HospitalInspections.org

Based on interview and record review, the facility failed to develop a process to ensure all inpatients signed a written notice that there was no Doctor of Medicine or Osteopathy onsite, in the CAH 24-hours per day, and may not be present during all hours services are furnished for the patient for 11 (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 19) of 22 sampled inpatients and 2 (#s 2 and 18) of 2 observation patients. Findings include:

Review of the following admission documents provided to inpatient admissions for patients (#s 1, 3, 4, 5, 6, 7, 8, 9, 10, 12, and 19) and observation patients (#s 2 and 18) failed to show in writing, and signed by the patient, the notification an MD or DO was not present in the CAH 24-hours a day, seven days a week:

- Patient Belongings Form, not dated;
- Tips to Prevent Fall, not dated;
- Patient Rights and Responsibilities, not dated;
- Important Message from Medicare, not dated; and
- General Consent for Admission or Treatment, not dated.

During an interview on 2/14/24 at 11:24 a.m., staff member A stated the notice regarding no MD or DO onsite was posted in the emergency room. Staff member A stated they did not provide a written notice and/or obtain a signed acknowledgement from all inpatient admissions and all patient observation stays.

A request was made on 2/13/24 at 3:00 p.m., for the facility policy regarding the written notice and signed acknowledgement, which was required when the CAH did not have an MD or DO onsite at all times. No policy was received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to establish written policies and procedures to include strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment utilized by the facility; failed to ensure all essential mechanical, electrical, and patient-care equipment were identified and included in an inventory list which included a record of maintenance activities; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy. The accumulative effect of this deficiency had the potential to affect all patients provided care services by the facility. Findings include:

1. Established Equipment Maintenance Policy and Procedures

A request was submitted on 2/13/24 at 4:30 p.m., to provide a copy of the facility's policy and procedure for strategies to ensure the maintenance of all essential mechanical, electrical, and patient-care equipment. No policy or procedure was provided by the end of the survey.

During an interview on 2/14/24 at 2:13 p.m., staff member A stated the facility did not have an established policy or procedure which ensured the maintenance of all essential mechanical, electrical, and patient-care equipment.

2. Patient-Care Equipment List

During an interview and record review on 2/14/24 at 1:00 p.m., staff member Y and B stated they did not have a complete inventory of equipment required to meet patient needs; which also readily identified critical-care equipment and equipment essential to patient care. A request to review the facility's complete inventory list was not provided by the end of the survey.

3. Initial Use Evaluation and Periodic Maintenance of Patient-Care Equipment

During an observation on 2/13/24 at 1:00 p.m., the following patient-care equipment was observed to not have a periodic maintenance sticker, which identified that the equipment had an initial safety inspection prior to being used and/or had received periodic maintenance to ensure the equipment was inspected, tested, and maintained to ensure patient safety for use:

- Located at the nurses' station: Huntleigh doppler, model number FD2,
- Located at the nurses' station: Autocode Prodigy glucometer, serial number: 51850-494036, and
- Located in the emergency department: LUCAS chest compression machine.

During an interview and record review on 2/14/24 at 1:00 p.m., staff member Y and A stated they did not have a record of the Huntleigh doppler, the Autocode Prodigy glucometer, and the LUCAS chest compression machine having been inspected, tested, and maintained by the facility or by their contracted alternative equipment maintenance (AEM) contractors.

During a phone interview on 2/14/24 at 1:30 p.m., NF4 stated they did not have a record of the Huntleigh doppler, the Autocode Prodigy glucometer, and the LUCAS chest compression machine, in their list of equipment to be maintained for the facility.

Based on observation, interview, and record review, the facility failed to store medications in a temperature-controlled room. This deficient practice has the potential to affect any patient who received medications from the pharmacy. Findings include:

During an observation on 2/12/24 at 2:28 p.m., the pharmacy medication storage room was inspected. Upon inspection, it was noted the temperature of the room felt cold. No thermostat or temperature control was observed in the room.

During an interview on 2/12/24 at 2:30 p.m., staff member F stated the medication storage room used to be extremely warm, but the facility now had air conditioning set up for that area. Staff member F stated the facility did not have a thermostat in the room to monitor the temperature.

Review of a facility document titled, "Medication Storage and Handling, Pharm,0016," with a revision date of 07/2023, showed:

... "9. Drug storage requirements are as follows: Refrigeration = 34-45 degrees F, Freezer = -13 to 14 degrees F, Cool Place = 46-59 degrees F, Room Temp. = 59-86 degrees F."

Based on interview and record review, the facility failed to complete a thorough investigation after theft of medications from the emergency room crash cart were discovered on two separate occasions. This deficient practice has the potential to affect any person in the facility. Findings include:

Review of a facility document titled, "Pharmacy and Therapeutics Minutes," dated February 2023, showed:

... "2.2 Medication occurrences/errors for January: 4
... 2.2.4 Crash cart tampered, 3 vials of naloxone (Narcan) missing. ..."

A review of a facility document titled, "Pharmacy and Therapeutics Minutes," dated November 2023, showed:

... "3.1 Medication occurrences/errors for October: 2
... 3.1.2 Crash cart lock broken, nitro tabs missing."

Review of a facility document titled, "Safety Committee Minutes," dated February 9th, 2023, showed:

..."Safety incident report-A med cart was left unattended and got broken into by a patient."

During an interview on 2/12/24 at 2:20 p.m., staff member F stated, "Any issues that arise with medications, medication errors, drug reactions, and diversions are all addressed through policy and procedures as well as through risk management and medical staff. We look for root causes and educate staff as needed."

During an interview on 2/13/24 at 9:30 a.m., staff member I stated if the plastic lock was broken or the tape that was covering the plastic lock is tampered with, the director of nursing was notified and a complete inventory of the crash cart was completed. Staff member I stated the carts are checked twice a day, at the beginning of each shift.

During an interview on 1/13/24 at 10:28 a.m., Staff member J stated, "They had some problems in the past with medications going missing. We do not keep controlled substances in the carts anymore, and there is one cart that we moved to a different area. We are to be checking on the patients frequently to decrease the amount of alone time they have with the crash cart."

During an interview on 2/15/24 at 10:23 a.m., staff member A stated there were no investigation reports for the two incidents of medication theft. Staff member A stated the thefts were discussed with nursing and administration. Staff member A stated, "I checked the cameras after the incidents, but I could not tell who the person was." Staff member A stated, "Law enforcement was not called, and I am really not sure why we did not notify them." Staff member A stated the crash carts were to be checked each shift by nursing staff. If the seal was broken, then a full inventory of the cart was to be completed and management and pharmacy was to be notified.

Review of a facility policy titled, "Drug Diversion Reporting and Response Pharm.0052," with a revision date of 10/2023, showed:

... "1. The prevention of drug diversion is essential to the safety of [Facility] patients and is the individual responsibility of every [Facility] employee.

... 3. All suspected incidents of drug diversion will be thoroughly investigated. ...

... 6. The President, CNO, Director of Acute Care Services, Pharmacist and Risk Manager will manage the investigation of all reports of suspected drug diversion. ..."

Based on observation, interview, and record review, the facility failed to ensure nutritional services were provided to meet the nutritional needs of inpatients by ensuring a dietitian reviewed and approved dietary menus supplied by the contracted meal service provider prior to the implementation of the menu; failed to ensure textured diets were approved by a dietitian; and failed to ensure the meals were prepared in a sanitary environment by the contracted meal service provider. This deficient practice had the potential to affect all patients receiving meal services provided by the facility. Findings include:

1. Review and Approval of Dietary Menus

A review of the facility's Dietary Contract, signed 10/5/20, showed in Addendum V - Dietitian Coverage Services:

- "...Dietitian Services: [Contracted Agency], through its employee or contractors...will provide to [the Facility] dietitian services of a clinical and non-clinical nature as follows:

- a. The [Contracted Agency] Dietitian(s) will meet with [Facility] [Staff member B], [Facility staff member D] (the [Facility] Management) to develop a plan and schedule to provide the following services:

- ... iii. Acute Care - [Contracted Agency] Dietitian(s) will review and approve dietary menus supplied by contracted meal service provider prior to implementation..."

During an interview on 2/12/24 at 11:15 a.m., staff member B stated the contracted dietitians do not come to the facility to provide oversight of patient dietary needs or complete nutritional assessments. She stated they review nutritional needs over the phone or through tele-medicine. Staff member B stated she was not sure if the contracted dietitians reviewed the menus prior to implementation.

During an interview on 2/13/24 at 9:20 a.m., staff member L stated they do not always receive the correct therapeutic diets for patients. She stated sometimes they will only receive a regular diet when a specific therapeutic diet was ordered for a patient. She stated when that happened, they would try to modify the meal to the best of their ability to reflect the correct therapeutic diet.

During an interview on 2/13/24 at 10:25 a.m., staff member B stated they have had difficulty getting the correct therapeutic diet from the contracted meal service. She said they must look at the provided meal and make sure it was correct and if not, they would try to modify the meal as needed.

During an interview on 2/13/24 at 11:00 a.m., staff member K stated she was only the contact dietitian, and she did not provide any direct oversight, review, or approval, of the facility's dietary and therapeutic menus. Staff member K stated she did not physically come to the facility. She stated none of the dietitians which work for her provide direct dietary oversight or review and approval of the dietary or therapeutic menus provided by the contracted meal service. Staff member K stated she relied on NF1 to review the menus. Staff member K stated she was not sure if NF1 was an employee of the facility.

During an interview on 2/13/24 at 11:15 a.m., NF1 stated he was not an employee of the facility and was not aware he was required to review and approve the dietary and therapeutic menus for the facility.

Review of the contracted meal service dietary menu for, 2/11/24 through 2/17/24, showed the menu was reviewed and approved by a dietitian, NF5. A review of dietary menus from 12/1/23 through 2/10/24 showed the menu was approved by NF1.

During a phone interview on 2/20/24 at 11:00 a.m., NF1 stated he was not sure who NF5 was, but assumed the person was a member of the nursing home administration staff. He stated he did not approve the menu for the week of 2/11/24 through 2/17/24.

During a phone interview on 2/20/24 at 11:30 a.m., staff member A stated they were not sure who NF5 was, but assumed they were a "nursing home employee likely on the corporate side."

During a phone interview on 2/20/24 at 12:01 p.m., staff member A stated they contacted the corporate department for their contracted dietary meal service, and stated NF5 was a corporate dietitian from the contracted food service provider.

2. Texture Diets not Approved

During an interview on 2/12/24 at 11:15 a.m., staff member B stated the expectation would be for the dietitian to approve any altered texture diets for dysphagia diets.

Review of the contracted meal service dietary menu for altered texture diets for dysphagia diets showed the following texture diets were not reviewed or approved by the facility's dietitian:

- Pureed Diet, Level 4 Pureed Food for Adults,
- Minced and Moist Diet, Level 5 Minced and Moist Food for Adults,
- Soft and Bite-Sized, Level 6 Soft and Bite-Sized for Adults,
- Regular Easy to Chew.

During an interview on 2/13/24 at 11:00 a.m., staff member K stated she was only the contact dietitian, and she did not provide any direct oversight, review, or approval, for the facility's altered texture diets for dysphagia diets provided by the contracted meal service. Staff member K stated she relied on NF1 to review the different diets and menus.

During an interview on 2/13/24 at 11:15 a.m., NF1 stated he was not an employee of the facility and was not aware he was required to review and approve the altered texture diets for dysphagia diets.

3. Ensure Dietary Services were Provided in a Sanitary Environment

During an observation on 2/13/24 at 9:20 a.m., the kitchen and meal prep of the contracted dietary meal service location was inspected. Observations reflected the following unsanitary food storage and preparation conditions:

- Opened and not sealed, and not dated, 25-pound bags of sugar in the primary food storage,
- Opened, not sealed, and not dated, 25-pound bag of confectioners' sugar,
- Raw beef sitting on the food prep counter next to onions being prepared for chopping,
- Eight clear bins with blue lids, containing dried food goods such as flour, sugar, powdered sugar; stored in an open cupboard. The blue lids were sticky to touch and littered with white powder and dried food debris.
- Food service plates, bowls, and utensils, were stored in an uncovered cabinet and not covered. The cabinet had scattered dried food debris and dust around the plates.
- The walk-in cooler had large pieces of food debris on the floor under the food shelves.
- Three covered drains recessed into the kitchen floor had a large accumulation of wet food debris.
- The floor and wall around the food service area had a large amount of accumulated dried and wet food debris. The wall next to the food service/plate warmer area had large amount of food spatter on the wall.
- The ceiling and the air vents in the kitchen had large accumulation of dust and cobwebs.

During an interview on 2/13/24 at 9:45 a.m., NF2 stated she had never been provided oversight by the facility. She stated they were supposed to complete the deep cleaning schedule every week. She said she posted the deep cleaning schedule on Sunday, and the kitchen staff had until Saturday to complete the items on the deep cleaning schedule. NF2 stated they have been short staffed, and they have also had their hours cut, so much of the deep cleaning had not been completed for several weeks.

A review of the contracted meal service's Master Deep Clean List, from 1/21/24 through 2/17/24, reflected the items on the list had not been completed for this time period.

Based on interview and record review, the facility failed to complete an AMA (Against Medical Advice) form prior to a patient leaving the facility for 1 (#17) of 22 sampled patients. This deficient practice has the potential to affect all patients in the emergency department who wish to leave the facility against medical advice. Findings include:

A review of patient #17's electronic medical record showed on 1/27/24, patient #17 had come to the emergency department for care. Patient #17 decided he no longer wanted to be in the emergency department and left. No AMA form was signed by patient #17 or emergency department staff. No AMA for was located in the patient's medical records.

During an interview on 2/15/24 at 10:00 a.m., staff member B stated she had held a nurses meeting on 2/14/24, and nursing staff told her they were not good at getting forms or consents signed by patients.

Review of a facility policy titled, "Against Medical Advice (AMA), Leaving Without Being Seen (LWBS), Clinical.0056," with a revision date of 02/2023, showed:

... "A. Patients Leaving Against Medical Advice:

... 5. Take all reasonable steps to have the patient or legally responsible person sign the appropriate section of the Leaving Without Being Seen/Leaving Against Medical Advice Form."

Based on interview and record review the facility failed to obtain consent to treat forms for 4 (#s 15, 16, 17, and 19) of 22 sampled residents. This deficient practice has the potential to affect all patients coming into the facility for treatment. Findings include:

A review of patient #15's electronic medical record showed no consent to treat was obtained during an emergency room visit on 2/11/24.

A review of patient #16's electronic medical record showed no consent to treat was obtained during an emergency room visit on 2/14/24.

A review of patient #17's electronic medical record showed no consent to treat was obtained during an emergency room visit on 1/27/24.

A review of patient #19's electronic medical record showed no consent to treat was obtained during an in-patient stay on 2/3/24.

During an interview on 2/14/24 at 3:27 p.m., staff member B stated all facility staff knew consents needed to be signed by the patients. During business hours, the business office would get the consents signed when they complete paperwork with the patient. Staff member B stated, "I see a pattern with this, it looks like these patients all came in on night shift. I now know what shift to start educating staff." Staff member B stated there was not follow through to make sure forms and charts are completed, it had, "fallen by the wayside."

During an interview on 2/15/24 at 10:00 a.m., staff member B stated she had held a nurses meeting on 2/14/24, and nursing staff told her they were not good at getting forms or consents signed by patients.

During an interview on 2/15/24 at 10:28 a.m., staff member A stated the facility did not have a policy for the hospital, but used the swing bed criteria and admission process for admissions and consent to treat in the hospital setting.

Review of a facility document titled, "[Location] Bed Criteria and Admission Process SWB110C," with a revision date of 03/2023, did not address patient consent to treat.

Based on observation, interview, and record review, the facility failed to have clean medical supplies in the emergency room. This deficient practice has the potential to cause infection and affect all patients in the emergency room requiring the use of medical supplies. Findings include:

During an observation on 2/13/24 at 9:20 a.m., the facility emergency department was inspected. The emergency department crash cart, located in the emergency department was inspected. One 100 mm oral airway, one 90 mm oral airway, two 80 mm oral airways, two 70 mm oral airways, two 60 mm airways, and two unpackage anal scopes were observed being stored in a plastic container that contained debris and fibers.

During an observation on 2/13/24 at 9:25 a.m., a large, discolored, clear plastic bag was observed, hung on a peg board by a hook though the bag. The bag had fibers and debris in the bottom of the bag. The bag contained the following supplies:

- two 100 mm oral airways,
- four 90mm oral airways,
- two 80 mm oral airways,
- two 70 mm oral airways, and
- twenty 60 mm oral airways.

Below the bag containing the oral airways, was a clear bag that hung on the peg board with a hook though it. The bag contained debris and fibers. A Yankauer suction set up was in the bag. This set up was out of the original packaging and placed in the contaminated bag.

During an interview on 2/13/24 at 9:45 a.m., staff member I stated, "The airways do not need to be sterile, it's just a clean procedure." Staff member I could not verbalize the facilities infection control plan.

During an observation and interview on 2/13/24 at 1:20 p.m., staff member AA explained the process for ordering supplies for the different departments. Staff member AA showed the packaging the Yankauer suction set up came in. The packaging was sealed. Staff member AA stated the packaging was sealed to keep the supplies clean until they were ready to be used.

During an interview on 2/15/24 at 8:10 a.m., staff member B stated staff have been educated on infection prevention. Staff member B stated all staff are educated upon hire, but also throughout the year by in-services, HealthStream assignments, and audits.

A review of a facility policy, untitled, with no revision date, showed:

"The purpose of the Infection Prevention and Control Program is to reduce the risk of acquiring and transmitting infections and communicable diseases between patients, employees, medical staff, volunteers, and visitors. ..."

... "I. IPC activities include, but are not limited to the following:

a. Monitoring and evaluating key performance aspects of infection control include eight (8) core competency activities:

... vi. Environment of care.
vii. Cleaning, sterilization, disinfection, and asepsis ..."

Based on interview, and record review, the facility failed to develop a patient-centered comprehensive care plan that included measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs for 7 (#s 1, 4, 5, 6, 7, 8, and 9) of 10 sampled swing bed patients. Findings include:

1. Patient #1 was admitted to acute care services on 2/6/24, and then to swing bed services on 2/9/24. The patient was an active patient during the course of the survey.

A review of patient #1's History and Physical, dated 2/6/24, showed, "Assessment: Left upper extremity weakness suspect CVA, elevated liver enzymes, generalized weakness..."

Review of patient #1's orders showed orders for PT and OT services.

Review of patient #1's Care Plan dated 2/9/24, showed:

- Fall Risk related to weakness

Patient #1's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs.

2. Patient #4 was admitted to swing bed services on 7/28/23.

Review of patient #4's History and Physical, dated 7/28/23, showed, "...Admitted to swing bed for continued physical therapy. She sustained a sacral fracture and bilateral transverse process fractures of L5... Assessment: Generalized disability and debility, sacral fracture, bilateral L5 spinous process fractures, new onset hypertension, COPD oxygen dependent, obesity... Plan: She'll receive physical therapy twice a day. We'll continue with strengthening exercises to improve her mobility and endurance. When she is safe to go home, she will be discharged back to her home residence...

Review of patient #4's Care Plan, dated 7/28/23, showed:

- Activity Intolerance related to pain.

Patient #4's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs.

3. Patient #5 was admitted to swing bed services on 5/18/23.

Review of patient #5's History and Physical, dated 5/15/23, showed, "Assessment: Comfort Care and Chronic Liver Failure... Plan: Will initiate further comfort care measures at this time. Will increase morphine dosing... She has on board PRN Ativan, Benedryl and Phenergan as needed."

Review of patient #5's Care Plan, dated 5/18/23, showed:

- Fall Risk related to [blank]
- Acute Pain related [blank]

Patient #5's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs including comfort care needs.

4. Patient #6 was admitted to swing bed services on 6/6/23.

Review of patient #6's History and Physical dated 6/6/23, showed, Plan: She'll be admitted to our swing bed program where she will receive physical therapy. Also made a consultation for occupational therapy. Her foley catheter was recently discontinued prior to her transfer today. We'll monitor for urinary retention and do bladder scan if indicated...Would like to avoid a long-term indwelling Foley catheter... Anticipated she will be here with us for approximate 2 weeks, receiving therapy."

Review of patient #6's Care Plan dated, 6/6/23, showed:

- Altered Thought Process related to dementia, expressive aphasia.
- Fall Risk related to ORIF.

Patient #6's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs.

5. Patient #7 was admitted to swing bed services on 10/18/23.

Review of patient #7's History and Physical, dated 10/18/23, showed, "Plan: we will have physical and occupational therapy see her. She'll be on Lantus twice daily plus a sliding scale of NovoLog insulin. She is also on Victoza... We'll continue her on oxycodone as needed. She is a patient of [Provider's Name] in Conrad. She will follow up there at the time of discharge."

Review of patient #7's Care Plan dated, 10/18/23, showed:

- Acute Pain related to bilateral femur fracture.
- Urinary Tract Infection - Actual or Potential.

Patient #7's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs.

6. Patient #8 was admitted to swing bed services on 10/13/23.

Review of patient #8's History and Physical, dated 10/13/23, showed, "...admitted to our swing bed program after a 4 day stay in acute acre for UTI and generalized weakness and acute kidney injury... Plan: we will continue physical and occupational therapy. We'll have her on Cipro... We'll continue to watch her kidney function. We'll plan to remove her Foley catheter on 10/17/23. Hopefully, she'll get stronger and is able to return home in1-2 weeks.

Review of patient #8's Care Plan dated, 10/13/23, showed:

- Activity Intolerance related [blank].
- Urinary Tract Infection - Actual or Potential.

Patient #8's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial and discharge needs.

7. Patient #9 was admitted to swing bed services on 9/24/23.

Review of patient #9's History and Physical, dated 9/24/23, showed, "Assessment: Congestive heart failure with respiratory distress, hypoxia, type 2 diabetes, hypertension, atrial fibrillation. Plan: We will admit her for care and comfort measures to swing bed. She does seem to responding and hopefully will be able to return to her colony soon. Family is okay with continued use of oral Lasix and oral antibiotics. We also have morphine and Ativan ordered if needed. We'll hold off on physical therapy at this point as she is too weak to participate."

Review of patient #9's Care Plan dated, 9/24/23, showed:

- Fall Risk related to [blank].
- Skin Integrity - Potential Impairment.
- Urinary Tract Infection - Actual or Potential.

Patient #9's care plan failed to include measurable objectives, interventions, and timeframes to meet the patients' medical, nursing, therapy, nutritional, psychosocial, discharge needs and comfort care.

During an interview on 2/15/24 at 10:00 a.m., staff member B stated it was the expectation that a comprehensive care plan was developed for all in-patient and swing bed patients.

Based on interview and record review, the facility failed to ensure a nutritional assessment was completed for a swing bed patient for 1 (#1) of 10 sampled swing bed patients. This deficient practice had the potential to affect swing bed patients with a need for nutritional assessment. Findings include:

Patient #1 was admitted to acute care services on 2/6/24 and then to swing bed services on 2/9/24. The patient was an active patient during the course of the survey.

A review of patient #1's History and Physical, dated 2/6/24, showed, "...Plan: ...CT of her abdomen shows some gallbladder sludge and possible gallbladder disease... We will make her NPO until then..."

Review of patient #1's Nursing Nutritional Assessment, dated 2/6/24, showed the patient scored a total of four on her assessment and did not meet the facility's guideline of eight or higher for a dietary consult.

Review of patient #1's EMR, showed a Nursing Nutritional Assessment by the nurse and/or a nutritional assessment by a dietitian was not completed for the patient when admitted to swing bed services on 2/9/24.

Review of patient #1's diet orders showed a regular diet was ordered by the physician.

Review of patient #1's dietary intake from, 2/9/24 through 2/14/24, showed:

- On 2/09/24 at 7:48 p.m., 50% dinner consumed regular diet with 20 ml fluid.

- On 2/10/24 at 10:42 a.m., "005% consumed", and at 6:45 p.m.,75% dinner consumed regular diet.

- On 2/11/24 at 7:34 p.m., 75% dinner consumed regular diet.

- On 2/12/24 at 9:23 a.m., 10% breakfast consumed regular diet, and at 8:00 p.m., 0% dinner consumed regular diet, patient refused dinner.

- On 2/13/24 at 8:30 a.m., 0% breakfast consumed regular diet, refused breakfast. At 12:00 p.m., 0% lunch consumed regular diet, patient refused lunch. At 1:53 p.m., 20% lunch consumed regular diet. At 8:05 p.m., 25% dinner consumed regular diet.

- On 2/14/24 at 09:13a.m., 0% breakfast consumed regular diet; patient refused breakfast. At 7:30 p.m., 100% dinner consumed regular diet.

- On 2/15/24 at 9:20 a.m., 15% breakfast consumed regular diet.

Review of patient #1's Nursing Assessment dated 2/14/24, showed, ..."Notes: Patient requesting pain medication, PRN Norco given along with scheduled medications. Patient had difficulty swallowing pills due to pocketed in left cheek. Patient attempted to swallow pills with water multiple times, pills remained on tongue or in cheek. Applesauce provided, pt able to swallow pills without difficulty with applesauce."

During an interview on 2/13/24 at 9:15 a.m., staff member J stated patient #1 was experiencing a decrease in her appetite and was not eating much of her provided meals. She stated they had been providing the patient with a Glucerna drink supplement because of her diminished appetite. Staff member J stated they did not have a dietitian that came to the facility for patient consults. She stated they were to complete the Nursing Nutritional Assessment for each patient and if the patient scored an eight or higher, they were to contact the dietitian via phone and they would review the patient's medical information and make a diet recommendation. Staff member J stated they had not notified the dietitian of the change in patient #1's appetite.

Review of patient #1's EMR on 2/15/24, failed to show the dietitian was notified of the patient pocketing pills and unable to swallow the pills with water and only with applesauce.

Based on interview and record review, the facility failed to inform patients and/or their representatives of their patient rights prior to providing or discontinuing care for 6 (#s 11, 15, 16, 17, 21, and 22) of 22 sampled residents. This deficient practice has the potential to affect all patients receiving care in the facility the ability to acknowledge their patient rights. Findings include:

A review of patient #11's electronic medical record showed an admission date of 7/20/23. No acknowledgement of patient rights was in the medical record.

A review of patient #15's electronic medical record showed an admission date of 2/11/24. No acknowledgement of patient rights was in the medical record.

A review of patient #16's electronic medical record showed an admission date of 2/14/24. No acknowledgement of patient rights was in the medical record.

A review of patient #17's electronic medical record showed an admission date of 1/27/24. No acknowledgement of patient rights was in the medical record.

A review of patient #21's electronic medical record showed an admission date of 10/19/23. No acknowledgement of patient rights was in the medical record.

A review of patient #22's electronic medical record showed an admission date of 2/9/24. No acknowledgement of patient rights was in the medical record.

During an interview on 2/14/24 at 10:32 a.m., staff members A and B stated they followed the policy for swing bed patient rights. Staff members A and B stated they were not aware that outpatient procedures/testing or emergency room visits required an acknowledgement of patient rights.

Review of a facility document titled, "[Location] Swing Bed: Swing Bed Patient Rights SWB190," with a revision date of 1/2023, showed: no information about patient rights for the facility.