HospitalInspections.org

Based on review of the Life Safety Code survey report of the Life Safety survey conducted May 23, 2013 through May 28, 2013, it was determined the Critical Access Hospital was not in compliance with 42 CFR Part 482: The facility was not in compliance with regulations set forth at Appendix W for Critical Access Hospitals and Swing Beds for Physical Environment.

Findings:

Please refer to the Life Safety Code report of May 28, 2013.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a comprehensive care plan was developed which was individualized and included all members of the interdisciplinary team for 3 (three) of 3 (three) "swing bed" residents of the facility, Residents # 1, # 2, and # 3.

The findings included:

1. Resident #1 was admitted to the facility on 4/29/13 and discharged/admitted to swing bed status on 5/3/13 with diagnoses of, but not limited to: pneumonia, convulsions, mental retardation, legal blindness and reflux disease. Review of the clinical record for Resident #1 revealed a "care plan" which was not individualized to meet the needs of the Resident. According to the clinical record, Resident #1 had a procedure in the past to suture the eyelids due to repeated infections and the resident was unable to see. The care plan contained interventions such as: calendar in view, clock in view, corrective lenses used, and large print patient education provided. The care plan also did not address the issue with the eyes and interventions that should be utilized by staff when rendering care. Resident #1 also had risk for aspiration and the hospital staff had in-serviced the staff of the group home where the resident lived regarding safe feeding practices. There was no documentation on the current care plan of any safe feeding practices or education which should be utilized for the resident. The care plan contained a section for "Oral Nutrition Promotion" which evidenced duplicate and irrelevant information such as: calorie count discontinued, calorie count initiated, diet adjusted, diet advanced and diet liberalized. All of these interventions were listed as current. The care plan for Resident #1 also did not specify how the resident was to be transferred. Multiple techniques were included in the care plan such as: mechanical lift used, transfer board used, trapeze bar used, turn sheet used. Resident #1 was observed on 5/8/13 at approximately 10:00 a.m. The resident was lying in bed, There was no trapeze bar on the bed. The resident was lying in a fetal position and the eyes were closed.

In the care plan section for Pressure Ulcer Risk, there were numerous interventions that were not applicable to Resident #1 such as: mittens applied to hands and pouching devices used. According to further documentation on the care plan, the only disciplines involved were case management and nursing.

2. Resident #2 was admitted to the facility on 4/17/13 and discharged/admitted to swing bed status on 4/22/13 with diagnoses that included, but were not limited to: back pain, debility, hypertension, acute compression fractures and pulmonary fibrosis. Resident #2 was observed on 5/7/13 at 8:40 a.m., sitting up in the chair in his/her room with oxygen being provided by nasal cannula at 2 (two) liters per minute (2 L /min).

Review of the comprehensive care plan for Resident #2 revealed interventions which were not pertinent to Resident #2 such as: Under the problem "Hypertensive Disease/Crisis" - chest tube placement per physician, referral to smoking program (patient was a non-smoker according to history). In the problem area "Pressure Ulcer Risk" was: calorie count initiated, calorie count discontinued, diet advanced, diet liberalized, diet adjusted, chin padded, heel suspension boots used, mittens applied to hands, pouching devices used, skin sealant/barrier applied, and under "Falls" - play therapy provided (Resident was 86 years old at the time of the survey). These interventions were not applicable to this resident. There was no evidence of any interdisciplinary participation on the care plan other than nursing and case management. Patient #2 was receiving respiratory services and therapies.

3. Patient #3 was admitted to the facility on 4/23/13 and discharged/admitted to swing bed status on 5/6/13 with diagnoses that included, but were not limited to: status post right wrist fracture, chronic obstructive pulmonary disease, diabetes, and MRSA pneumonia (Methicillin resistant staphylococcus aureus). Patient #3 was observed on 5/7/13 at 12:15 p.m. in bed. The patient was alert and oriented and receiving a respiratory treatment. Patient #3 was on isolation for the MRSA infection.

The care plan for Patient #3 included interventions which were not applicable to the Resident such as, in the section for "Diabetes" was listed: continuous insulin infusion (resident was not receiving insulin infusion), enteral feeds adjusted (resident did not have a feeding tube), and parental feeds adjusted (resident did not have parental feeding). Under the section for "Pressure Ulcer risk" was: absorbent garment/pad/diaper changed (resident was not incontinent), gauze applied between skin folds, mittens applied to hands, and pouching devices used. Under the section for "Fall Risk" was: play therapy provided (Resident was 89 years old at the time of the survey). Under "Hypertensive Disease" was listed: seizure precautions, and chest tube placement per physician. In the section for "Infection Risk" was: warm fluids administered, warming devices used, chilled fluids administered, cold packs applied, cooling devices utilized, tepid bath given, sitz bath given, mittens applied to hands. These interventions were not applicable to this resident. There was no documentation/evidence of any interdisciplinary team collaboration on the care plan as the care plan was signed only by case management and nursing.

On 5/7/13 at 4:10 p.m., the surveyor discussed the concerns regarding the individualization of the care plans with Staff #1 and # 3.

On 5/8/13 at 2:00 p.m., Staff #3 stated the care plans are electronic and the staff have to go in to the system and remove the interventions that are not applicable to the residents/patients. Staff #3 acknowledged the care plans were not individualized and stated the staff would address the concerns.