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Based on clinical record review and interview, it was determined the facility failed to assure the plan of care included interventions based on identified needs and a method to measure progression or digression toward established goal for 20 of 20 (#1-20) patients. Without the implementation of interventions, staff was unable to evaluate a response to care in the event of modification required to assist patients in meeting their maximum potential. The failed practice had the potential to affect any inpatient admitted to the facility. The findings follow:

A. In review of the clinical record on 10/28/11 at 0900-1330 for 20 of 20 (#1-#20) patients, there was no evidence of interventions or as to how the goals were to be accomplished.
B. In an interview on 10/28/11 at 1030, the Quality/Risk Director confirmed the problem activity list utilized as the plan of care lacked evidence of interventions.

Based on observation, Environmental Services Policy review and interview, it was determined the Infection Control Officer failed to have a process in place to monitor and evaluate linen sanitation techniques and failed to assure techniques were in place to identify equipment and supplies that could not be disinfected due to their non-impervious surfaces . The failed practice did not assure patients and staff were protected against the spread of infection. The failed practice had the potential to affect all patients admitted to the outpatient clinic, nursery and Operating Room #1. Findings follow:

A. Tour of the Outpatient Clinic on 10/26/11 at 0910 revealed, a room identified as utilized for patients who require recurring outpatient visits contained, a cabinet with seven crochet afghans. In an interview on 10/26/11 at 0920, the Outpatient Director stated the seven crochet afghans were made by volunteers in the community and were utilized by patients receiving treatment. The Outpatient Director further stated the blankets were bagged and taken home and washed by "The Pink Ladies" who were hospital volunteers. There was no evidence provided of a monitoring process to ensure the blankets were washed for the correct time and temperature and processed to minimize the spread of infection.
B. Observation of the Nursery was conducted with the Labor Delivery Recovery Post Partum (LDRP)/Nursery Director on 10/26/11 at 0900-1000. The following was observed and confirmed by the LDRP/Nursery Director at the time of the observation: A three section expandable portable privacy screen contained an attached multi-color porous fabric curtain.
C. Observation of the Surgical Department was conducted with the Surgical Services Director on 10/26/11 at 1330-1430. The following was observed and confirmed by the Surgical Services Director at the time of the observation: Operating Room #1 contained a black rolling chair made of non-impervious fabric which could not be cleaned or disinfected.
D. Review of Environmental Services Policy #2002-Cleaning Supplies and Chemicals on 10/27/11 at 1500 revealed "The Environmental Services Director and Infection Control Practitioner should determine which items/surfaces/areas need to be cleaned with soap and water and those that need to be cleaned with soap and water and then disinfected."

Based on review of policies and procedures for the Swing-Bed Program, clinical record review, and interview, it was determined the facility failed to have patient activities and failed to have activities directed by a qualified professional for one of one (#1) patient on Swing-Bed status. Failure to provide an activities program and a qualified professional to direct the program, created the potential for unmet activity needs for the physical, mental, and psychosocial well-being of each patient. The failed practice affected patient #1, and had the potential to affect all patients admitted to the Swing-Bed program. The findings are:

A. Review of the clinical record for Swing-Bed Patient #1 on 10/28/11 revealed it did not include documentation of a comprehensive activities assessment designed to meet the interests and the physical, mental and psychosocial needs for Swing-Bed patient.
B. In an interview with the Social Worker designated as the Director of Continuum of Care on 10/28 at 1130, she confirmed there was not a qualified individual on staff to direct the activities for patients admitted to the Swing-Bed program.

Based on review of policy and procedures and interview, it was determined the facility failed to have a process in place to meet the dental care needs of Swing-Bed patients as needed on a routine or 24 hour emergency basis. Without a process in place, the facility could not assure dental care needs of Swing-Bed patients could be met. The failed process had the potential to affect Swing-Bed Patient #1 and had the potential to affect all patients admitted to the Swing-Bed program. The findings are:

Review of the policy and procedures for the Swing-Bed Program was completed on 10/28/11. In an interview with the Social Worker, designated as the Director of the Continuum of Care on 10/28/11 at 1130, she confirmed the facility did not have a dentist on staff nor did the facility have a contractural agreement to provide dental services to Swing-Bed patients as needed for routine or 24 hour emergency dental care.