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Based on record review and staff interview, it was determined that the CAH failed to adhere to professional standards for 5 (#s 1, 2, 3, 4 and 6) of 6 swing bed patients. The Provision of Services was not met and the facility was notified of the Immediate Jeopardy finding on 7/11/12 at 1:35 p.m. The Immediate Jeopardy was not abated when the surveyors exited the facility at 2:30 p.m. on 7/11/12.

On 7/16/12 at 10:30 a.m., a surveyor entered the facility. During the entrance conference, the administrator stated that all of the patients were transferred out of the swing bed unit and there were not any patients in the swing bed unit . A tour of the hospital revealed there were not any patients in the hospital swing bed unit.

The findings include:

Based on record review, and staff interview, it was determined that the CAH failed to follow physician or physician assistant (PA) orders, request physician or PA orders when needed, and administer medications as physician or PA ordered for 5 (#s 1, 2, 3, 4, and 6 ) of 5 patients reviewed. The findings included:

1. Patient #1 was admitted to swing bed status on 6/25/12 with diagnosis including s/p hip replacement and anti-coagulation therapy. The patient's medical record was reviewed on 7/10/12.

a. On 6/25/12, the physician wrote admission medication orders for Lovenox 40 mg sq q am x 5 doses, Coumadin 5 mg po QD, and Hydrocodone/Acetaminophen 5/325 mg 1 - 2 po q 4 hrs PRN.

Review of the Medication Administration Record documented the patient received I-CAPS Plus 60 mg every day and Glucosamine Sulfate 1000 mg twice a day, since admission. The surveyor was unable to locate an order in the medical record.

On 7/10/12 at 11:00 a.m., the RN and HUC were asked to locate the order. Later, the RN and HUC both stated to the surveyor that there was no order located, but it did appear the patient had been on the I-CAPS and Glucosamine at a previous facility.

b. On 7/5/12, the PA wrote an order to change the patient's Coumadin dose to 5 mg q other day to start 7/6/12, and Coumadin 7.5 mg q other day to start 7/7/12.

Review of the Medication Administration Record documented the patient received Coumadin 5 mg on 7/7/12. The surveyor was unable to locate documentation in the medical record of the patient receiving the correct dose of Coumadin, or that the PA was notified of the medication error.

On 7/10/12 at 11:00 a.m., the RN stated she was the charge nurse for day shift. She was unaware the patient had not received the correct dose on 7/7/12. She further stated the nurse would document in the medical record or the log book at the nurses' station if the PA had been notified of the medication error. She stated that because it was not in the notes or the log book, that the PA had not been notified.

c. On 7/5/12, the PA wrote an order for the patient to have lab work drawn for an INR/PT on 7/7/12. The HUC and RN were unable to locate the INR/PT lab results for that date in the medical record.

On 7/10/12, at 11:00 a.m., the HUC stated she contacted the lab and they had not received an order to do the INR/PT on 7/7/12. The last INR/PT done on the patient was 7/6/12. There was no order from the physician or PA to do an INR/PT for 7/6/12. The HUC and RN both stated the PA had not been notified the lab work had not been done per his order.

On 7/11/12 at 8:15 a.m., the PA was interviewed. The surveyor discussed the findings from 7/10/12 regarding patient #1. The PA stated he had only been told of the missing lab work. He had not been told of the medication errors.

2. Patient #2 was admitted to swing bed status on 7/6/12 with diagnoses including acute stroke. The patient's medical record was reviewed on 7/10/12.

a. There was no order in the medical record for admission to swing bed. There was no order for diet or care needs. The nurse had received a verbal order for medications on 7/6/12.

On 7/10/12 at 10:45 a.m., the RN stated the physician would be in at noon to write admission orders. At 2:00 p.m., the RN and LPN stated the physician would be in "in an hour or so" to sign the admission record.

On 7/11/12 at 8:40 a.m., the physician signed the medication verbal orders and the "Routine Nursing Home/Swing Bed Orders" for patient #2.

3. Patient #3 was admitted to swing bed status on 7/6/12 with diagnoses including dementia with behaviors, convulsions, hypothyroidism, and macular degeneration. The patient's medical record was reviewed on 7/10/12.

a. On 7/6/12, the PA wrote admission medication orders for Diprosone 0.05% cream to be applied twice a day.

Review of the Medication Administration Record for the Diprosone cream showed that a nurse discontinued the medication on 7/6/12 and documented, "OMITTED: PRN med". According to the admission orders, there was no PRN Diprosone cream listed.

On 7/7/12, a verbal order was noted for Diprosone/Clotrimazole 0.05%-1% to apply to groin BID PRN.

On 7/10/12 at 10:45 a.m., the RN was asked to locate the discontinue order by the PA. The RN stated to the surveyor that she did not know if the order was discontinued by the PA. She thought that it may be somewhere in the computer system and she would check. Later, she stated that it did not appear that the PA discontinued the order. She did not know if he was aware that it was discontinued.

b. On 7/6/12, the PA wrote admission medication orders for Dilantin 100 mg every day.

Review of the Medication Administration Record documented the patient received Dilantin 400 mg every day. The surveyor was unable to locate documentation in the medical record of the patient receiving the correct dose of Coumadin, or that the PA was notified of the medication error.

On 7/10/12 at 1:30 p.m., the HUC was asked to locate the order for Dilantin 400 mg and the order to discontinue the Dilantin 100 mg. The HUC stated to the surveyor that she did not know how the medication had been changed as there were no orders. She did state that when the patient had been in the nursing home, patient #3 had been on Dilantin 400 mg so that is why the nurse changed it. The HUC did not know if the PA had been notified as there was no documentation to indicate the nurse notified him.

c. On 7/6/12, the PA wrote admission medication orders for Motrin 800 mg BID.

Review of the Medication Administration Record documented the patient received Motrin 800 mg at 8:17 p.m. and again at 8:19 p.m., for a total of 1600 mg at one time. The surveyor was unable to locate documentation in the medical record that the patient received the correct dose of Motrin, or that the PA was notified of the medication error.

On 7/11/12 at 8:15 a.m., the PA was interviewed. The surveyor discussed the findings from 7/10/12 regarding patient #3. The PA stated he had not discontinued any of the medications for patient #3 and was unaware the nurses had changed the orders for the Diprosone cream or the Dilantin. He further stated he had not been notified of the medication error with the Motrin.

4. Patient #4 was admitted to swing bed status on 7/6/12 with diagnoses including post polio syndrome, chronic radicular pain, generalized anxiety disorder, hypertension, generalized pain disorder and urinary urgency. The patient's medical record was reviewed on 7/10/12.

a. On 7/7/12, the physician wrote admission orders for oxygen at 2-5 liters per nasal cannula, keep sats (sic) greater than 94%.

Review of the patient progress notes documented that the patient's oxygen saturations were 91% on 7/7 at both 6:30 a.m. and 7:20 p.m., 93% on 7/8 at 9 a.m., 91% at 7:47 a.m. and 90% at 7:20 p.m. on 7/9 and 91% at 7 a.m., 93% at 9:23 a.m. and 93% at 7:10 p.m. on 7/10/11. The surveyor was unable to locate information indicating that the doctor was notified of these oxygen saturations below 94% on 7/7, 7/8 and 7/9/12.

On 7/11/12, during an interview at 8:15 a.m., the PA stated he had not been notified of oxygen saturations below 94%.

5. Patient #6 was admitted to swing bed on 7/6/12 with diagnoses including constipation, slow speech, bladder atony, depression and gait instability all secondary to Parkinson's Disease. The patient's medical record was reviewed on 7/10/12.

a. There was a telephone order in the medical record dated 7/7/12 at 8:00 a.m. for Sinemet 25/100 CR 1 tab p.o. daily at 5:30 a.m.

At 1:50 p.m., there was a telephone order to start Sinemet 25/100 CR when available from pharmacy on 7/10/12.

Review of the Medication Administration Record documented that Sinemet 25/100 CR was omitted on 7/8, 7/9 and 7/10 because medication was not available from the pharmacy.

On 7/10/12 at 8:00 p.m., there was a verbal order to discontinue Sinemet 23/100 CR. The provider signed the verbal order, but did not date or time the order.

b. On 7/10/12 at approximately 2:00 p.m. the CEO stated that if a medication was not available from the local pharmacy, the facility used another pharmacy to obtain medications for the residents.

c. There was no order in the medical record for admission to swing bed. There was no order for diet or care needs. The nurse had received a phone order for medications on 7/6/12.

On 7/10/12 at 10:45 a.m., the RN stated the physician would be in at noon to write admission orders. At 2:00 p.m., the RN and LPN stated the physician would be in "in an hour or so" to sign the admission record.

On 7/11/12 at 8:40 a.m., the physician signed the medication verbal orders and the "Routine Nursing Home/Swing Bed Orders" for patient #6.