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Based on Life Safety Code (LSC) survey, Adams Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

Adams Memorial Hospital is comprised of the main hospital in Decatur, IN (Building 01), Adams Memorial Hospital Multi-Specialty MOB in Decatur, IN (Building 02), Adams Memorial Cancer Center in Decatur, IN (Building 03), and the Berne Outpatient in Berne, IN (Building 04).

Building 01, is a three story building with a basement fully sprinklered, with exception of two elevator equipment rooms, of Type II (222) construction containing a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 19, Existing Health Care occupancies. Building 01 provides 24 hour medical services. The facility has a capacity of 25 medical beds with a census of 22, and has a capacity of 10 behavioral health beds with a census of 6 at the time of this survey.

Building 02, is a two story fully sprinklered building of Type II (222) construction with fire alarm system and smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 38, New Business occupancies. Building 02 provides outpatient services during normal business hours.

Building 03 is a one story fully sprinklered building of Type II (222) construction with a fire alarm system and smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 38, New Business occupancies. Building 03 provides outpatient services during normal business hours.
Building 04, is a one story fully sprinklered building with a basement of Type V (000) construction with no fire alarm system or smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 38, New Business occupancies. Building 04 provides outpatient services during normal business hours.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 1 gift shop storage doors and 1 of 1 laundry room doors were held open only by a device which would allow it to close automatically upon activation of the fire alarm system (see K 021), failed to ensure corridor doors to 5 of 35 hazardous areas were provided with self closing devices allowing the doors to automatically close and latch into the door frame (See K 029), failed to conduct fire drills at unexpected times under varying conditions in 12 of 12 fire drills (see K 050), failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms to provide complete sprinkler coverage for all portions of the building (see K 056), failed to ensure 1 of 1 fire pumps was provided with an adequate and reliable water supply for the automatic sprinkler system (see K 063), failed to ensure 2 of 30 oxygen cylinders in the oxygen storage room on the surgery hall were properly restrained, Building 01, (see K 076), failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 9 of 9 battery operated emergency lights, failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 7 of 7 exit signs with battery back-up, failed to ensure the fire alarm system was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code,1999 Edition, failed to ensure the sprinkler system was maintained in accordance with the applicable requirements of NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Building 03, failed to maintain 1 of 1 sprinkler systems in accordance with LCS 9.7.5, failed to ensure 2 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance, failed to ensure 1 of 10 emergency lighting was working in accordance with LSC 7.9, Building 04 (see K 130) and failed to ensure that periodic fire inspections by State or local fire control agencies were conducted at the facility, Building 01 (see C 0234).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review and interview, the facility failed to ensure that all essential mechanical, electrical, and patient care equipment received preventive maintenance (PM) and was maintained in safe operating condition in 5 instances.

Findings include:

1. On 11-09-15 at 1015 hours, the director of quality, staff A8, was requested to provide documentation of PM for the nurse emergency call (code) system, two (2) floor scrubbers, and two (2) infant or toddler cribs and none was provided prior to exit.

2. Documentation provided by the facilities supervisor, staff A12, and by the biomedical engineer, staff A10, failed to indicate preventive maintenance had been performed for the indicated equipment.

3. During an interview on 11-10-15 at 1530 hours, the biomedical engineer, staff A10 confirmed that the facility failed to maintain documentation of PM for the indicated equipment and no further documentation was provided prior to exit.

Based on observation, document review and interview, the facility failed to ensure 1 of 1 gift shop storage doors and 1 of 1 laundry room doors were held open only by a device which would allow it to close automatically upon activation of the fire alarm system, failed to ensure corridor doors to 5 of 35 hazardous areas were provided with self closing devices allowing the doors to automatically close and latch into the door frame, failed to conduct fire drills at unexpected times under varying conditions in 12 of 12 fire drills, failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms to provide complete sprinkler coverage for all portions of the building, failed to ensure 1 of 1 fire pumps was provided with an adequate and reliable water supply for the automatic sprinkler system, failed to ensure 2 of 30 oxygen cylinders in the oxygen storage room on the surgery hall were properly restrained, Building 01, failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 9 of 9 battery operated emergency lights, failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 7 of 7 exit signs with battery back-up, failed to ensure the fire alarm system was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code,1999 Edition, failed to ensure the sprinkler system was maintained in accordance with the applicable requirements of NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Building 03, failed to maintain 1 of 1 sprinkler systems in accordance with LCS 9.7.5, failed to ensure 2 of 3 vertical openings was enclosed with construction having at least a one hour fire resistance, failed to ensure 1 of 10 emergency lighting was working in accordance with LSC 7.9, Building 04 and failed to ensure that periodic fire inspections by State or local fire control agencies were conducted at the facility, Building 01.

Findings include:

1. Observation during a tour of the facility (Building 01) with the Lead Maintenance Technician (LMT#1) on 11/09/15 at 11:30 a.m. noted the following doors were held open with devices that would not release upon activation of the fire alarm:
a. the door leading into the gift shop store room, which was greater than 50 square feet and was filled with boxes of merchandise, was held open by a wedge door stop.
b. the corridor door leading into the basement laundry room was held open by a self-locking door holder.

2. In interview, these were acknowledged by LMT#1 at the time of observation.

3. Observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 between 10:30 a.m. and 3:30 p.m., and on 11/10/15 between 8:30 a.m. and 9:30 a.m. noted the following doors to hazardous areas lacked a self closer and/or failed to latch into the frame:
a. both corridor doors leading into the C.T. (computerized tomography) record storage room, which were greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
b. the corridor door leading into the third floor Business Office storage room one, which was greater than 50 square feet and contained 50 plus boxes, were not equipped with a self closing device.
c. the corridor door leading into the third floor Business Office storage room two, which was greater than 50 square feet and contained 50 plus boxes, was not equipped with a self closing device.
d. the corridor door leading into the room 303, which was being used for storage, was greater than 50 square feet, and contained 50 plus boxes, was not equipped with a self closing device.
e. the corridor door leading into the basement storage room one, which was greater than 50 square feet and contained 40 plus boxes, was equipped with a self closing device but failed to latch in to the frame.

4. In interview, these were acknowledged by the Lead Maintenance Technician at the times of observation.

5. Review of monthly fire drill report documentation with the Environmental Services Manager (ESM#1) on 11/09/15 at 11:15 a.m., indicated the following:
a) Fire drills were conducted at or near the end of the month on 01/30/15, 02/27/15, 03/30/15, 04/30/15, 05/28/15, 06/30/15, 07/24/15, 08/27/15, 09/29/15, 10/30/14, 11/28/14 and 12/24/14.
b) Fire drills were conducted with a predictable time pattern for both the second and third shifts as follows:
Second Shift: 02/27/15-2:38 p.m.; 05/28/15-2:54 p.m.; 08/27/15-2:46 p.m.; 11/28/15-2:46 p.m.
Third Shift: 03/30/15-6:17 a.m.; 06/30/15-6:12 a.m.; 09/29/15-5:38 p.m.; 12/24/14-6:15 a.m.

6. In interview at the time of review, the dates of when fire drills were conducted and the time of day the second and third shift fire drills were conducted was acknowledged by the Environmental Services Manager.

7. Observations during a tour of the facility with the Lead Maintenance Technician and the Environmental Services Manager on 11/09/15 from 2:28 p.m. to 3:30 p.m., noted the following:
a. the service elevator equipment room in the basement lacked sprinkler coverage.
b. the passenger elevator equipment room in the basement lacked sprinkler coverage.

8. In interview at the time of observations, the Environmental Services Manager acknowledged the elevator equipment rooms lacked sprinkler coverage.

9. Review of the "Sprinkler Inspection Certificate" dated 06/08/15 for the hospital on 11/09/15 at 12:15 p.m. with the Environmental Services Manager indicated the pump failed the "Annual Pump Test Under Flow".

10. In interview with the Environmental Services Manager after a phone call to the facility's sprinkler contractor, the fire pump failed to reach 100% capacity and recommended contacting the city to verify the city water valves were fully open.

11. Observation during a tour of the facility with the Lead Maintenance Technician on 11/09/15 at 12:05 p.m. noted there were two unsupported "E" cylinders of compressed oxygen in the oxygen storage room on the first floor surgery hall.

12. In interview, this was acknowledged by the Lead Maintenance Technician at the time of observation.

13. Observations with the Environmental Services Manager from 9:00 a.m. to 915 a.m., on 11/10/15 noted Building 03 had nine battery operated emergency lights. A ceiling mounted battery operated light above the receptionist's desk failed to illuminate when tested.

14. In interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, it was acknowledged there was no written record of 30 second monthly tests or a 90 minute annual test regarding the battery operated emergency lights available for review.

15. Observation with the Environmental Services Manager from 9:00 a.m. to 9:15 a.m., on 11/10/15 noted there were seven exit signs with battery-up.

16. In interview from 10:30 a.m. to 12:30 p.m. on 11/09/15 with the Environmental Services Manager, it was indicated that there was no written record of 30 second monthly tests or a 90 minute annual test regarding the exit signs with battery back-up available for review.

17. Observation with the Environmental Services Manager at 9:20 a.m. on 11/10/15 noted the fire alarm control panel (FACP) was located just inside the main public entrance and was unlocked.

18. In interview at the time of observation, the aforementioned condition was acknowledged by the Environmental Services Manager.

19. Observation with the Environmental Services Manager noted the following:
a) At 9:00 a.m. on 11/10/15, the stock of spare sprinklers in the spare cabinet was not complete. There were only three pendant sprinklers and no upright sprinklers in the box. At least one upright sprinkler was observed in the facility mechanical room.
b) At 11:00 a.m. on 11/09/15, the sprinkler system waterflow devices were documented as being tested semiannually instead of quarterly on 06/09/15 and 12/18/14.

20. In interview at the time of observation of the stock of spare sprinklers, the aforementioned condition was acknowledged by the Environmental Services Manager and the Environmental Services Manager was unable to locate any additional documentation to verify the waterflow devices were tested quarterly.

21. Review of Building 04's sprinkler inspection documentation with the Director of Maintenance on 11/09/15 at 11:22 a.m. noted the facility lacked documentation of a sprinkler inspection where the waterflow alarms were tested for the fourth quarter of 2014, first quarter of 2015 and the third quarter of 2015.

22. In interview at the time of record review, Director of Maintenance acknowledged the missing sprinkler inspections.

23. Observation during a tour of Building 04 with the Lead Maintenance Technician on 11/10/15 at 11:31 a.m. noted in the North stairwell there was a five inch by ten inch hole in the ceiling, at 11:43 a.m., the South stairway doors in the basement leading to the first was provided with a self closer but failed to latch into the door frame and at 11:58 a.m., the battery operated emergency light in the Northwest stairwell did not operate when tested.

24. In interview, this was verified by the Lead Maintenance Technician at the time of observations.

25. On 11-09-15 at 1015 hours, the quality director, staff A8, Building 01, was requested to provide documentation of a recent State and/or local fire inspection conducted in 2014 or 2015 and none was provided prior to exit.

26. Documentation provided by the facilities supervisor, staff A12, indicated the most recent State fire inspection was conducted in September 2011 and indicated one request was sent to the State agency in July 2014.

27. During an interview on 11-10-15 at 1435 hours, the facilities supervisor, staff A12, confirmed the most recent State fire inspection was conducted in September 2011, confirmed the facility lacked documentation of a State or local fire inspection in 2014 or 2015, and confirmed no 2015 documentation indicating a request for an inspection from State or local fire officials was available.

Based on document review and interview, the hospital failed to ensure that periodic fire inspections by State or local fire control agencies were conducted at the facility (Building 01).

Findings include:
1. On 11-09-15 at 1015 hours, the quality director, staff A8, was requested to provide documentation of a recent State and/or local fire inspection conducted in 2014 or 2015 and none was provided prior to exit.

2. Documentation provided by the facilities supervisor, staff A12, indicated the most recent State fire inspection was conducted in September 2011 and indicated one request was sent to the State agency in July 2014.

3. During an interview on 11-10-15 at 1435 hours, the facilities supervisor, staff A12, confirmed the most recent State fire inspection was conducted in September 2011, confirmed the facility lacked documentation of a State or local fire inspection in 2014 or 2015, and confirmed no 2015 documentation indicating a request for an inspection from State or local fire officials was available.

Based on document review and interview, the facility failed to ensure that all patient care policy/procedures were developed and reviewed at least annually by a group of professional personnel including at least one physician for 10 of 17 policy/procedures reviewed.

Findings include:
1. The policy/procedure titled: Framework for Policy Development (issued 1-14; annual review date 1-16) failed to indicate a process to ensure documentation of physician participation in the patient care policy development and annual approval process including a method to confirm an annual review was conducted within the past year.

2. Review of the nursing policy/procedure Code Blue (annual review date 12-15) indicated the following: Approval by Nurse Leadership. The policy/procedure failed to indicate a date of revision or review and approval within the prior year or indicate the approval by a group including at least one physician.

3. Review of the pharmacy policy/procedures Medication Error Reporting (revised 8-15) and Medication Management Reporting Suspected Adverse Drug Reactions (annual review date 7-15, 7-16) failed to indicate the approval by a group including at least one physician.

4. In interview on 11-10-15 at 1025 hours, the chief nursing officer, staff A2, confirmed that the indicated policy/procedures failed to indicate documentation of an annual review and/or indicate the approval by a group including at least one physician.

5. Review of the Quality Council minutes dated 5-26-15 indicated 34 policy/procedures including the following titled: Assessment of Patient, Aspiration Precautions, Medication Administration Verification, HIV Testing Information and Consent, Brain Death, and Death Post Mortem Care were presented for review and approval and the committee meeting documentation failed to indicate a physician was in attendance.

Based on document review and interview, the facility failed to maintain its patient care policy/procedures and ensure the reporting of all adverse drug reactions (ADRs) included a practitioner responsible for the care of the patient.
Findings include:
1. Review of the policy/procedure Medication Management Reporting Suspected Adverse Drug Reactions (annual review date 7-15, 7-16) failed to indicate a requirement for immediately reporting the ADR to a responsible practitioner.
2. In interview on 11-10-15 at 1120 hours, the pharmacy director, staff A15, confirmed that the policy/procedure lacked the indicated requirement.

Based on document review, observation, and interview, the facility failed to ensure the implementation of its policy regarding glucometer control solutions, failed to ensure that expired lab tubes were removed from floor stock, failed to monitor the lab specimen refrigerator at one off site for appropriate temperature levels and cleanliness, and failed to implement the facility lab policy related to weekly eye wash station checks in the endoscopy cleaning room.

Findings Include:
1. Review of the policy: Use of Accu-Check Inform II System, policy number 710151.001, issued by laboratory, and issued 6/3/13, indicated under supplies and reagents, in item 4., a. Storage, 2) Controls expire 3 months from opening or the date on the bottle, whichever comes first 3) Record the date opened and the expiration date on the vial cap or label.

2. While on tour of the med/surg nursing unit on 11/9/15 at 3:00 PM, in the company of staff member #54, the nurse manager, it was observed that two sets of glucometer high and low control solution vials lacked a dating by nursing staff of the date opened and the 3 month expiration date on all 4 vials.

3. At 3:10 PM on 11/9/15, interview with staff member #54 confirmed that the 4 vials of control solutions, for the Accu-Check glucometer, lacked dating by nursing staff when opened, and the 3 month expiration date, as required by policy. No other documentation was provided prior to exit.

4. Review of the ED (emergency department) monthly maintenance log indicated the clean utility room was cleaned, and expiration dates were checked, on 8/25/15, 9/25/15, and 10/20/15.

5. While on tour of the ED at 10:20 AM on 11/9/15, in the company of staff member #53, the charge nurse, it was observed that in the clean utility there were 3 gray top lab tubes that expired 7/15 and 4 Pediatric blood culture vials/bottles that expired 10/31/15.

6. At 10:25 AM on 11/9/15, interview with staff member #53 confirmed that the gray lab tubes should have been removed during the August and September staff checks for expiration dates, and the Pediatric tubes should have been removed on 10/20/15, when that month's check was completed. No other documentation was provided prior to exit.

7. Review of the "Laboratory Temperatures" log sheet indicated specimen refrigerators should range in temperature between 2 and 8 degrees C (Celsius), and freezer temperatures should be at or less than 10 degrees C.

8. At 8:20 AM on 11/10/15, while on tour of the lab off site, in the company of staff member #56, a rad tech and phlebotomist, it was observed that the lab refrigerator was dirty with dust and two 2 inch hairs on the lower ledge (in front of the vegetable drawers), dust on the shelves of the door, and lacked a refrigerator temperature log.

9. At 8:25 AM on 11/10/15, interview with staff member #56 confirmed that refrigerator temperatures have not been checked for some time, as this staff member didn't think this was required any longer. It was unknown the last time refrigerator temperatures had been taken, or the last time the refrigerator had been cleaned.

10. At 1:45 PM on 11/10/15, interview with staff member #63, the lab manager, confirmed that there is no policy specific to monitoring lab refrigerator specimens, or related to routine cleaning of specimen refrigerators, but that there is a temperature log to be completed daily in monitoring refrigerator temperatures. Staff member #63 confirmed that lab specimen refrigerators are to have temperatures monitored, should be cleaned "as needed", and did not know that this was not being accomplished at the off site. No other documentation was provided prior to exit.

11. Review of the Laboratory policy number 710.174.003, last revised 6/19/15, indicated under Procedure, in item C., Maintenance of the eye wash station and emergency shower 1. Eye wash station a. Perform maintenance weekly.

12. At 9:50 AM on 11/10/15, while touring the endoscopy cleaning room in the company of staff member #59, the charge nurse for the surgery area, it was observed that the eye wash station checks were done monthly in February, March, April, May, June ,July, and August of 2015, done 3 times in September and had no October checks noted on the tag.

13. Interview with staff member #59 at 9:55 AM on 11/10/15 confirmed that the eye wash station tag lacked weekly documentation of safety checks, as required by facility policy.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the nature and scope of services provided for 12 of 55 contracted services.

Findings include:

1. Review of the 2015 list of contracted services failed to indicate a description of the service for 3 of 4 listed surgical services (CS1, CS3, CS4), 1 fire protection service (CS11), and 2 of 11 radiology services (CS13, CS23). The list of contracted services lacked an indication whether each service is provided on- or off-site, or limited in volume or frequency, or when the services are available and the list failed to indicate a date or process to identify when the list is updated by adding or removing a contracted service.

2. The list failed to indicate an air exchange certification service (CS50), a dietary dishwasher service (CS51), a fire extinguisher (CS52), fire sprinkler (CS53), or fire pump (CS54) service, or an emergency generator (CS55) fuel provider identified during a review of preventive maintenance documentation and requested provider agreements.

3. In interview on 11-10-15 at 1215 hours, the quality director, staff A8, confirmed the list of contracted services failed to indicate all the required information and failed to indicate the contracted service providers listed above.

Based on document review and interview, the nursing staff failed to implement the fall policy for 2 of 2 patients (Pts. #10 and #11) on the behavioral health nursing unit.

Findings Include:
1. Review of the policy for falls, titled Falls Project Team Committee, policy number 929.235.005, last revised 4/2013, indicated under procedure: 1. All inpatients will be assessed for a fall risk on admission and reassessed every shift by the nurse who is assigned to care for that individual patient for that shift.

2. Review of the open medical records on the behavioral unit indicated that:
A. Pt. #10, in room 347, was assessed at 11:37 PM on 11/6/15, upon admission, and reassessed at 2:30 AM and 10:15 AM on 11/7/15, but only one reassessment on 11/8/15 as noted at 8:45 AM.
B. Pt. #11, in room 348, was assessed on admission 11/9/15 at 9:49 PM and had no other assessments documented as the medical record was reviewed at 10:45 AM on 11/10/15.

3. At 10:50 AM on 11/10/15, interview with the manager of the behavioral health unit, staff member #57, confirmed that the unit has 8 hour nursing shifts, that patients #10 and #11 did not have fall risk assessments done on each 8 hour shift after admission, and that the behavioral health unit does not comply with the hospital's fall risk policy for assessments and reassessments.

Based on document review and interview, the facility failed to ensure that all patient care policy/procedures were reviewed and/or revised as a part of the annual program evaluation.

Findings include:
1. The policy/procedures titled Framework for Policy Development (issued 1-14; annual review date 1-16), Quality Assessment Performance Improvement (QAPI) Program (approved 12-14) description, and Charter of the Quality Council (approved 2-15) failed to indicate a requirement to evaluate and review or revise the patient care policy/procedures as a part of the annual program evaluation.

2. In interview on 11-09-15 at 1315 hours, the quality director, staff A8, confirmed that the patient care policy/procedures were not reviewed during an annual program review and confirmed the policy/procedures were reviewed annually on an ongoing or as-needed basis.

Based on document review and interview, the facility failed to ensure that all services were evaluated and reviewed through the Quality Assessment Performance Improvement (QAPI) program for 2 services (central sterilization, housekeeping services)

Findings include:

1. On 11-09-15 at 1015 hours, the quality director, staff A8, was requested to provide documentation of evaluation and review of the central sterilization services and housekeeping services at the facility and none was provided prior to exit.

2. On 11-13-15 at 1400 hours, the quality director, staff A8, confirmed the central sterilization services and environmental services were currently not being reviewed through the QAPI program and no other documentation was available.

Based on document review and interview, the facility failed to ensure that the comprehensive care plan, and weekly multidisciplinary care plan conference, included all disciplines for 1 of 1 swing bed patient who was hospitalized long enough to have a multidisciplinary care plan conference held, pt. #14.

Findings Include:
1. Review of the policy Patient Care Services, policy number 601.508.003, last revised 7/6/12, indicated under Procedure: 1. Multidisciplinary care plan conferences will be held weekly for any patient in the swing bed program, 2. Notification of the meeting will be given to the attending physician and interdisciplinary team members, 3. The meeting shall be conducted by Patient Care Services personnel or the Occupational Therapist, 5. All involved departments shall offer input and review and update goals, and 8. Care plans are available for review by the Attending Physician through the electronic medical record.

2. Review of the swing bed record for pt. #14, admitted 4/25/15, indicated, per the discharge summary, that this patient was 100 years of age, was very feeble/frail, had multiple hospitalizations, was on TPN (total parenteral nutrition), had discussions with physicians and family regarding a possible feeding tube, and required "several blood transfusions".
A. Patient Care Services noted a "Weekly Care Plan Meeting" at 12:58 PM on 5/1/15 that listed the family and multidisciplinary team were present, but failed to list the team members so that it was unclear if all involved in the care of patient #14 were present. It was noted that physician "input" was given.
B. At 2:21 PM (amended at 2:36 PM) on 5/8/15, the Patient Care Services worker noted that the patient, family and Patient Care Services were "in attendance", but lacked documentation of other disciplines and attending physician attendance, or input.

3. At 3:45 PM on 11/10/15, interview with staff member #61, a Patient Care Services/case worker, confirmed that:
A. Swing bed patients are scheduled for their first care conference one week after admission to swing bed status.
B. Pt. #14 had care conferences on 5/1/15 and 5/8/15.
C. It cannot be confirmed what multidisciplinary team members attended on 5/1/15 as the writer failed to list them specifically.
D. No multidisciplinary team members were noted as having attended the 5/8/15 meeting, nor was there documentation of any input by the attending physician.
E. Physicians can write in their progress notes that they have reviewed the care plan meeting minutes and patient goals and that they agree with them, but no progress notes stating this were found related to either the 5/1/15 or the 5/8/15 care plan meetings, except for the surgeon note on 5/1/15 regarding discussion with family about a possible feeding tube placement. No other documentation was provided prior to exit.