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Based on observation, interview, record review, policy review, and review of the United States Pharmacopoeia (USP) Chapter 797, the facility failed to:
- Ensure that staff followed the infection prevention standards for the USP for compounded sterile preparations.
(C-0276).
- Ensure that staff followed infection control policies and infection prevention standards. (C-0278).
- Ensure that staff followed the standard of practice and provided consistent cardiac (heart) monitoring for two patients (#5 and #6) of two patients observed, that were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm). (C-0294).
- Ensure that staff followed physician orders for one patient (#4 ) of two patients observed for wound care treatment and prevention. (C-0294).
- Consistently assess pain levels per use of a numeric or visual pain rating scale prior to the administration of as needed (PRN) medications for three patients (#10, #14, #17) of five patients reviewed. (C-0297).
- Follow the medication administration policy and assess patients' responses to PRN medications for three patients (#10, #14, #17) of five patients reviewed. (C-0297).
The cumulative effects of these failures resulted in non-compliance with 42 CFR 485.635 Condition of Participation: Provision of Services.

Please see the 2567 for additional information.

C-0276

Based on observation, interview, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination), the facility failed to ensure that staff followed the infection prevention standards when they failed to:
- Provide an adequate segregated compounding area (SCA, a separate area designated for drug compounding) for the Benchtop Bioflow Chamber (BBF, a chamber that provides an environment free of dust particles, aerosol particles, and other contaminates).
- Document and clean the buffer area (sterile zone in the pharmacy where CSPs are prepared) on days that medications were compounded.
- Have a documented growth media (test to ensure proper cleaning technique) sampling;
- Have a documented proper garbing/procedure (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test (test to ensure staff who process CSPs were able to prevent contamination of the CSP);
- Have a written record or log that demonstrates that the CSP was performed properly.
These failed practices had the potential to increase the risk of cross contamination in CSPs that may result in patient harm and/or death. The facility performs approximately 300 CSPs per month. The facility census was 8 swing-bed and 4 acute.

Findings included:
Review of the USP, Chapter 797, dated 2013, showed that:
- The buffer area floors should be cleaned daily, and walls, ceilings and storage shelving cleaned monthly, and documented on a cleaning log;
- Sampling plans that included surface disinfection sampling (growth media requirements) should be performed on a periodic basis, at a minimum of every six months;
- Low risk compounding required proper garbing/procedures (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test; and
- A documented log or written record that the CSP was performed properly, should be easily accessible.

Review of the facility's policy titled, "Laminar Airflow Hoods", dated 01/20/16 showed:
- Laminar airflow hoods are required for preparing sterile products. It will be located in a clean, well-lit room that provides ISO class seven air (the level of cleanliness of the room).
- The hood will be located in a buffer or clean area, free from traffic. The clean area will be an area which extends a reasonable clearance in front of the hood.
- Personnel must comply with aseptic practices (prevent contamination from germs) and procedures prior to entering the buffer area.
- The work area should be cleaned with 70% alcohol. The work surface should be cleaned prior to and after each shift, after spills, and a minimum of every 12 hours while the pharmacy is open.
Review of the facility's policy titled, "Aseptic Technique", dated 01/20/16 showed:
- The pharmacy will prepare sterile products using aseptic technique.
- Personnel preparing to enter the clean room must remove all outer garments and don personnel protective equipment (gown, shoe covers, head and facial hair covers, and face masks).
Review of the facility's policy titled, "Education, Training, Competency, and Documentation Checklist" dated 01/20/16 showed:
- The Director of Pharmacy should verify, as a part of the pharmacy's competency program, that personnel who prepare sterile products are properly trained and can demonstrate proficiency in preparing sterile products. Training should be completed initially, and annually thereafter.
- All compounding personnel will successfully complete didactic review, observation of technique, testing, glove fingertip and thumb sampling, and media fill testing initially, a documented breach of procedure, and annually.
- After used supplies have been removed, clean the hood.

Observation on 01/29/19 at 2:50 PM showed the following:
- A barrier isolator (provides a physical barrier for compounding CSPs) within the pharmacy;
- The barrier isolator was located to the right of the main entrance to the Pharmacy.
- There was no area of separation between the isolator and the main Pharmacy prep and storage area.
- There was no log that demonstrated when the buffer area was cleaned;
- There was no log that demonstrated a successful glove fingertip test; and
- No documented written record or log that demonstrated that the CSPs were performed properly.

During an interview on 01/29/19 at 3:00 PM, Staff C, Director of Pharmacy, stated that he:
- Performed approximately 300 CSPs per week;
- Had no log of the CSPs that were performed;
- Had no documented growth media sampling;
- Had no documented successful glove fingertip test available;
- Had no cleaning log for the buffer area or the barrier isolator;
- Was unaware that personnel performing compounding should wear personal protective equipment;
- Was unaware that the isolator should be cleaned prior to and after each shift, after spills, and a minimum of every 12 hours while the pharmacy is open;
- Was aware that the isolator should be in a separate are with minimum traffic and away from stored items.
- Was aware of the education requirements and that they had not been done.

During an interview on 01/29/19 at 3:00 PM, Staff A, CEO, Interim CNO, stated that she was unaware of the requirements of compounding and that the Pharmacy was not in compliance.

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene (wash hands with soap and water or use alcohol-based hand sanitizer) before and after glove use, after touching inanimate objects (non-living objects, such as containers, tables, etc.), and between wound care tasks for one patient (#4) of two patients observed for wound care.
- Ensure staff did not place supplies directly on the contaminated, over-the-bed tables, without disinfection or barrier, for one patient (#4) of two patients observed for wound care.
- Ensure over-the-bed tables were disinfected after contaminated supplies were placed on the surface of one patient's (#4) table of two patients observed for wound care.
- Disinfect the contaminated wound cleanser and medication containers used for wound care before they were returned to the storage area in the patient's room for one patient (#4) of two patients observed for wound care.
- Ensure infection control procedures were followed when contaminated bed linens were thrown onto the floor from one patient's (#4) bed of two patients observed for wound care.
- Discard contaminated wound dressing into bio-hazardous waste receptacle for one patient (#4) of two patients observed for wound care.
- Place initials and date on the new dressing after wound care was completed on one patient (#4) of two patients observed for wound care.

These failed practices had the potential to expose all patients, visitors, and staff to cross-contamination and increased the potential to spread infection. The facility census was 12.

Findings included:

1. Review of the facility's policies titled, "Handwashing," reviewed 04/2018, and "Hand Hygiene-Centers for Disease Control (CDC) Guidelines," reviewed 04/2018, showed the following:
- The facility followed the recommended practices for Infection Prevention by the CDC.
- Hand hygiene is a simple procedure that had been proven to be the most effective way to prevent infection.
- All staff would use hand-hygiene techniques as set forth in the CDC recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water, or an alcohol-based hand rub before coming on duty, when hands were soiled, before each patient encounter, before and after glove use, after contact with patient's intact and non-intact skin, after staff worked on a contaminated body site and before staff moved to a clean body site on the same patient, and after contact with bodily fluids, dressings, mucous membranes and hands that were visibly soiled.
- Effective hand hygiene removed microorganisms (bacteria, virus or fungus), dirt, and material from the hands, and decreased the risk of cross-contamination from patients, patient care equipment, and the environment.

2. Review of the facility's policy titled, "Standard Precautions: Infection Control," reviewed 11/2011, showed directives for staff to perform the following:
- Standard precautions were designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Patient care equipment soiled with blood or body fluids must be handled in a manner that prevented skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.
- Handle, transport, and process used linen soiled with blood and body fluids in a manner that prevented skin and mucous membrane exposures, contamination of clothing, and avoided transfer of microorganisms to other patients and environments.
- Soiled linen should be handled as little as possible to prevent the spread of infectious diseases. Soiled linen may be contaminated with pathogenic microorganisms and should not be shaken. They should be placed in covered linen bags and closed when full.
- Infection prevention techniques for cleaning and disinfecting environmental surfaces, carpeting and furniture, and techniques for disposal of regulated and non-regulated waste.

3. Review of the facility's policy titled, "Non-Sterile Dressing Change," reviewed 05/2013, showed the following:
- Prepare a clean, dry work area at the bedside with disinfection solution.
- Place trash bag at end of the bed or within easy reach of work area. Discard into bio-hazardous waste receptacle when finished.
- Place initials and date on the new dressing.

Observation on 01/30/19 between 10:15 AM and 10:45 AM on the Medical Unit, showed Staff S, Registered Nurse (RN), entered the room of Patient #4 to apply a dressing to Patient #4's sacral wound. Staff S failed to:
- Disinfect or place a barrier on the work area before the wound care supplies were placed on the surface.
- Ensure the over-the-bed table was disinfected after contaminated supplies were placed on the surface for wound care.
- Disinfect the wound cleanser and medication containers used for wound care before they were returned to the storage area.
- Change gloves or perform hand hygiene between tasks and before the contaminated containers were returned to the storage area.
- Ensure infection control procedures were followed when contaminated bed linens were thrown onto the floor for wound care.
- Discard the contaminated wound dressing that was removed from Patient #4 into a bio-hazardous waste receptacle.
- Place initials and date on the new dressing when wound care was completed.

During an interview on 01/30/19 at 04:30 PM, Staff X, Infection Control Nurse, stated that staff were to:
- Disinfect and place a barrier on the work area when they performed wound care;
- Change gloves and perform hand hygiene after they touched inanimate objects and in between tasks after they worked on a contaminated body site and before they moved to a clean body site on the same patient for wound care.
- Disinfect the over-the-bed table after they placed contaminated supplies on the surface for wound care;
- Disinfect the wound cleanser and medication containers that were contaminated during wound care;
- Place contaminated bed linens in covered linen bags;
- Discard contaminated wound dressings into bio-hazardous waste receptacles; and
- Date and initial the new dressing when wound care was completed.

Based on observation, interview, record review, and policy review, the facility failed to:
1. Follow the standard of practice and provide consistent cardiac (heart) monitoring for two patients (#5 and #6) of two patients who were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm) in the Emergency Department (ED). This failure had the ability to affect all patients on cardiac telemetry, when the potential for abnormal changes in the heart's rhythm could go unnoticed.
2. Follow physician orders for one patient (#4) of two patients that received wound care and prevention.
The facility census was 12.

Findings included:

1. Review of the facility's policy titled, "Telemetry," reviewed 12/2018, showed that the purpose of telemetry was to provide a uniform method of performing cardiac monitoring. Patients that were ordered to have cardiac monitoring were to be assigned to Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) who were competent in cardiac rhythm strip interpretation.

Observation on 01/30/19 at 12:30 PM and again at 1:00 PM, at the nurses' station in the Emergency Department (ED), showed that two patients' (#5 and #6) heart rhythms were displayed on the cardiac telemetry monitor. No staff members were at the nurses' station, and the patients' heart rhythms were not monitored.

Review of Patient #6's physician's orders and History and Physical (H&P), dated 01/30/19, showed that Patient #6 was a 42-year-old male who arrived at the ED with complaints of fever that had persisted for two weeks, accompanied by rash, chills, and cough. Patient #6 was admitted due to his condition and the probability of imminent or life-threatening deterioration. Tachycardia (an abnormally rapid heart rate) was present and he was placed on telemetry for consistent cardiac monitoring.

Review of Patient #5's physician's orders and H&P, dated 01/30/19, showed that Patient #5 was a 61-year-old male who arrived at the ED with complaints of shortness of breath (SOB), and a medical history of asthma, chronic obstructive pulmonary disease (COPD, a lung disease that interferes with normal breathing), congestive heart failure (CHF, a weakening of the heart that leads to fluid in the lungs and surrounding body tissues), and hypertension (HTN, elevated blood pressure). Cardiac monitoring was initiated and Tachycardia was present.

During an interview on 01/30/19 at 3:00 PM, Staff B, RN, ED Director, stated that telemetry was not monitored continuously by staff, but that nurses were often in the area and when the telemetry alarm sounded, the nursing staff would hear it. If a patient was critical, they would be monitored at all times.

During an interview on 01/30/19 at 3:30 PM, Staff P, RN, Quality Assurance, and Staff A, RN, Chief Executive Officer (CEO) and Interim Chief Nursing Officer (CNO), stated that the telemetry monitor was located at the desk at the back nurses' station, where there were less staff available. She stated movement of the telemetry monitor to the desk at the front nurses' station had been discussed, as there were more nursing staff in the area. Staff A stated that the expectation of staff was that someone watched the cardiac monitors at all times.

2. Review of the facility's policy titled, "Transcribing Physician Orders," reviewed 11/2013, showed that the purpose was to outline the procedure for transcription, verification, and communication of physician orders in a timely manner. Once the orders were on the patients' charts, the nurses would verify the orders were correct in the Electronic Medical Record (EMR) and the orders would be initiated in a timely manner.

Review of Patient #4's physician's orders dated 01/15/2019, showed that the patient was to be up in the chair for four hours per day, in divided times, and heels floated when in bed or prevalon boots (help protect heels from pressure sores) used.

Observation of and simultaneous interview with Patient #4 on 01/29/19 at 10:30 AM, showed that prevalon boots were not in place and his heels were not floated. Patient #4 stated that he had not been up in his chair for days. He stated that he was not told to float his heels, he was not aware of any boots, and he thought he must have been on bedrest because no one told him he could get up in his chair. The white board that hung in his room indicated "Bedrest".

Observation on 01/30/19 at 11:00 AM, showed that Patient #4's prevalon boots were not in place and his heels were not floated. Patient #4 stated he still had not been offered to be up in his chair. The white board that hung in his room stated, "Bedrest".

During an interview on 01/30/19 at 11:30 AM, Staff F, RN, stated she was not aware that Patient #4 was to be up in a chair and she had not seen him up in a chair. Staff F stated that Patient #4 had pads in his socks, but she had not seen boots.

C-0297
Based on interview, record review and policy review, the facility failed to ensure nursing staff followed facility policy for PRN (as needed) pain medication, appropriately assessed pain level prior to administering PRN pain medications and reassessment for the patient's response to the medication, for three current patients (#10, #14, #17) of five patients reviewed. This failure had the potential to place all patients at risk for unrelieved pain, injury or death. The facility census was acute 4 and swing-bed 8.

Findings include:
Review of the facility policy titled, "Pain Management", revised 04/2017, showed that:
- It is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the intensity, quality and response to treatment.
- Patients are to rank their pain using a linear pain scale of 0-10 with 0 indicating no pain and 10 indicating severe pain.
-Patients should be taught that pain management is part of their treatment and the goal is to achieve optimal pain management.
- Management of the patient's pain is an interdisciplinary process and will to be included in the plan of care.
-All patients will undergo reassessment of pain at least twice per shift and after every pain control intervention.
- Oral pain medications will be reassessed and documented within one hour of administration.
- Intravenous (IV, given by vein) medications will be reassessed and documented within 30 minutes of administration.
- Reassessment should assess the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating scale and any use of analgesics (medications used to treat pain).

Review of Patient #10's History and Physical dated, 01/14/19 showed:
- Patient #10 was a 74 year old female admitted to the facility swing-bed program for Occupational Therapy (OT, rehabilitation specific to performance of activities of daily living), Physical Therapy (PT, treatments to help patients regain mobility and motion), Speech Therapy (ST, treatment that assists patients to relearn how to speak after an illness) and Social Services (SS, a program that assists patients and families to secure and sustain a healthy, safe, and productive lives) consult;
- Had a recent cerebrovascular accident (CVA,damage to the brain from interruption of its blood supply), and intracranial bleed (bleeding around or in the brain), causing weakness and chronic headaches;
- Had a G-Tube (a tube surgically implanted into the stomach used to provide nutrition to people who cannot obtain nutrition by mouth);
- Had physician orders for Tylenol (a medication to treat minor aches and pains) 325 milligrams (mg, a measure of dosage strength) PRN every 4 hours and Tramadol (an opioid medication used to treat moderate to severe pain) 50mgs PRN every 12 hours.

Review of Patient #10's Patient Progress Notes showed:
- On 01/15/19 at 8:18 AM the patient rated her pain a five on the pain scale of 0-10. There was no documentation that pain medications were given and reassessment performed.
- On 01/23/19 at 9:42 PM the patient rated her pain as three on the pain scale of 0-10. There was documentation that a PRN medication was given, but there was no documentation of the type of medication and no reassessment performed.

Review of Patient #14's History and Physical, showed that he had been admitted to the facility swing-bed program on 12/31/18 at 1:21 PM for Osteomyelitis (inflammation of bone caused by infection) of his left foot. He had physician orders for Percocet (a strong medication used to treat moderate to severe pain) 5/325mgs, one tablet every four hours PRN pain.

Review of Patient #14's Patient Progress Notes showed:
- On 12/31/18 at 2:15 PM Patient #14 rated his pain a seven on the pain scale of 0-10. Documentation on progress note stated, "will give PRN medication." There was no documentation of the the type of medication given, and no reassessment performed.
- On 01/01/19 at 3:00 AM there was no pain scale documented. Documetation on the progress note showed that Percocet 5/325mgs. was given. No reassessment performed.
- On 01/01/19 at 3:01 PM there was no pain scale documented. Documentation on the progress note showed a PRN medication was given. There was no documentation of the type of medication given and no reassessment performed.
- On 01/02/19 at 9:00 AM, Patient #14 complained of pain rated a 10 on the pain scale of 0-10. The progress note did not show any type of medication given and no reassessment performed.
- On 01/02/19 at 10:30 AM, Patient #14 complained of pain rated a 10 on the pain scale of 0-10. The progress note did not show any type of medication given and no reassessment performed.
- On 01/02/19 at 2:51 PM the patient reported uncontrolled pain.

Review of Patient #17's Physician Progress Notes showed that she was a 49 year old female, admitted on 01/28/19 at 4:52 PM for abdominal pain, liver cirrhosis (damage to liver), portal (an increase of blood pressure in the veins coming from internal organs), and pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the heart), and prerenal insufficiency (acute kidney damage). She had physician orders for Dilaudid 2mgs PRN pain.

Review of Patient #17's Patient Progress Notes showed:
- On 01/29/19 at 6:35 AM the patient received Dilaudid 2mgs. There was no documentation of the the patient's level of pain and no reassessment.
- On 01/29/19 at 8:49 PM the patient rated her pain as a 4 on the pain scale of 0-10. There was no further documentation.
- On 01/29/19 at 11:05 PM the patient received Dilaudid 2mgs. There was no documentation of the patient's level of pain and no reassessment performed.

During interview and concurrent record review on 01/29/19 at 10:14 AM Staff H, Medical Unit Nurse Manager, stated that her expectations of the nursing staff were to document a pain scale and a reassessment for PRN pain medications. She assisted with the chart reviews and was aware of the documentation failures.

C-0385

Based on observation, interview, and record review, the facility failed to complete comprehensive patient assessments for activities offered to swing bed patients (a specific type of reimbursement program for patients that require a skilled service, like therapy, but do not require acute care) for five current swing bed patients (#10, #11, #12, #14, and #18) of six reviewed. This had the potential to negatively impact the quality of life for the swing bed patient during their admission to the facility by failing to individualize activities to each patient's preference.
The total facility census was 12, which included eight swing bed patients.

Findings include:

Review of the facility's policy titled, "Patient Activities, Swing Bed," reviewed 10/2011, showed the following:
- The Certified Activities Director will be responsible for the Activities Program.
- Activities will be provided on a daily basis.
- The attending Physician and the Interdisciplinary Treatment Team approve each activity to avoid conflicts with other treatment plans.
- Appropriate staff members will be consulted in order to ensure the activities are designed to promote physical, social and mental well-being for the Patient.
- Activities will be designed to promote opportunities for the Patient to engage in normal pursuits, including religious activities.
- Activities will be offered individually or within a group.
- The patient's response, participation, and refusal to participate will be documented and monitored.
- Programs in art, crafts, music, recreation and library will be available and offered to the patient.

During observation and concurrent interview on 01/29/19 at 10:14 AM showed no activity calendars posted in any of the patient rooms, waiting rooms, hallway or nursing station. Staff H, RN, Nurse Manager, Medical Unit, stated there were no activity calendars and all activities were based on each patient's individual likes and dislikes.

During an interview on 01/30/19 at 10:00 AM, Patient #10 stated that she did not know of a calendar for activities and did not recall any group activities. She had not been offered anything to do outside of her room.

Review of Patient #10's medical record, showed the patient was a 74 year old female, admitted on 01/14/19 at 1:17 PM to the facility swing-bed program for Occupational therapy (OT, treatments specific to helping patients regain activities of daily living), Speech Therapy (assisting patients to relearn how to speak after an illness), Physical Therapy (PT, treatments to help patients regain mobility and motion), and Social Services (SS, a program that assists patients and families to secure and sustain a healthy, safe, and productive lives) consult.

Review of Patient #10's Social Services Assessment showed that on 01/15/19 at 11:24 AM, Staff N, Social Worker (SW), documented that socialization (a verbal conversation between the patient and the Social Worker) had been the patient's activity for the day. The patient had not felt up to activities at that time, and stated that she may have her family bring books and crafts from home.

Review of Patient #10's activity documentation, completed on 01/15/19 at 11:12 AM, showed socialization, reading, puzzles and visitors as the activities.

Review of Patient #10's Social Services Patient Progress Notes showed socialization and reading as the only activities listed for 12 days.

Review of Patient #10's Nursing Care Plan revealed no activity entries.

During an interview on 01/30/19 at 10:30 AM, Patient #11 stated that he did not know of a calendar for activities and did not recall any group activities.

Review of Patient #11's medical record, showed the patient was an 84 year old male, admitted to the facility swing-bed program on 01/26/19 at 12:47 PM for weakness and deconditioning (an adaptation to a less demanding environment).

Review of Patient #11's Social Services assessment on 01/28/19 at 8:30 AM, Staff M, Director of Social Services noted socialization as the patient's activity for the day and his current interests were reading, watching movies, talking, spiritual/religious events and yard work. She offered him reading material, puzzles, word search and a trip to the gift shop. He stated that he wanted to rest.

Review of Patient #11's Nursing Care Plans reveled no activity entries.

During an interview on 01/30/19 at 11:00 AM, Patient #12 stated that she colored in her coloring books and watched television. She did not recall anything about group activities.

Review of Patient #12's medical record, showed the patient was a 68 year old female, admitted to the facility swing-bed program on 01/14/19 at 11:07 AM for antibiotics (medications that fight bacterial infections in the body), OT and PT following hospitalization for Osteomyelitis (an infection in a bone) to the right ankle.

Review of Patient #12's Social Services Assessment on 01/15/19 at 10:51 Staff N, listed the patient's current interests as talking, watching television and exercise.

Review of Patient #12's Social Services Patient Progress Notes showed socialization, reading, coloring and watching television as the only activities listed for 10 days since his admission.

Review of Patient #12's Nursing Care Plan revealed no activity entries.

Review of Patient #14's medical record, showed the patient was a 72 year old male admitted on 12/31/18 at 1:21 PM to the facility swing-bed program for antibiotics and pain management for Osteomyelitis to the left foot.

Review of Patient #14's Social Services Progress Notes showed socialization, reading, and walking in the halls as the only activities listed for seven days since his admission.

Review of Patient #14's Nursing Care Plan revealed no activity entries.

Review of Patient #18's medical record showed the patient was a 70 year old female admitted on 01/26/19 at 8:30 PM to the facility swing-bed program for wound care, antibiotics, PT, and OT.

Review of Patient #18's medical record showed Social Services had not completed the Social Service Assessment.

Review of Patient #18's Social Services Progress Notes on 01/28/19 at 1:35 PM showed socialization as the only activity for three days since her admission.

Review of Patient #18's Nursing Care Plan revealed no activity entries.

During an interview on 01/29/19 at 2:04 PM Staff M, Director of Social Services stated that:
- She had her certification as an Activity Director.
- Her work hours were Monday through Friday at 8:00 AM to 5:00 PM and on call 24 hours a day seven days a week.
- Staff N, Social Worker also had her certification as an Activity Director.
- They had stopped using the activity calendar due to patient disinterest. No one went to the activities. She stated that group activities didn't work in the facility. The activities were individualized for each patient and their specific needs.
- Staff M and Staff N stated that they made rounds every day on the patients in the facility swing-bed program. Weekends and holidays were covered by nursing.