HospitalInspections.org

Based on review of Board of Directors, Medical Staff meeting minutes, document review and staff interviews, the Board of Directors (governing body) failed to ensure the Board of Directors and Medical Staff only approved candidates to join the Medical Staff which met the Medical Staff's criteria for membership when credentialing and granting medical staff privileges to providers and ensured only qualified staff provided surgical services to patients at the Critical Access Hospital.

Please refer to C- 962.

The cumulative effect of the systemic failure and deficient practice resulted in the facility's inability to ensure quality health care provided to patients.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 Orthopedist (Orthopedist F), selected for review, held approved privileges prior to performing surgical procedures, since his initial appointment to the Medical Staff. Failure to ensure Orthopedist F had surgical privileges to perform surgical procedures could potentially result in the CAH staff allowing Orthopedist F to perform a procedure he lacked competence and skill to safely perform and result in a practitioner providing care beyond their capabilities and compromise safety of CAH patients. The CAH administrative staff identified Orthopedist F, appointed to the CAH Medical Staff on 6/18/2019, performed the following procedures:

June to December 2019: 1 open reduction and internal fixation (ORIF), 1 patellar bone spur excision, 3 rotator cuff repair and 2 joint manipulations.
January to December 2020: 3 wrist ORIF, 1 ankle ORIF, 1 tibial plateau fracture repair, 3 elbow release, 21 shoulder arthroscopy and 1 joint manipulation
January to April 2021: 1 distal radius ORIF, 1 foot ORIF, 7 shoulder arthroscopy, 1 joint manipulation and 2 elbow incision and drainage.

Findings include:

1. Review of the CAH Governing Body by-laws, adopted on 12/18/2007, revealed in part "... Each member of the Medical Staff shall have appropriate authority and responsibility for the care of his/her patients subject to such limitations as are contained in these by-laws and in the by-laws, rules and regulations for the Medical Staff ... The Board shall, in the exercise of it's overall responsibility to promote good patient care, delegate this responsibility for the quality of medical care to the Medical Staff ... The Medical Staff shall make recommendations to the Board of Directors concerning: ... granting of clinical privileges; ...".

2. Review of the CAH Medical Staff by-laws, approved 3/21/2017, revealed in part "... Every practitioner practicing at this hospital by virtue of Medical Staff membership, or otherwise, shall be entitled to exercise only those clinical privileges specifically granted to him by the Governing Body ... Every initial application for Medical Staff membership must contain a request for specific clinical privileges desired by the applicant ...".

3. Review of a CAH policy titled "Clinical Privileges Delineation", reviewed 9/28/2020, revealed in part "... Any practitioner who provides clinical services at [CAH] may exercise only those privileges the governing board granted him or her ... Each applicant must include in his or her application for appointment or reappointment to the medical staff a request for specific clinical privileges that he or she seeks ...".

4. Review of the CAH surgery schedule for 5/25/2021 revealed Orthopedist F was scheduled to perform a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis at 8:00 AM.

5. Review of Orthopedist F's credential file revealed a privilege list effective 6/18/19 to 6/18/21, approved by the Governing Body on 6/18/21, which failed to identify privileges to perform the procedures on the CAH's surgery schedule at 8:00 AM on 5/25/2021, which included a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis.

6. Review of an othopedic procedure log for Orthopedist F, from April 2019 through April 2021, revealed Orthopedist F performed the following procedures, but the approved delineated privileges failed to include them: ORIF (wrist, ankle, radius and foot), bone spur exclusion, rotator cuff repair, joint manipulations, tibial plateau fracture repair, elbow release, shoulder arthroscopy, joint manipulation, and elbow incision and drainage.

7. During an interview on 5/26/2021, at 10:40 AM, the Finance Manager acknowledged Orthopedist F's delineation of privileges failed to identify privileges to perform a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis.

8. During an interview on 5/26/2021, at 11:45 AM, the Assistant Director of Nursing expressed surprise that Orthopedist F did not have identified privileges for the procedures scheduled on 5/25/2021 at 8:00 AM. She reported the surgery staff have access to surgical privileges in the surgery area and would check a provider's privileges if they questioned the procedure.

9. During an interview on 5/26/2021, at 11:52 AM, the Assistant Director of Nursing confirmed Orthopedist F's credential file and the list of privileges for Orthopedist F, available in the surgical services area, failed to identify the surgical procedure performed on 5/25/202.


II. Based on observation, document review, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 Athletic Trainers, who performed the role of first assistant, during surgical procedures performed by Orthopedist F (Athletic Trainer G and Athletic Trainer H), were qualified to assist in surgical procedures, according to the Medical Staff bylaws and CAH policies. The administrative staff identified Athletic Trainer G assisted Orthopedist F on 66 surgical procedures and Athletic Trainer H assisted Orthopedist F on 80 surgical procedures, from 11/21/2019 to 5/25/2021.

Failure to ensure the qualifications of all individuals providing assistance to surgical procedures of CAH patients could potentially result in the performance of care beyond their capabilities and placing the patient at risk for surgical complications and potential harm.

Findings include:

1. Observation in the surgery department on 5/25/2021, at approximately 9:50 AM, revealed Orthopedist F performing a knee surgery with the assist of scrub personnel. During an interview at the time, the Operating Room Manager reported Orthopedic Surgeon F, brings has 2 Athletic Trainers that he utilizes as first assist in surgery, indicated the 2 individuals had been credentialed.

2. Review of an operating room log report, dated 5/26/2021, identified Athletic Trainer G as part of the surgical team for an orthopedic procedure performed by Orthopedist F.

2. Review of the CAH Medical Staff Rules and Regulations, approved 3/21/2017, revealed in part "... The decision of a first assistant will be at the discretion of the surgeon. The first assistant shall be a physician with surgical privileges, a physician assistant with surgical privileges, a Registered Nurse (RN) qualified by means of a Registered Nurse First Assistant (RNFA) Program who is under the direct supervision of a surgeon, or a physician assistant may assist if the supervising physician (or alternate) is immediately available ...".

3. Review of a CAH policy titled "Operating Room personnel", reviewed 5/4/2021, identified the purpose of the policy included to delineate qualifications of surgical personnel and to list qualified personnel. The policy revealed in part "... Qualification are defined as follows: First Assistant/Scrub - [Physician Assistant-Certified], [Registered Nurse] (under direct supervision of Surgeon) ... All assistants must have documented appropriate knowledge and skills to function in the [Operating Room]...".

4. Review of a CAH policy titled "Surgical Assistants and Duties", reviewed 6/11/2015, revealed in part "... First assistant shall be a licensed physician with surgical privileges, a Registered Nurse (RN) qualified by means of a Registered Nurse First Assistant (RNFA) Program who is under the direct supervision of a surgeon, or a physician's assistant if the supervising physician (or alternate) is immediately available ... These privileges are documented in approved applications to the [CAH] ...".

5. Review of CAH files for Athletic Trainer G and H failed to show they met the qualifications, identified in the Medical Staff bylaws and CAH policies and procedures, to perform the position of first surgical assistant.

6. During an interview on 5/26/2021, at 3:15 PM, the Assistant Director of Nursing confirmed the files for Athletic Trainer G and H failed to show qualifications to perform as first surgical assistant.

7. During an interview on 5/27/2021, at 10:10 AM, the Chief Executive Officer reported when Orthopedist F requested to have Athletic Trainer G and H assist him in surgical procedures, and the CAH checked with another CAH where Orthopedist F practiced and followed their process, but confirmed they failed to ensure the process followed the Medical Staff Bylaws and CAH policies and procedures.

I. Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the radiology staff removed 1 of 1 barium sulfate for oral suspension bottle after video swallow studies on each patient, in accordance with the manufacturer's directions. Failure to remove the barium sulfate oral suspension after each patient could potentially result in bacteria growing in the bottle and potentially causing an infection in the next patient. The Radiology Coordinator identified that Speech therapy performed an average of 7 video swallow study procedures from 07/2020 to 05/2021.

Findings include:

1. Observations during a tour of the radiology department on 05/26/2021 at 12:27 PM in the preparation room of radiology revealed 1 of 1 bottle Bracco Diagnostics E-Z HD (Barium Sulfate) of oral suspension for video swallow studies (an exam to look at the patient's ability to swallow safely and effectively). Review of the manufacturer's instructions indicated in part..."E-Z-HD (barium sulfate) for suspension, is supplied as a fine, white to lightly colored powder (98% w/w) in a single-dose HDPE plastic bottle..." The hospital staff must discard any unused suspension after use on a single patient.

2. During an interview at the time of the tour, Lead Radiology Tech K stated the E-Z-HD barium sulfate oral suspension was a single dose bottle.

3. During an interview on 05/27/2021 at 10:45 AM, Physical Therapist (PT) J reviewed and confirmed the manufacturer's directions for the E-Z-HD oral barium sulfate suspension. PT J acknowledged the manufacturer did not support using the bottle of E-Z-HD Oral barium sulfate suspension for more than one patient.


II. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) staff failed to store 5 of 5 observed vials of succinycholine (medication used to relax muscles during surgery) according to manufacturer's recommendations. Failure to ensure succinycholine is stored according to manufacturer's recommendations could potentially result in patients receiving a medication that does not work in the body as expected resulting in unintended consequences or side effects. The CAH's administrative staff identified the surgical services staff performed 702 surgical procedures from July 1, 2020 - April 30th, 2021.

Findings include:

1. Observations on 05/25/2021 at approximately 9:55 AM, during Patient #5 surgical procedure in operating room #1 revealed in an interview with Certified Registered Nurse Anesthestist (CRNA) I (a registered nurse with specialized training in administering medication to render a patient unconscious for surgery) stated the succinycholine was kept in a monitored, secured refrigerator, removed everyday of surgery, has a shorter expiration date once removed from the refrigerator, has reached room temperature, and is returned to the refrigerator everyday after surgeries are completed. During further observation of the succinycholine 4 more bottles were observed in the plasitc kit that they were stored in for use, no date of the initial removal from the refigerator was identified on the bottles.

2. Review of manufacturer's recommendations for the storage of succinycholine, revised 2/2019, revealed, in part: "Refrigeration of the undiluted agent will assure full potency until expiration date...Store in refrigerator 2 degrees - 8 degrees C [Celsius] (35.6-46.4 degrees F)...the multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

3. During an interview on 05/27/2021 at 11:05 AM, Pharmacist L acknowledged the current process for storing the succinycholine does not follow the manufaturer's recommendations.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the staff kept patient medical information secure from unauthorized access to 6 of 6 banker boxes with patient information found in an unsecured storage closet. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patient's personal/medical information and potentially result in unauthorized release of personal information. The CAH administrative staff identified 52 swing bed admissions in Fiscal Year 2020 with an average length of stay of 71 hours.

Findings include:

1. Review of policy, "Standard Operating Procedure Security of Medical Records" dated effective -08/09/1994, revised 09/29/2020 revealed in part, "The Health Information Management (HIM) Department will monitor and control paper medical record access limit access to those Virginia Gay Hospital Staff members ..... HIM is also responsible for safeguarding both paper record and its information content against loss, defacement, and tampering."

2. Review of policy, "Protecting Patient Information" dated effective 10/10/2001 last reviewed 09/29/2020, revealed in part, " ...HIM Department will ensure the protection of patient information ...as outlined in the standard operating procedure for the security of medical records."

3. Observation on 05/24/21 at 11:30 AM, during a tour of the medical surgical-swing bed department, revealed 6 of 14 boxes located in storage 76 room was unlocked area of the supply closet, potentially allowing unauthorized personnel access to confidential patient information.

4. During an interview on 05/24/2021 at approximately 11:30 AM, at the time of the tour, the Director Of Nursing (DON) and Assistant Director of Nursing (ADON) revealed these 6 banker boxes were not secured and private patient information, predominately Operating Room (OR) log books, OR surveys, Post Infection Surveillance, Emergency Room (ER) log books, and Post Discharge Infection sampling. The DON and ADON acknowledged that the private patient information in storage 76 room was available for unauthorized personnel access as patient care staff come into this area to obtain respiratory care supplies as needed, potentially on a daily basis. The Respiratory Therapy Coordinator acknowledged the private and confidential patient information is not secured as hospital policy requires.

Based on :review of Medical Staff meeting minutes, document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to to ensure surgical services and surgical procedures were performed by qualified practitioners, granted privileges by the governing body, or other responsible individuals, in accordance with the CAH's medical staff bylaws, policies and procedures.

The CAH administrative staff and Medical Staff failed to follow their bylaws, policies and procedures to ensure only qualified practitioners, granted the appropriate privileges, provided surgical services to CAH patients.

Please refer to C-1142.

The cumulative effect of the systemic failure and deficient practices resulted in the facility's inability to ensure quality and safe health care provided to patients.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 Orthopedist (Orthopedist F), selected for review, held approved privileges prior to performing surgical procedures, since his initial appointment to the Medical Staff. Failure to ensure Orthopedist F had surgical privileges to perform surgical procedures could potentially result in the CAH staff allowing Orthopedist F to perform a procedure he lacked competence and skill to safely perform and result in a practitioner providing care beyond their capabilities and compromise safety of CAH patients. The CAH administrative staff identified Orthopedist F, appointed to the CAH Medical Staff on 6/18/2019, performed the following procedures:

June to December 2019: 1 open reduction and internal fixation (ORIF), 1 patellar bone spur excision, 3 rotator cuff repair and 2 joint manipulations.
January to December 2020: 3 wrist ORIF, 1 ankle ORIF, 1 tibial plateau fracture repair, 3 elbow release, 21 shoulder arthroscopy and 1 joint manipulation
January to April 2021: 1 distal radius ORIF, 1 foot ORIF, 7 shoulder arthroscopy, 1 joint manipulation and 2 elbow incision and drainage.

Findings include:

1. Review of the CAH Governing Body by-laws, adopted on 12/18/2007, revealed in part "... Each member of the Medical Staff shall have appropriate authority and responsibility for the care of his/her patients subject to such limitations as are contained in these by-laws and in the by-laws, rules and regulations for the Medical Staff ... The Board shall, in the exercise of it's overall responsibility to promote good patient care, delegate this responsibility for the quality of medical care to the Medical Staff ... The Medical Staff shall make recommendations to the Board of Directors concerning: ... granting of clinical privileges; ...".

2. Review of the CAH Medical Staff by-laws, approved 3/21/2017, revealed in part "... Every practitioner practicing at this hospital by virtue of Medical Staff membership, or otherwise, shall be entitled to exercise only those clinical privileges specifically granted to him by the Governing Body ... Every initial application for Medical Staff membership must contain a request for specific clinical privileges desired by the applicant ...".

3. Review of a CAH policy titled "Clinical Privileges Delineation", reviewed 9/28/2020, revealed in part "... Any practitioner who provides clinical services at [CAH] may exercise only those privileges the governing board granted him or her ... Each applicant must include in his or her application for appointment or reappointment to the medical staff a request for specific clinical privileges that he or she seeks ...".

4. Review of the CAH surgery schedule for 5/25/2021 revealed Orthopedist F scheduled to perform a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis at 8:00 AM.

5. Review of Orthopedist F's credential file revealed a privilege list effective 6/18/19 to 6/18/21, approved by the Governing Body on 6/18/21, which failed to identify privileges to perform the procedures on the CAH's surgery schedule at 8:00 AM on 5/25/2021, which included a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis.

6. Review of an othopedic procedure log for Orthopedist F, from April 2019 through April 2021, revealed Orthopedist F performed the following procedures, but the approved delineated privileges failed to include them: ORIF (wrist, ankle, radius and foot), bone spur exclusion, rotator cuff repair, joint manipulations, tibial plateau fracture repair, elbow release, shoulder arthroscopy, joint manipulation, and elbow incision and drainage.

7. During an interview on 5/26/2021, at 10:40 AM, the Finance Manager acknowledged Orthopedist F's delineation of privileges failed to identify privileges to perform a left shoulder arthroscopy, rotator cuff repair, biceps tenotomy; open biceps tenodesis.

8. During an interview on 5/26/2021, at 11:45 AM, the Assistant Director of Nursing expressed surprise that Orthopedist F did not have identified privileges for the procedures scheduled on 5/25/2021 at 8:00 AM. She reported the surgery staff have access to surgical privileges in the surgery area and would check a provider's privileges if they questioned the procedure.

9. During an interview on 5/26/2021, at 11:52 AM, the Assistant Director of Nursing confirmed Orthopedist F's credential file and the list of privileges for Orthopedist F, available in the surgical services area, failed to identify the surgical procedure performed on 5/25/202.


II. Based on observation, document review, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 Athletic Trainers, who performed the role of first assistant, during surgical procedures performed by Orthopedist F (Athletic Trainer G and Athletic Trainer H), were qualified to assist in surgical procedures, according to the Medical Staff bylaws and CAH policies. The administrative staff identified Athletic Trainer G assisted Orthopedist F on 66 surgical procedures and Athletic Trainer H assisted Orthopedist F on 80 surgical procedures, from 11/21/2019 to 5/25/2021.

Failure to ensure the qualifications of all individuals providing assistance to surgical procedures of CAH patients could potentially result in the performance of care beyond their capabilities and placing the patient at risk for surgical complications and potential harm.

Findings include:

1. Observation in the surgery department on 5/25/2021, at approximately 9:50 AM, revealed Orthopedist F performing a knee surgery with the assist of scrub personnel. During an interview at the time, the Operating Room Manager reported Orthopedic Surgeon F, brings has 2 Athletic Trainers that he utilizes as first assist in surgery, indicated the 2 individuals had been credentialed.

2. Review of an operating room log report, dated 5/26/2021, identified Athletic Trainer G as part of the surgical team for an orthopedic procedure performed by Orthopedist F.

2. Review of the CAH Medical Staff Rules and Regulations, approved 3/21/2017, revealed in part "... The decision of a first assistant will be at the discretion of the surgeon. The first assistant shall be a physician with surgical privileges, a physician assistant with surgical privileges, a Registered Nurse (RN) qualified by means of a Registered Nurse First Assistant (RNFA) Program who is under the direct supervision of a surgeon, or a physician assistant may assist if the supervising physician (or alternate) is immediately available ...".

3. Review of a CAH policy titled "Operating Room personnel", reviewed 5/4/2021, identified the purpose of the policy included to delineate qualifications of surgical personnel and to list qualified personnel. The policy revealed in part "... Qualification are defined as follows: First Assistant/Scrub - [Physician Assistant-Certified], [Registered Nurse] (under direct supervision of Surgeon) ... All assistants must have documented appropriate knowledge and skills to function in the [Operating Room]...".

4. Review of a CAH policy titled "Surgical Assistants and Duties", reviewed 6/11/2015, revealed in part "... First assistant shall be a licensed physician with surgical privileges, a Registered Nurse (RN) qualified by means of a Registered Nurse First Assistant (RNFA) Program who is under the direct supervision of a surgeon, or a physician's assistant if the supervising physician (or alternate) is immediately available ... These privileges are documented in approved applications to the [CAH] ...".

5. Review of CAH files for Athletic Trainer G and H failed to show they met the qualifications, identified in the Medical Staff bylaws and CAH policies and procedures, to perform the position of first surgical assistant.

6. During an interview on 5/26/2021, at 3:15 PM, the Assistant Director of Nursing confirmed the files for Athletic Trainer G and H failed to show qualifications to perform as first surgical assistant.

7. During an interview on 5/27/2021, at 10:10 AM, the Chief Executive Officer reported when Orthopedist F requested to have Athletic Trainer G and H assist him in surgical procedures, and the CAH checked with another CAH where Orthopedist F practiced and followed their process, but confirmed they failed to ensure the process followed the Medical Staff Bylaws and CAH policies and procedures.

Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure 1 of 1 observed anesthesia providers wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed 702 surgical procedures from July 1, 2020 - April 30th, 2021.

Findings include:

1. Observations on 05/25/2021 at approximately 9:45 AM, during a tour of the operating rooms (OR), revealed the following:

a. Patient #5 was undergoing a surgical procedure in operating room #1. Observations during the procedure revealed Certified Registered Nurse Anesthestist (CRNA) I (a registered nurse with specialized training in administering medication to render a patient unconscious for surgery) wore a skull cap. The skull cap consisted of a cap covering CRNA I's forehead and central part of CRNA I's hair. The skull cap did not cover the lower approximately one inch of CRNA I's hair on the back of CRNA I's head.

2. Review of the AORN Guidelines for Perioperative Practice: Surgical Attire, copyright 2021, revealed in part, " Cover the scalp and hair when entering the semi-restricted and restricted areas....Cover a beard when entering the restricted area..." "Hair and skin can harbor bacteria that may be dispersed into the perioperative environment.[operating rooms.]"

3. Review of the hospital's OR Policy and Procedure, Operating Room Apparel, reviewed 04/16/2021, revealed in part "Hair/Head coverings - All head and facial hair including sideburns and necklines are to be covered in the semi-restricted and restricted area of the surgical suite. Hair, when not completely covered can be a source of infection causing bacteria."

4. During an interview on 05/27/2021 at approximately 8:00 AM, the Assistant Director of Nursing acknowledged skull caps that were worn by CRNA I's did not completely cover their hair and ears.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 4 of 4 reviewed 2 open swing bed patients (Patient# 1, Patient# 2) and 2 closed swing bed patients (Patient#3 and Patient #4). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehabilitation services appropriate to their medical condition. The CAH administrative staff identified 52 swing bed admissions in Fiscal Year 2020 with an average length of stay of 71 hours.

Findings included:
1. Review of the CAH's policies/procedures revealed the CAH lacked a policy/procedure which addressed the requirement for a physician to order specialized rehabilitation services for swing bed patients.

2. Review of Patient# 1's open medical record revealed the CAH staff admitted Patient# 1 for swing bed level care on 05/ 21/2021. Physician Assistant PA-C B (a staff member with advanced training to diagnose and treat patients) wrote an order on 05/ 21/2021 at 4:40 PM for the Physical Therapist to evaluate and treat Patient# 1 and for the Occupational Therapist to evaluate and treat Patient# 1.

3. Review of Patient# 2's open medical record revealed the CAH staff admitted Patient# 2 for swing bed level care on 05/ 13/ 2021. PA-C B wrote an order on 05/13/2021 at 5:57 PM for the Physical Therapist to evaluate and treat Patient# 2 and for the Occupational Therapist to evaluate and treat Patient# 2.

4. Review of Patient# 3' s closed medical record revealed the CAH staff admitted Patient# 3 for swing bed level care on 05/08/21. The CAH staff discharged Patient# 3 on 05/08/2021. PA-C C wrote an order on 05/08/2021 at 3:05 PM for the Physical Therapist to evaluate and treat Patient# 3 and for the Occupational Therapist to evaluate and treat Patient# 3.

5. Review of Patient# 4's closed medical record revealed the CAH staff admitted Patient# 4 for swing bed level care on 03/30/2021. The CAH staff discharged Patient# 4 on 04/08/2021. ARNP A wrote an order on 03/30/21 at 3:48 PM for the Physical Therapist to evaluate and treat Patient# 4 and for the Occupational Therapist to evaluate and treat Patient# 4.

6. During an interview on 05/27/2021 at 10:45 AM, Physical Therapist E acknowledged that PA-C B wrote the therapy orders for Patient# 1 and Patient# 2 when the patients received swing bed services.

7. During an interview on 05/27/2021 at 10:45 AM, Physical Therapist E acknowledged that PA-C C wrote the therapy orders for Patient# 3 and Patient# 4 when the patients received swing bed services.

7. During an interview on 05/27/2021 at 12:35 PM, the Director of Nursing (DON) acknowledged a physician did not write the therapy orders for Patient# 1, Patient# 2, Patient# 3, and Patient# 4 per CAH policy for Swing Bed Rehabilitative Services.