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Based on review of Facility documents and staff interviews, the Facility failed to ensure that its staff was licensed, certified, or registered in accordance with Federal, State and local laws and regulations.

FINDINGS:

1. The Facility did not ensure that all staff required to be licensed possessed a current license or otherwise met the minimum requirements of certification or registration.

a) A review of the Facility's credential files revealed a physician whose appointment expired 12/14/12. The physician's lack of appointment was not discovered by the Facility until 04/04/13 and the physician was providing care in the Facility. The physician was given temporary privileges on 05/02/13 during the survey.

b) A review of the Facility's human resource records revealed a Registered Nurse (RN) had been providing care without a Colorado license since 03/30/12.

c) A review of the Facility's human resource records revealed a Certified Nurse Assistant (CNA) whose licensed expired 01/31/12 had been providing care and continued to be scheduled to provide care and sign documents as a CNA dispute the expired license.

d) A review of the Facility's human resource records revealed a Surgical Technician had been employed and oriented dispute having no surgical technician registration in Colorado.

e) The Facility did not have a policy addressing licensure/certification verification until 05/01/13 which had not yet been reviewed and approved by the governing body.

Based on observations, interviews, and document review, the facility failed to ensure that medications and supplies available for patient use were appropriately stored.
This failure created the potential for negative patient outcomes by the facility having expired medications and supplies readily available for staff to use in providing patient care.

Findings:

1. The facility did not follow manufacturer's specifications when warming intravenous fluid.

a) Observations were conducted on 04/30/13 at 8:13 a.m. of the facility's Emergency Department and Medical-Surgical Nursing Unit with the facility's Emergency Department/Med-Surg Director. A warming cabinet in the department contained 6 bags of intravenous fluids. One of the bags of fluid was removed from the outer protective bag. None of the bags had an indication of when they had been placed in the warmer or when they needed to be removed from the warmer. The findings were confirmed with the Emergency Department/Med-Surg Director.

b) During the above observation, it was noted that there was not a record of the temperature of the cabinet being monitored. An interview with the facility's Emergency Department/Med-Surg Director during the observation confirmed the lack of monitoring. S/he also confirmed that the one bag of intravenous fluid should not have been in the warmer after it was removed from its outer covering.

c) An interview was conducted with the facility's pharmacist on 04/30/13 at 8:43 a.m. S/he confirmed that there was a defined time frame from each manufacturer that stated how long fluids can remain in the fluid warmer. S/he confirmed that the hospital staff should be following these specifications.

d) A subsequent interview with the facility's Emergency Department/Med-Surg Director on 05/02/13 at 11:50 a.m. revealed that the facility had adopted a policy regarding fluids in warmers to follow the strictest specifications of the multiple manufacturers the hospital uses.

2. The facility did not follow standards of practice for multidose intravenous medications.

a) A position paper from the Association of Professionals in Infection Control and Epidemiology (APIC) titled, "Safe Injection, Infusion and Medication Vial Practices in Healthcare" published July 30th, 2009 stated the following:
"The transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures continues to occur due to unsafe and improper injection, infusion and medication vial practices being used by healthcare professionals within various clinical settings throughout the United States ...
APIC strongly supports adherence to the following safe injection, infusion and medication vial practices...Dispose of opened multidose medication vials 28 days after opening..."

b) Observations, on 04/30/13 at 10:00 a.m., were conducted in the surgical department of the cart used by anesthesia staff for medications. Within the care was found open vials of labetalol, succinylcholine, and lidocaine without indication of when the vials had been opened or needed to be discarded. Additionally, there was a vial of neostigmine that was dated 3/5/13 (indicating that the vial had been opened nearly 2 months).

c) An interview was conducted with the Certified Registered Nurse Anesthetist (CRNA) that was present during the above observations. S/he stated that the vials were typically kept for one week after opening and stated that it was expected for staff to write when the vial had been opened. S/he stated that s/he had not opened the vials that were in the cart that day as the facility had no surgical cases scheduled that day.

3. The facility did not discard expired medications.

a) Observations were conducted on 04/30/13 at 8:13 a.m. of the facility's Emergency Department and Medical-Surgical Nursing Unit with the facility's Emergency Department/Med-Surg Director. A refrigerator contained 3 saline bullets with a manufacturer's expiration date of 01/12. Within the medication room cabinet 2 bottles of betadine were found that had manufacturer's expiration dates of 06/12 and 10/10.

b) An interview was conducted with the facility's pharmacist and the facility's Emergency Department/Med-Surg Director on 04/30/13 at 8:43 a.m. They stated that expired medications should be discarded before the manufacturer's expiration date. They confirmed the above findings of expired items.

Based on medical record review, and staff interview the facility failed to ensure that the CAH's policies and procedures were administered so as to provide quality health care in a safe environment.

Findings:

1. The facility did not ensure that orders for care were written by a credentialed and privileged member of the CAH's medical staff.

a. A review of Sample Patient #15's medical record revealed that the patient's admission orders to the hospital's Swing-Bed program were written by the physician from the sending acute care hospital in another city. The orders were on the distant Acute Care Hospital's letterhead and were titled "Nursing Home Admission Orders" and were only signed by the physician at the distant Acute Care Hospital. There were no additional orders for admission to the CAH's Swing-Bed program and the orders included medications and treatments that were then provided to the patient in the CAH upon the patient's admission on 03/25/13 at 1:15 p.m. The attending physician at the CAH wrote an order on 03/26/13 at 12:15 a.m. to "Please see [distant Acute Care Hospital's] transfer/swingbed orders."

b. An interview was conducted with the facility's Emergency Department/Med-Surg Director on 05/02/13 at 11:58 p.m. S/he confirmed that the physician that signed the order for Sample Patient #15 was not privileged at the CAH to write orders for care. Additionally, s/he confirmed that the care provided to the patient was guided by the orders written by the non-privileged provider.

c. A review of Sample Patient #14's medical record revealed that the patient's admission orders to the hospital's Swing-Bed program were written by the physician from the sending acute care hospital in another city. The orders were on the distant Acute Care Hospital's letterhead and were titled "Nursing Home Admission Orders" and were only signed by the physician at the distant Acute Care Hospital. There were no additional orders for admission to the CAH's Swing-Bed program and the orders included medications and treatments that were then provided to the patient in the CAH upon the patient's admission on 04/24/13 at 7:15 p.m. The attending physician at the CAH wrote an order on 04/25/13 at 8:30 a.m. to change doses to two of the medications listed on the previous order, but did not address the remaining orders written by the non-privileged provider.

d. An interview was conducted with the facility's Emergency Department/Med-Surg Director on 05/02/13 at 11:18 p.m. S/he confirmed that the physician that signed the order for Sample Patient #14 was not privileged at the CAH to write orders for care. Additionally, s/he confirmed that the care provided to the patient was guided by the orders written by the non-privileged provider.



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Based on tours/observations, staff interviews, review of medical records and Facility documents, the governing body and/or responsible individual failed to adequately determine, implement and monitor the policies governing the Facility's total operation and to ensure that those policies were administered so as to provide quality health care in a safe environment in multiple departments and functions of the facility.

The failures created the potential for negative patient outcomes.

FINDINGS

Reference Tag C 224 - Maintenance: the facility failed to ensure that drugs and biologicals available for patient use were stored so that expired medications were not available for patient use.

Reference Tag C 278 - Patient Care Policies - Infection Control:
The facility failed to ensure that infection control and safe food handling standards were maintained in food and nutrition areas.

Reference Tag C 279 - Patient Care Policies - Food and Dietary:
The Facility failed to ensure that all food stored in refrigerators, freezers, and in other storage areas was labeled to identify open date, expiration/discard date and manufacturer's expiration date, to prevent use of contaminated or "spoiled" food products in the preparation and serving of meals to patients. The failure created the potential for negative patient outcomes.

Reference Tag C 280 - Patient Care Policies - Annual Provider Review of Policies:
The Facility failed to have a process in place for annual policy review by a group of professionals.

Reference Tag 285 - Services provided through agreements or arrangements:
The Facility failed to assess its contracted services and take actions through the Facility's Quality Assurance program to identify and correct quality or performance problems and implement improvement activities.

Reference Tag C 291 - Services by Agreement -Contract List:
The facility failed to maintain a complete and accurate list of all services furnished under arrangements or agreements, including the nature and scope of the services provided.

Reference Tag C 298 - Nursing Care Planning:
The Facility failed to ensure a nursing care plan was developed and kept current for each inpatient.

Reference Tag C 331 - Periodic Evaluation:
The Facility failed to ensure that an evaluation of its total program was carried out at least once a year.

Reference Tag C 333 - Periodic Evaluation:
The Facility failed to ensure that an evaluation was done at least once a year that included a review of a representative sample of both active and closed clinical records. The facility failed to ensure that members of the medical staff were involved in the annual review.

Reference Tag C 334 - Health Care Policies:
The facility failed to ensure that its health care policies were reviewed and revised as a part of an annual program evaluation.

Based on the manner and degree of deficiencies cited the Facility failed to be in compliance with the Condition of Participation of Provision of Services. The Facility failed to ensure that all clinical services were provided in a safe and effective manner to meet the needs of the patients.

The Facility failed to meet the following standards under the Condition of Provision of Services:

Reference Tag C 276 - Patient Care Policies - Safe Storage of Medications:
The facility failed to ensure that all medications were maintained and stored in accordance with accepted professional principle and their own policies and procedures.

Reference Tag C 278 - Patient Care Policies - Infection Control:
The facility failed to ensure that infection control and safe food handling standards were maintained in food and nutrition areas.

Reference Tag C 279 - Patient Care Policies - Food and Dietary:
The facility failed to ensure that all food stored in refrigerators, freezers, and in other storage areas was labeled to identify open date, expiration/discard date and manufacturer's expiration date, to prevent use of contaminated or "spoiled" food products in the preparation and serving of meals to patients.

Reference Tag C 280 - Patient Care Policies - Annual Review:
The facility failed to have a process in place for annual policy review and approval by a group of professionals.

Reference Tag 285 - Services provided through agreements or arrangements:
The Facility failed to assess its contracted services and take actions through the Facility's Quality Assurance program to identify and correct quality or performance problems and implement improvement activities.

Reference Tag C 291 - Services Provided Through Agreement/Arrangement - List of Contracted Services:
The Facility failed to maintain a complete and accurate list of all services furnished under arrangements or agreements, including the nature and scope of the services provided.

Reference Tag C 298 - Nursing Care Planning:
The Facility failed to ensure a nursing care plan was developed and kept current for each inpatient.

Based on observations, document review, and staff interviews, the facility failed to ensure that facility practices were performed in a manner that would prevent communicable diseases and food-bourne illnesses.

These failures created the potential for harm to patients from infectious agents and food-borne pathogens.

FINDINGS:

1. The facility did not ensure that cleaning solutions were properly diluted to ensure effective cleaning and disinfection of equipment used during patient procedures prior to sterilization

a) On 04/30/13 at 10:15 a.m., a tour of the facility's surgical area was conducted with the facility's Director of Surgical Services. During the tour, the facility's sterile instrument cleaning area was viewed and an interview was conducted with the Technician responsible for the processing of surgical instruments. The Technician stated that sterile equipment was pre-cleaned in a cleaning solution that s/he mixed prior to putting them into the sterile instrument washer. The Technician confirmed that the manufacturer had specifications on the proper dilution of the solutions used, but admitted that the amount of water used was not measured. S/he stated there was no marking on the sink to indicate the level of water in the sink or how many gallons it could hold. The facility's Technician was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

b) A review of the manufacturer's directions for use was performed with the Technician and the Director of Surgical Services. The instructions stated that 1/8 to 1/2 ounce of the solution was to be diluted in each gallon of water used.

2. The facility did not ensure that food stored in patient care areas was discarded per the facility's policy, or per manufacturer's expiration dates.

a) On 04/30/13 at 09:09 a.m., observations were conducted of the facility's Medical/Surgical Patient Care area and Emergency Department. A refrigerator, used for storage of food items available for patient use, was found to contain a a container of romaine lettuce (that had turned brown on the edges) with a manufacturer's use by date of 3/16/13. Additionally the freezer contained 2 beef stew meals with a manufacturer's use by date of 3/1/13 and 5 macaroni and cheese meals with a manufacturer's use by date 4/2/13. The freezer also contained three baggies with 2 slices of bread in each that were not labeled with a date as to when they were placed into the freezer or when the bread should be consumed by. The Interim Dietary Manager was present during the observations and confirmed the dates above. Additionally, in the cupboard in the kitchen contained 11 baggies of various dry cereals that had no indication of when the cereal would no longer be safe for consumption.

b) An interview was conducted with the Interim Manager of the Dietary Department during the above observations. S/he stated that the staff was expected to indicate on items when they needed to be discarded. S/he also stated that the dietary staff was expected to discard the expired items when found on their regular rounds of the kitchen area and when they restocked.


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3. The Facility did not ensure food items in the kitchen were dated for expiration.

a) Food items i,e. green chili sauce and cooked eggs were stored in the refrigerated unit by the stove and were not dated to indicate when the items were made or when they would expire.

b) Food and condiments in the stand up refrigeration unit i.e. individual butter, liquid cooking butter and salad dressings were not labeled with an expiration date.

c) In an interview on 04/30/13, the Interim Dietary Manager confirmed that the items lacked expiration dates.

Based on Facility record review and interviews, the Facility failed to assess the services provided to the Facility by agreement or arrangement.

FINDINGS:

1. The Facility did not ensure that contracts were reviewed by the governing body and integrated into the Facility's quality assurance (QA) program to identify quality performance problems and implement appropriate corrective or improvement and monitoring activities.

a) There was no evidence of a process of assessment of the Facility's contracted services in the Facility's QA meeting minutes.

b) There was no evidence of a review of the Facility's contracted services by the governing body.

c) In an interview on 05/01/13, the Directors of Nurses (DON) and the Quality Manager admitted that the contract services were not integrated into the Facility's QA program for assessment of the quality of services rendered. The DON stated that each department "head" reviews their own contracts.

Based on Facility record review and interviews, the Facility failed maintain a list of contracted services provided.

FINDINGS:

1. The Facility did not maintain a list of contracted services with delineation of contractor responsibility.

a) A list of the Facility's contracted services was compiled during the survey. The compiled list did not delineate contractor responsibilities and the terms of renewal of some contracts were not defined on the list.

b) In an interview on 05/02/13 Directors of Nurses (DON) and the Quality Manager confirmed that the contract services were not in a central list. The DON stated that each department "head" reviews their own contracts.

Based on tours/observations, staff interviews and review of medical records and facility documents, the governing body and the person principally responsible for the operation of the Facility failed to ensure that the policies were administered so as to provide quality health care in a safe environment in multiple departments and functions of the facility and outpatient clinics.

FINDINGS:

1. The Governing Body and the person principally responsible for the operation of the Facility did not ensure that Facility areas of operation were monitored and managed through operating policies.

a) The Facility's Quality Assurance program did not meet the Conditions of Participation for annual evaluation of the total program's appropriateness and effectiveness.

b) Patient Care policies were not reviewed and revised annually by the Governing Body and a group of professionals.

c) Contracts were not listed centrally with a delineation of contractor responsibilities and terms of renewal.

d) Credential files were incomplete and 1 physician was not credentialed but continued to provide care.

e) Human Resource files were incomplete with 3 practitioners practicing without licensure, certification or registration.

f) Medical records are not consistently reviewed for quality of care and documentation.

g) Medical records did not include documentation of comprehensive patient care plans as required.

g) Food and nutrition areas were not managed according to infection control and safe food handling standards.

i) Expired medications were found stored in areas available for patient use.

Based on medical record review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that a nursing care plan was developed and kept current for each inpatient.

This failure resulted in patient care not being directed by a plan that addressed the patient's ongoing needs.

Findings:

1. A review of 14 inpatient records revealed that 13 of the 14 inpatient records did not contain an adequate nursing care plan.

a. A review of the facility's policy, "Care Planning", revealed that the facility expected the nursing staff to create and keep updated a nursing care plan for "all patients." The policy specified that care plans needed to be developed within 24 hours of admission.

b. A review of 11 inpatient records (Sample Patients #1, 4, 5, 6, 7, 8, 9, 11, 12, 13, and 16) and 3 swing-bed patient records (Sample Patients #10, 14, and 15) revealed that there were no documented nursing care plans in 11 (Sample Patients #1, 4, 5, 6, 7, 9, 10, 11, 12, 13, and 16) of the records. Additionally a review of the care plans present in Sample Patients #14 and 15 record's revealed that the care plans were inadequate and did not address multiple issues for each patient.

c. An interview was conducted with the facility's Emergency Department/Med-Surg Director on 05/01/13 at 8:05 a.m. S/he stated that every patient, except observation status patients were expected to have a nursing care plan in their record. During a subsequent interview on 05/02/13 at 11:50 a.m. s/he confirmed that the above records did not have a nursing care plan.

d. A review of Sample Patient #14's record was conducted on 05/02/13 with the facility's Emergency Department/Med-Surg Director. The patient was admitted to the hospital's Swing-Bed program for hepatic encephalopathy. The patient's care plan addressed "fluid volume excess, nutrition, knowledge deficit, and ineffective therapeutic regimen management." The care plan did not address the patient's skin (which was reddened and required interventions to prevent further breakdown), respiratory status (the patient required supplemental oxygen his/her entire stay) or the patient's safety (the patient was determined to be a "high fall risk"). An interview with the facility's Emergency Department/Med-Surg Director during the record review confirmed that the nursing care plan did not adequately address the patient's ongoing needs.

e. A review of Sample Patient #15's record was conducted on 05/02/13 with the facility's Emergency Department/Med-Surg Director. The patient was admitted to the hospital's Swing-Bed program for recovery after having spinal surgery at another hospital. The patient's care plan addressed "activity intolerance, impaired physical mobility and potential for infection." The care plan did not address the patient's skin (which was compromised as the patient's wound had separated during her acute care hospitalization elsewhere), pain (the patient required pain medication due to his/her surgery and ongoing chronic pain) or the patient's nutrition status (the patient required a dietician consult due to poor appetite and the sensation that all food tasted like chemicals to the patient). An interview with the facility's Emergency Department/Med-Surg Director during the record review confirmed that the nursing care plan did not adequately address the patient's ongoing needs.

Based on medical record review and staff interview the facility failed to ensure that each patient receiving health care services had a medical record that included evidence of a properly executed informed consent for treatment.

The failure for staff to ensure that informed consent is obtained from each patient resulted in the potential for patients to be treated against their will.

Findings:

1. A review of 16 inpatient records revealed that 1 (Sample Patient #1) of the 16 records did not have a signed informed consent for treatment.

a. A review of Sample Patient #1's medical record was conducted on 05/01/13. The chart contained an informed consent form for admission. The form was not signed and rather stated that the "patient not willing to sign." The patient's record contained forms stating that the patient had a court appointed guardian. There was no documentation that the patient's guardian signed the consent form for the patient or that any effort was taken to obtain a signature to document that the patient or the patient's guardian consented for the patient's treatment and admission.

b. An interview was conducted with the facility's Emergency Department/Med-Surg Director on 05/01/13 at 10:08 a.m. confirmed that Sample Patient #1's record did not contain a signed informed consent, but that it should have.

Based on the manner and degree of deficiencies cited the Facility failed to be in compliance with the Condition of Participation of Periodic Evaluation and Quality Assurance Review. The Facility failed to ensure that it had an effective and comprehensive program to periodically evaluate the care provided and conduct quality assurance activities that were required by regulation.

The Facility failed to meet the following standards under the Condition of Periodic Evaluation and Quality Assurance Review:

Reference Tag C 331 - Periodic Evaluation: the Facility failed to ensure that an evaluation of its total program was carried out at least once a year.

Reference Tag C 333 - Periodic Evaluation: the Facility failed to ensure that an evaluation was done at least once a year that included a review of a representative sample of both active and closed clinical records. The facility failed to ensure that members of the medical staff were involved in the annual review.

Reference Tag C 334 - Health Care Policies: the facility failed to ensure that its health care policies were reviewed and revised as a part of an annual program evaluation.

Based on record review and staff interview, the Facility's failed to carry out an evaluation of its total program at least yearly.

FINDINGS:

1. The Facility did not have a mechanism evaluate the appropriateness and effectiveness Quality Assurance (QA) program.

a) There was no documentary or other evidence that the QA program had been evaluated or that the medical staff had been involved an evaluation of the program.

b) In an interview on 05/013 the Quality Manager confirmed that the program had not been evaluated since s/he became the manager of the program.

Based on Facility record review and staff interviews, the Facility failed to ensure that an evaluation was done at least once a year that included a review of a representative sample of both active and closed clinical records. The facility failed to ensure that members of the medical staff were involved in the annual review.

FINDINGS:

1. The Facility did not carry out a periodic record review of a representative sample of open and closed records.

a) There was no documentary or other evidence demonstrating that periodic record reviews were consistently carried out.

b) In an interview on 05/02/13 the Quality Manager confirmed that periodic record reviews were not consistently carried out.

Based on document review and interviews the facility failed to evaluate the health care policies annually as required.

FINDINGS:

1) The facility did not have revised, signed and approved policies.

a.) A review of the Facility's policies revealed polices that were not approved and signed by the governing body, medical staff or nursing leadership.

b.) In an interview on 05/01/13 the DONs and the Quality Manager acknowledged that the policies were not signed or approved by the governing body or medical staff. The DONs and Quality Manger stated that a process had been developed, and was currently in progress, for the revision and approval of all of the policies at certain times during the year.

Based on medical record review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that a comprehensive care plan was developed and kept current for each swing-bed patient.

This failure resulted in patient care not being directed by a plan that addressed the patient's ongoing needs.

Findings:

1. A review of 3 swing-bed patient records revealed that all 3 of the 3 records did not contain an adequate nursing care plan.

a. A review of the facility's policy, "Care Planning", revealed that the facility expected the nursing staff to create and keep updated a nursing care plan for "all patients." The policy specified that care plans needed to be developed within 24 hours of admission.

b. A review of 3 swing-bed patient records (Sample Patients #10, 14, and 15) revealed that there were no documented nursing care plans in 1 (Sample Patient #10) of the records. Additionally a review of the care plans present in Sample Patients #14 and 15 record's revealed that the care plans were inadequate and did not address multiple issues for each patient.

c. An interview was conducted with the facility's Emergency Department/Med-Surg Director on 05/01/13 at 8:05 a.m. S/he stated that every patient, except observation status patients were expected to have a nursing care plan in their record. During a subsequent interview on 05/02/13 at 11:50 a.m. s/he confirmed that the above records did not have a nursing care plan.

d. A review of Sample Patient #14's record was conducted on 05/02/13 with the facility's Emergency Department/Med-Surg Director. The patient was admitted to the hospital's Swing-Bed program for hepatic encephalopathy. The patient's care plan addressed "fluid volume excess, nutrition, knowledge deficit, and ineffective therapeutic regimen management." The care plan did not address the patient's skin (which was reddened and required interventions to prevent further breakdown), respiratory status (the patient required supplemental oxygen his/her entire stay) or the patient's safety (the patient was determined to be a "high fall risk"). An interview with the facility's Emergency Department/Med-Surg Director during the record review confirmed that the nursing care plan did not adequately address the patient's ongoing needs.

e. A review of Sample Patient #15's record was conducted on 05/02/13 with the facility's Emergency Department/Med-Surg Director. The patient was admitted to the hospital's Swing-Bed program for recovery after having spinal surgery at another hospital. The patient's care plan addressed "activity intolerance, impaired physical mobility and potential for infection." The care plan did not address the patient's skin (which was compromised as the patient's wound had separated during her acute care hospitalization elsewhere), pain (the patient required pain medication due to his/her surgery and ongoing chronic pain) or the patient's nutrition status (the patient required a dietician consult due to poor appetite and the sensation that all food tasted like chemicals to the patient). An interview with the facility's Emergency Department/Med-Surg Director during the record review confirmed that the nursing care plan did not adequately address the patient's ongoing needs.

Based on medical record review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that a comprehensive care plan was developed and kept current for each swing-bed patient.

This failure resulted in patient care not being directed by a plan that addressed the patient's ongoing needs.

Findings:

Cross Reference to C0395 - Comprehensive Care Plans: for findings related to the facility's failure to ensure that a comprehensive care plan was developed and kept current for each swing-bed patient.

1. A review of Sample Patient #15's record revealed that the patient's care plan was not updated and periodically reviewed according to the facility's policy.

a. An interview with the facility's Emergency Department/Med-Surg Director was conducted on 05/02/13 at 11:43 a.m. S/he stated that the facility was required to have the interdisciplinary team to meet and update the patient's plan of care every 7 days while the patient remained in the facility's Swing-Bed program.

b. A review of Sample Patient #15's record was conducted on 05/02/13 with the facility's Emergency Department/Med-Surg Director. The patient was admitted to the hospital's Swing-Bed program for recovery after having spinal surgery at another hospital on 03/25/13. There was no documentation of the interdisciplinary team meeting at any point during the patient's 16 day stay.

c. An interview with the facility's Emergency Department/Med-Surg Director during the review of the above record confirmed that there was no documentation of the team meeting with the patient or at all to address the plan of care for the patient. S/he stated that it would be expected that the team would have met twice during the patient's stay since the team was expected to meet every 7 days.