HospitalInspections.org

Based on medical record review, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a complete discharge summary for 4 of 4 swing bed patients (Patients 32, 33, 35 and 36) reviewed. This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 24 was 54 swing bed patients.

Findings are:

A. Review of Patient 32's medical record (5/21/25 at 5:00 PM) revealed a swing bed admission of 12/31/24 - 2/14/25 for a right distal femur fracture (a broken thigh bone that happens near the knee joint). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient's status with all comprehensive assessment requirements documented (Customary routine, communication, mood and behavior patterns, disease diagnoses and health conditions, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications).
- Review of Patient 33's medical record (5/22/25) revealed a swing bed admission of 1/22/25 - 1/27/25 for a catheter associated urinary tract infection and clostridioides difficile (c-diff a serious infection leading to diarrhea and inflammation of the colon). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient's status with all comprehensive assessment requirements documented (customary routine, mood and behavior patterns, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications).
- Review of Patient 35's medical record (5/22/25) revealed a swing bed admission of 4/30/25 - 5/5/25 for pneumonia needing intravenous antibiotics (antibiotics given through a catheter in the vein). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient's status with all comprehensive assessment requirements documented (customary routine, vision, continence, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications).
- Review of Patient 36's medical record (5/22/25) revealed a swing bed admission of 2/3/25 - 2/27/25 for congestive heart failure exacerbation (CHF - the heart is unable to pump enough blood to meet the body's needs with a sudden worsening of symptoms such as shortness of breath, fatigue, swelling in extremities and persistent cough). Review of the entire medical record revealed a lack of evidence of a complete discharge summary of the patients stay that included a final summary of the patient's status with all comprehensive assessment requirements documented (customary routine, mood and behavioral pattern, continence, skin condition, and reconciliation of all pre-discharge medications with the post discharge medications).


B. Review of facility policy Discharge Summary Policy (Effective Date: 5/20/2025) revealed, the discharge summary will include a synopsis of the patient's swing bed stay, disposition, plans for continuity of care and condition at the time of discharge. Additional pages may be attached.

C. Interview with Chief Nursing Officer (CNO) (5/22/25 at 11:05AM) revealed, the current swing bed policies provided on request are all the facility has. CNO has started to review policies but was unaware that policies were from outdated regulations.

-Interview with RN-A (5/22/25 at 11:20AM) revealed, all printed documents requested for swing bed patients are the complete discharge summary or recapitulation of the patient stay.