HospitalInspections.org

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the medical record contained a diet order for 10 of 36 sampled patients (Patients 4, 7, 8, 9, 10, 12, 13, 17, 18 and 29). This had the potential to affect all patients admitted to the CAH who receiving diets.

Findings are:

A. A review of the medical record for the following patients revealed the lack of a diet order:

-Patient 4 admitted 11/10/14 and dismissed 11/12/14.
-Patient 7 admitted 3/3/15 and dismissed 3/6/15.
-Patient 8 admitted 4/14/15 and dismissed 4/17/15.
-Patient 9 admitted 5/26/15 and dismissed 5/29/15.
-Patient 10 admitted 5/27/15 and dismissed 5/29/15.
-Patient 12 admitted 1/18/15 and dismissed 1/19/15.
-Patient 13 admitted 6/3/15 and dismissed 6/4/15.
-Patient 17 admitted 10/28/14 and dismissed 10/30/14.
-Patient 18 admitted 4/27/15 and dismissed 5/1/15.
-Patient 29 admitted 4/26/25 and dismissed 5/1/15.

A review of the medical records showed that the patients did receive a diet and assistance as needed during their stay.

B. An interview with the Nurse Practitioner [NP] on 8/26/15 at 1:45 PM, revealed that the NP did provide the kitchen with a diet for the patients on a 'communication sheet', but due to a glitch in the electronic record did not enter it into the electronic record and did not write an order.

Based on staff interview and review of 5 of 5 swing bed patient records (Patients 29, 30, 31, 32 and 33), the CAH (Critical Access Hospital), failed to ensure that a qualified professional directed the patient activities program for the swing bed patients. This had the potential to effect all patients admitted to swing beds.

Findings are:

A. An interview with Registered Nurse [RN] A on 8/26/15 at 11:10 AM, verified that the nursing staff complete the Activity Assessments for the swing bed patients. RN A verified that the nurses who were currently completing the activity assessments were not qualified activity professionals.

B. The patient record review for Patients 29, 30, 31, 32 and 33, revealed that nursing staff (who did not have the training required to be a qualified activity professional) completed the Activity Assessment for those patients.

Based on record review and staff interview, the facility failed to ensure that swing bed patient records included a recapitulation (a concise summary) of the swing bed stay for 5 of 5 (Patients 29, 30, 31, 32 and 33) discharged swing bed records reviewed. This had the potential to affect all discharged swing bed patients.

Findings are:

A. A review of Patient 29's medical record lacked a recapitulation of the patient's swing bed stay from 4/26/15-5/1/15.

B. A review of Patient 30's medical record lacked a recapitulation of the patient's swing bed stay from 3/23/15-3/31/15.

C. A review of Patient 31's medical record lacked a recapitulation of the patient's swing bed stay from 2/10/15-2/13/15.

D. An interview with Registered Nurse A on 8/26/15 at 11:10 AM revealed, that the CAH utilized a 'computer generated form which identified where in the chart to find the information that is used in the recapitulation. We used to do a different type of summary before we went electronic'.

E. The Recapitulation Policy and Procedure (undated) identified:
-The policy as: "...shall provide a recapitulation form on all swing bed patients 14 days and then every 7 days. and shall complete one on discharge even if patient is transferred to acute care or another facility..."
-The procedure as: "...This is used only on Medicare patients in swing-bed... The discharge form is used only upon discharge. If patient is transferred or put back into acute care the discharge form does need to be completed. (Skilled Care Discharge Recapitulation)."