facility's policy titled "Swing Bed Activities," dated 01/03/97, showed the residents were provided planned individual and group activities which included needle crafts, drawing, painting, leather crafts, wood crafts and other activities to produce an opportunity for self-expression and verbalization.

Record review of the facility's undated policy titled "Swing-Bed Activity Program Assessment," showed:
- An activities assessment was completed and documented on each resident as soon as possible after admission but no later than the next scheduled working day for the Activity Director.
- Participation in the activity program was encouraged to prevent further deterioration of mental, physical and emotional functions through restoration to self-care through programmed activities.
- Activities were pre-planned according to each resident's schedule on their individual calendars posted in their room with general choices available.

2. Record review of Resident #2's medical record on 07/29/14 at 10:30 AM, 11 days after admission, showed no documentation of an activity assessment.

Record review of Resident #3's medical record on 07/29/14 at 10:40 AM, five days after admission, showed no documentation of an activity assessment.

3. During an interview on 07/30/14 at 10:30 AM, Staff R, Case Manager, stated that the activities program was her responsibility. She stated that essentially all patients (including those admitted to swing beds) in the facility are treated the same and get the same thing. She stated that it had been approximately six years since the last individual activity was provided to a resident and that the activity was a puzzle.

4. During an interview on 07/30/14 at 1:15 PM, Staff L, Chief Nursing Officer, stated that she was not aware of the lack of an activity program and assessments. She stated that she thought activity assessments were conducted regularly and policies and procedures were available to all staff.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were developed for two residents (#2 and #3) of two residents care plans reviewed. The failure to develop a comprehensive care plan that addressed identified residents needs had the potential to prevent the resident's from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. The facility census was seven of which two were swing bed (a Medicare program with distinct admission and reimbursement requirements) residents.

Findings included:

1. Record review of facility policies showed no policy for comprehensive care planning. Even though requested, the facility failed to provide comprehensive care planning policies for residents in swing beds.

2. Observation on 07/28/14 at approximately 3:15 PM on the medical surgical unit showed Resident #2 in bed with a wound cover/bandage at the site of an above the knee left leg amputation.

During an interview on 07/28/14 at approximately 3:15 PM, Staff P, Registered Nurse (RN) assigned to care for Resident #2, stated that the resident received wound care and dressing changes and experienced pain related to the recent surgical amputation of the left leg.

3. Observation on 07/28/14 at approximately 3:25 PM on the medical surgical unit showed Resident #3 in the hallway sitting in a wheel chair with a wound cover/bandage at the left knee.

During an interview on 07/28/14 at approximately 3:15 PM, Staff Q, RN, assigned to care for Resident #3, stated that the resident received wound care and dressing changes when needed to the left knee surgical incision site and experienced pain.

4. During an interview and concurrent care plan review on 07/29/14 at 10:30 AM, Staff P stated that Resident's #2 and #3 did not have care plans for wound care or pain assessment. She stated that the nurses use the physician orders to provide care such as the frequency of wound care and pain medication. She stated that nursing staff know what to do and give verbal report at shift change regarding what nursing care was needed on each resident.

5. During an interview and concurrent reviews of Resident #2 and Resident #3's care plans on 07/29/14 at 3:30 PM, Staff M, Medical Surgical Services Director, stated that nurses just know what to do and document what they actually do when needed in the nurses' notes. Staff M stated that she was responsible for nursing education and nursing documentation in the medical record and that the nurses have done what was expected. She stated that the nurses use the problem list and care plan templates built into the computer system and they cannot be changed in anyway by editing, adding interventions or comments. Staff M stated, "The nurses just know what to do and tell each other what's going on with the patients in report" and, "Nurses go by whatever the doctors order".

6. During an interview on 07/30/14 at 1:15 PM, Staff L, Chief Nursing Officer, stated that after review of current nursing documentation the facility nursing care plan documentation did not identify individualized patient goals, planned nursing interventions with ongoing assessment and re-evaluation to ensure patient's met the goals.

Based on interview, record review and policy review, the facility failed to ensure that their policies were reviewed and revised on an annual basis for eight departments (Emergency, Radiology, Infection Prevention, Medical Surgical Unit, Nursing, Dietary, Surgical/Anesthesia and Swing Bed) of nine departments' policies reviewed. This failed practice had the potential to affect the quality of care for all patients, when policies do not contain current standards of care. There were 14 clinical departments and nine non-clinical departments with department specific policies in the facility. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "Hospital Policy and Procedure Process," reviewed 10/13, showed that all hospital departments will maintain an up-to-date policy manual and that each clinical department policy and procedure manual shall be reviewed on an annual basis and revised as needed. The sponsoring leader will be responsible to coordinate the review of their department policies annually and make necessary revisions.

Record review of facility document titled, "Mercy Hospital Aurora CAH (Critical Access Hospital, a Centers for Medicare & Medicaid Services designation) Program Annual Evaluation July 2013 - June 2014," dated, 7/16/14, showed, "All healthcare policies are reviewed annually by senior leadership and physician leadership with any necessary revisions implemented".
2. During an interview on 07/30/14 at 1:30 PM Staff N, Vice President of Quality Resources, stated that she was the author of that report and meant that all policies that were reviewed were done by the group. Staff N stated that she had not intended to mislead and stated that, "We are very aware that the facility policy review process was way behind".

3. Record review of Emergency Department policies showed the policies were reviewed in 06/14, but were not current as evidenced by:
- Use of the former name of the hospital in the body of the policies;
- A process to copy the patient's medical record when the facility's medical records were electronic;
- Direction to triage (determine how urgent a patient needed to receive medical care) was based on a three level system instead of the nationally recognized five level triage system the department was currently using.

During an interview on 07/30/14 at 3:00 PM, Staff I, Emergency Department Director, stated that the Emergency Department policies had not been revised to include current processes and procedures. Staff I stated that an example of this was that the hospital transitioned to electronic medical records one and one-half to two years ago, but the policy related to copying patient medical records had not been revised with the electronic process.

4. Record review of Imaging Services (Radiology) policies showed the policy titled, "Patient Concerns and Cleaning of Carts, Wheelchairs and IV (Intravenous, in the vein) Poles" (portable poles that are used with IV equipment during medication or fluid infusions) had not been revised since 08/15/12.

During an interview on 07/30/14 at 12:00 PM, Staff T, Radiology Director, stated that she did not have evidence that she reviewed the Radiology Department policies annually.

5. Record review of Infection Prevention policies showed the policies titled, "Healthcare Associate Infections", "Hand Washing", and Guidelines for Infection Prevention" had not been reviewed since 05/11;

During an interview on 07/30/14 at 9:05 AM, Staff E, Infection Preventionist, stated that she did not have evidence of annual review of the infection control policies.

6. Record review of Medical Surgical Unit policies showed the following:
- "Care of the Hemovac" (use of manual suction to remove drainage from a surgical wound) was effective 11/15/03 and had not been reviewed or revised.
- "Hoyer Lift" (machine used to assist in the physical transfer of a patient from a bed to a chair) was effective 11/15/03 and had not been reviewed or revised.
- "Gait Belt Use" (belt used to assist in the physical transfer of a patient from a bed to a chair and during ambulation) was revised 11/03 and had not been reviewed or revised since that time.

7. Record review of Nursing Department policies showed the policy, "Medication Administration" had not been revised since 09/28/11.

During an interview on 07/30/14 at 12:00 PM, Staff L, Chief Nursing Officer, and Staff M, Medical Surgical Director, stated that they realized the policies were outdated.

8. Record review of the facility's Dietary department policy and procedure manual showed the policies were not reviewed annually.

During an interview on 07/28/14 at 2:26 PM, Staff A, Dietary Manager, stated that the department policies and procedures had not routinely been reviewed annually.

9. Record review of Surgical/Anesthesia policies showed:
-Policies titled, "Organization of Department of Anesthesia", "Department Mission", "Scope of Services", and "Scope of Practice", had no effective dates, revision dates of 03/01 and no review dates;
- Policies titled, "Guidelines and Standards for Nurse Anesthesia Practice", "Qualification of Personnel", "Rules and Regulations: Pre Anesthetic Care", "Post Anesthetic Evaluations", and "Position Description CRNA (Certified Registered Nurse Anesthetist)", had effective dates of 03/01, revision dates of 07/11, and no review dates;
- Policy titled, ""Surgeon Credentialing" had an effective date of 01/03 and review/revision dates of 02/11;
- Policy titled, "Holding a Sterile Set Up" had an effective date of 04/04, revision date of 07/11, and no review dates.
During an interview on 07/29/14 at 1:45 PM Staff V, Director of Surgery, stated that she was aware that policy review/revisions were not up to date.
10. Record review of facility policies in the Swing Bed Manual provided by the facility and verified by Staff L, Chief Nursing Officer (CNO), as the current Swing Bed Manual showed policies dated from the year 1997 through the year 2007. No current policies were in the manual.

During an interview on 07/30/14 at 10:30 AM, Staff R, Case Manager, stated that she was responsible for the facility Swing Bed Services. Staff R stated, "The Swing Bed Manual is a disaster and needed to be revised" and "there aren't any policies on the computer, they were deleted years ago." Staff R stated that the policies used for swing bed residents were the same policies used for all patients in the hospital and all patients were treated alike.

11. Record review of the facility annual program evaluation dated June 2014 review showed no review of the Swing Bed Program.
















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