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Based on observation and interview, it was determined the facility did not meet the Life Safety Code requirements related to the fire protection of the Soiled Linen Room. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due to the potential spread of smoke and fire due to the opening left by the missing door hardware and inability of the door to close due to the damage to the door. The facility had a census of two patients on 01/11/16. See K29.

Based on interview, it was determined there was no evidence an activity calendar had been developed. Failure to develop an activities calendar did not allow the Swing Bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any Swing Bed patient. Findings follow:

During an interview with Registered Nurse #1, she stated there was not an activity calendar prepared for Swing Bed Activities.

Based on interview and clinical record review, it was determined the facility failed to document activities for one (#2) of two (#1 and #2) Swing Bed patients. Failure to document activities did not allow the physician and other staff to be knowledgeable regarding the patient's emotional and physical progress related to the plan of care. The failed practice affected Patient #2. Findings follow:

Review of the clinical record of Patient #2 revealed no activities documented. During an interview with the Director of Nursing at 0915 on 01/14/16, she verified the findings.