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Based on observation, interview, and review of the facility's Policy and Admission Packet, it was determined the facility failed to inform patients receiving information on an Advance Directive that complaints concerning Advance Directive requirements could be filed with the State Survey and certification Agency.
The findings include:

Review of the facility's Policy titled, "Advance Directives/Patient Rights," dated 11/2000, last reviewed 03/2018, revealed all competent adults, upon admission to the hospital, would be informed of their rights to refuse or receive medical care, their rights to execute Advance Directives, and their rights to give informed consent for treatment procedures. Further review revealed the admitting clerk, in addition to providing Advance Directive forms, should provide the telephone number to the Kentucky Department of Health to report non-compliance with Advance Directive requirements.

Review of the facility's Admission Packet, effective date 03/22/17, revealed to file a complaint or report a concern, the patient/family should call the facility or the corporate office. Their telephone numbers were listed. It also stated a written complaint could be sent to the United States Department of Health and Human Services. There was no information given on how to contact the State Survey and Certification Agency.

Observation of the registration area, on 03/15/18 at 3:55 PM, revealed the State Survey and Certification Agency's contact information was not posted.

Interview with the Patient Financial Services Director, on 03/15/18 at 4:00 PM, revealed she supervised the admitting clerks that handled Advance Directive procedures. She stated the clerks did not give out contact information about the patient's right to make a complaint to the State Survey and Certification Agency. The Director revealed she was unaware of this Advance Directive requirement.

Based on interview and review of the facility's Policy, it was determined the facility failed to maintain nursing competencies for administration of nebulizer treatments.

Review of competency documentation, revealed no documented evidence nursing staff maintained ongoing competencies for administration of nebulizer treatments routinely administered by a Respiratory Therapist.

The findings include:

Review of the facility's Policy titled "Staff Competencies" dated 11/2000 ,with a review date of 02/2016, revealed department orientation was individualized by the department director. The Policy further revealed all equipment used in a department would be reviewed and the employees' competency to work with the equipment would be assessed. The Policy stated the Annual Performance Appraisal would include assessment by the supervisor for equipment competencies and ongoing educational needs of the employee.

Review of the "Orientation/Competency Validation Checklist" form, page 4, dated 03/23/17, for Registered Nurse (RN) #1 and RN #2 included a competency validation for administration of nebulizer treatments. The Nebulizer Treatment Competency on the Orientation/Competency form for RN #1 was dated 03/17/17. The Checklist revealed nebulizer competency and skill under the Respiratory Therapy section had been signed off by RN #1 at a competent level of performance. No evaluator initials were present on the document. The "Orientation/Competency Validation Checklist" dated 03/23/17 for Nurse #2 revealed the nurse demonstrated the procedure, initialed the Checklist, was assessed to be competent, and was evaluated by "RS".

Review of the RN Competency Report, undated, revealed no further competencies for nebulizer treatments were included on the annual ongoing competency assessment form. Review of the RN Competency Report completed 05/15/17, for RN #3 who was hired in May 2010, revealed no ongoing competency assessment for administration of nebulizer treatments. Review of the RN Competency Report completed 05/17/17, for RN #4, who was hired in January 2005, revealed no ongoing competency assessment for administration of nebulizer treatments.

Review of the "Emergency Room Orientation/Competency Validation Checklist, page 9, dated 03/15/18, revealed Neb Treatments had been added back to the Checklist.

Review of the untitled document with the first line "Procedure: Nebulizer therapy, in line, respiratory" revealed the Respiratory Therapy Manager used the tool to evaluate staff with the objective of administering in-line nebulizer therapy according to the standard of care. One employee had been assessed with the tool.

Review of the "Sign In Sheet For Competency Hands On Check Off 2017" revealed eighteen (18) signatures with no supporting documentation of what the check offs included.

Interview with the Director of Respiratory Therapy, on 03/15/18 at 8:55 AM, revealed Respiratory Therapy Services including nebulizer treatments were administered by the Respiratory Therapist when he was on site and by the nursing staff in his absence. He further stated he was responsible for teaching nursing competencies for respiratory procedures, including nebulizer treatments, to the nursing staff during orientation and annual competencies. The Director of Respiratory Therapy stated nebulizer competencies were completed annually and documentation maintained by the nursing managers. He stated he handed off completed competencies to the nursing manager and the nursing managers maintained competencies for nursing staff.

Interview with the Nursing Manager for the Emergency Room and the Medical Surgical Unit, on 03/15/18 at 12:55 PM, revealed the initial and ongoing competencies for administration of nebulizer treatments for nursing were completed by the Director of Respiratory Therapy. After review of the "RN Competency Report", undated, she stated she was in the process of revising the "Hospital Emergency Room Orientation/Competency Validation Checklist" to include a nebulizer competency. She further stated she had one (1) nurse who had a completed form and one (1) nurse who was in her initial employment period and had the orientation competency at home. Per interview, nebulizer competencies for nurses were done annually and maintained by the Director of Respiratory Therapy. She stated she did not have further completed nebulizer competencies.

Interview with the Chief of Nursing Officer (CNO), on 03/15/18 at 4:20 PM, revealed nursing competencies were in the purview of Department Managers. Per interview, Department Managers determined competency needs with input from management and ensured compliance of competencies. She stated she did not think annual nebulizer competencies for nursing staff were necessary. She further stated if Department Managers felt the nebulizer treatments should be part of annual competencies she would defer to their judgment. The CNO stated tasks normally performed by one profession and covered by another profession could require more training to ensure a consistent level of care for patients.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to provide activities for two (2) of four (4) Swing Bed residents (Swing Bed Resident #23 and Swing Bed Resident #24).

Swing Bed Resident #23 was admitted to the facility on 03/02/18; however, did not receive an Initial Activity Assessment until 03/14/18.

In addition, Swing Bed Resident #24 was admitted to the facility on 03/01/18 and received an Initial Activity Assessment on 03/02/18; however, there was no further documentation of the resident's activity participation.

The findings include:

Review of the facility's Policy titled, "Swing Bed Program Information", dated 04/2013, last reviewed 06/2017, revealed an Activities Program was provided without charge to the Swing Bed resident.

Review of the facility's Policy titled, "Assessment of Patient", dated 11/2000, last reviewed 01/2017, revealed Swing Bed residents were to have an Initial Assessment and Plan of Care completed within twenty four (24) hours of admission by a Registered Nurse (RN). The Policy further stated the Activity Assessment and Plan were included as part of the Assessment.

Observation of the second floor space designated as "Activity Room," on 03/13/18 at 1:35 PM, revealed a room with multiple pieces of equipment including two (2) activity carts, one (1) computer on a cart, one (1) resident lift, six (6) poles to hold intravenous fluid bags, one (1) blanket warmer in operation, and one (1) computer server mounted on the wall. Further observation of the second floor patient/resident care areas revealed no Activity Calendar posted.

1. Review of Resident #23's Electronic Medical Record (EMR), revealed the facility admitted the resident on 03/02/18. On 03/14/18, at 3:15 PM, the Occupational Therapist (OT) responsible for the Activities Program entered a Note in the EMR stating Resident #23 was given an Activity Assessment form to complete. The Note stated the resident reported no interest in activities on the list and preferred to play adult video games. Per the Note, the OT provided a "WI" machine for the resident. Review of an untitled form dated "Wednesday 14" with Resident #23's name at the top, contained a list of activities and was blank with the exception of "video games" written in the "Additional Interests" section. This form was taped to the white board in the resident's room.

Interview with Resident #23, on 03/13/18 at 1:35 PM, revealed he/she preferred receiving care at this facility instead of going to a facility closer to home. Resident #23 further stated staff were nice, and he/she had no concerns about care received at the facility.

Observation of Resident #23 on 03/13/18 at 4:30 PM, during medication administration, revealed he/she was using his/her cellular phone to play video games. Observation of room 212, Resident #23's room, revealed no posted Activity Calendar.

Interview with the OT, on 3/15/18 at 3:40 PM, revealed she was responsible for the Activities Program for Swing Bed residents. She stated she usually assessed residents on the first or second day of admission. Per interview, she became aware of a new rehabilitation resident by electronic orders she received. She stated, if the resident was not a rehabilitation patient, the she became aware of the resident's admission through a verbal communication from the nursing staff. She further stated Resident #23 was not a rehabilitation resident, and she was unaware of the admission until 03/14/18. Per interview, she saw the resident on the initial assessment visit, and then she completed the form with activity preferences. She stated Resident #23 was not interested in any activities on the preference list during her first visit with him/her on 03/14/18, but he/she preferred adult video games. The OT further stated she set up a WI for the resident; however, he/she had no interest in the game machine. Per interview, the OT documented the encounter in the EMR on 03/14/18.

2. Review of Resident #24's EMR revealed the facility admitted the resident on 03/01/18 and discharged the resident on 03/14/2018. There was no documentation of evaluation or participation in the Activities Program by the OT/staff. Review of the paper medical record revealed an untitled form, dated 03/02/18, with Resident #24's name and resident identification sticker attached. The form had sewing/quilting, walking, cooking, word finds, and TV reruns/older shows check marked. There was no other documentation present in the EMR pertaining to his/her activities.

Interview with Resident #24 and a family member, on 3/13/18 at 1:35 PM, revealed the resident and family member were pleased with the "outstanding" nurses and had no concerns with the facility.

Observation on 03/13/18 at 4:35 PM, of room 224, Resident #24's room, revealed no posted Activity Calendar.

Interview with the OT, on 03/15/18 at 3:40 PM, revealed she met with Resident #24 on 03/02/18 and completed the preference list. She stated she provided adult coloring books and word search puzzles to the resident. The OT further stated Resident #24 did not want to engage in activities. The OT revealed she did not document monitoring, reviewing, or evaluating activities other than on the initial untitled activity assessment form, but stated maybe she should have provided follow-up documentation. In addition, the OT stated she did not keep a Swing Bed Activity Calendar. Per interview, she preferred to make individual Activity Calendar for each resident. She stated she did not create an individual Activity Calendar for Resident #23 or #24.

Interview with the Director of Rehabilitation, on 03/15/18 at 3:10 PM, revealed she was a Physical Therapist (PT) and was responsible for oversight of the OT who was responsible for activities for Swing Bed residents. The Director stated she was unaware of a time frame for the Initial Activity Assessment by the OT; however, after reviewing the facility's policy, she stated the time frame was within twenty four (24) hours of admission. The Director revealed the OT performed the Initial Assessment on paper and created the Activity Calendar which was kept on the computer. She further stated activities conducted with each resident were recorded in the EMR, and the activity preferences were hung on the white boards in each resident's room. Upon review of the untitled activity preference form dated "Wed 14" for Resident #23, she stated it was consistent with the initial documentation in the EMR entered by the OT, on 03/14/18 at 3:15 PM. She located the Initial Activity Assessment for Resident #24 in the Medical Record Department, and stated she had no other information or documentation for Resident #24 related to activities.

Interview with the Chief Nursing Officer (CNO), on 03/15/18 at 4:20 PM, revealed the OT was responsible for the Swing Bed Activity Program. Per interview, the OT reported to the Director of Rehabilitation. She stated every Swing Bed resident admission generated an OT consultation from an order set, and the OT received the order on the first business day after the Swing Bed admission. The CNO stated the order for the OT consultation would initially go to the Director of Rehabilitation who gave it to the OT. She further stated the OT evaluated the resident for activities, determined what was appropriate, and documented this in the EMR. Per interview, the OT should complete the initial activity evaluation by the next business day after admission. The CNO stated the initial activity assessment was done twelve (12) days after admission for Resident #23 which was unacceptable. She further stated there was a lack of progress notations for Resident #24 which was also unacceptable. The CNO stated her expectation was for the OT to follow facility Policy, and complete the Initial Activity Assessment within twenty-four (24) hours and document participation, progress, and declination of activities in the medical record. She stated this was an important part of care for Swing Bed residents.