HospitalInspections.org

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Based on interview and review of the hospital's long-term care ("swing bed") program, the Critical Access Hospital failed to develop a process for evaluating the quality of care provided to swing bed patients.

Failure to develop and monitor quality indicators for all hospital services limits the hospital's ability to develop action plans for improvement of patient care.

Findings included:

On 06/26/18, Surveyor #7 reviewed the hospital's swing bed program. At 9:30 AM, the surveyor interviewed the hospital's Director of Quality and Performance Improvement (Staff #705). During the interview, the director stated that the hospital had not developed quality indicators for the hospital's swing bed services.
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Based on interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that the long-term care ("swing bed") activities program director was oriented to the duties and responsibilities of his position.

Failure to develop and implement an activities program that is directed by a qualified professional limits the hospital's ability to provide and meaningful and therapeutic healthcare environment for swing bed patients.

Findings:

1. On 06/26/18, review of the hospital's policy and procedure titled "Swing Bed Activity Program Policy" (Revised 02/11/18) showed that the hospital's swing bed activity program would be directed by a qualified professional.

2. On 06/26/18 at 11:35 AM, Surveyor #7 interviewed the hospital's rehabilitation program director (Staff #706). During the interview, the director stated that the hospital's occupational therapist (Staff #707) was the swing bed program director. Staff #706 stated the occupational therapist had been recently hired and had not yet been oriented to his duties and responsibilities as swing bed program director.
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Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed an individualized activity plan in accordance with interests identified in the patient's activities assessment for 2 of 2 long-term care ("swing bed") patients reviewed (Patients #701, #702).

Failure to develop and implement an individualized activities plan for long-term care patients risks impairment of physical, mental, and psychosocial well-being.

Findings included:

1. Review of the hospital's swing bed policies and procedures showed the following:

a. The hospital's policy and procedure titled "Swing Bed Admission, Assessment, Documentation and Care Planning Policy" stated that a comprehensive care plan would be developed for each swing bed patient within 3 days of admission based on a comprehensive assessment of the patient's needs. This assessment would include an assessment of the patient's activity needs.

b. The hospital's policy and procedure titled "Swing Bed Activity Program Policy" (Revised 02/11/18) stated that the hospital's occupational therapist and/or activities program coordinator would assess each swing bed patient's activity interests and develop an activities plan within 72 hours of admission.

2. On 06/26/18 at 3:30 PM, Surveyor #7 reviewed the medical records of two swing bed patients who were hospitalized between 08/13/15 and 09/01/15. The review showed that hospital staff members had performed an assessment of each patient's activity interests. The records did not include plans for providing activities that met the patients' individual interests and needs.

3. During an interview at the time of the record review, the hospital's swing bed coordinator (Staff #702) confirmed that the comprehensive plans of care for these patients did not include an activities plan as directed by hospital policy.
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