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Based on interview and record review, the facility failed to provide notice of the right to formulate an advance directive for 2 (#s 10 and 12) of 35 sampled patients. This deficient practice had the potential for the facility to provide life-sustaining treatments against the patient's wishes. Findings include:

A review of patient #10's medical record showed an inpatient admission date of 11/13/23. No notification of advance directives was present in the medical record.

A review of patient #12's medical record showed an inpatient admission date of 6/24/23. No notification of advance directives was present in the medical record.

Record review of a facility policy, "Advance Medical Directives," last revision date of 10/2015, showed:

" ...1. At time of admission assessment, nursing staff will question all patients, or their surrogate decision-maker as to whether they have an Advance Medical Directive document. ...This will be documented on the Advanced Directive Acknowledgement form. ..."

During an interview on 1/30/24 at 1:33 p.m., staff member B said the facility would usually provide information on advance directives for inpatients and swing bed patients. Staff member B said advance directive information was not provided for emergency room, respite, observation, or outpatient testing.

Based on observation, interview, and record review, the facility failed to establish and implement a procedure for ensuring expired supplies in the pediatric crash cart were replaced prior to the expiration date. This deficient practice had the potential to affect any pediatric patient requiring the need of these supplies. Findings include:

During an observation and interview on 1/30/24 at 11:30 a.m., staff member I pointed to the pediatric crash cart and said outdates would be found in the cart. Staff member I said the items were on backorder and were left on the pediatric cart. The cart was not used often and the emergency room did not see many pediatric patients.

The following items were found expired in the pediatric crash cart:

Cardiac Pediatric ECG pads: Expiration 9/3/20, 2 packages, Expiration 6/9/22, 5 packages
Suction Catheter 8fr: Expiration 1/5/23, 1 each
Salem Sump 8fr: Expiration 3/1/23, 1 each
Endotracheal Tube 3.5mm uncuffed: Expiration 4/8/23, 1 each
Intubating Stylet 6fr: Expiration 5/2023, 1 each
Endotracheal Tube 4.0mm cuffed: Expiration 5/28/23, 2 each
Pediatric Pulse Oximeter 10-50kg: Expiration 1/1/24, 3 each
Endotracheal Tube 4.5mm cuffed: Expiration 7/8/23, 2 each
Endotracheal Tube 5.0mm cuffed: Expiration 2/28/23, 1 each
Endotracheal Tube 5.5mm cuffed: Expiration 6/28/23, 2 each

During an interview on 1/30/24 at 12:10 p.m., staff member E said she was not aware of any items being on backorder at this time. Staff member E said the emergency room staff had not notified central supply of the outdated items.

During an interview on 1/30/24 at 1:45 p.m., staff member B said she expected the carts to be checked twice a week and all outdated items to be replaced.

Review of a facility policy, "CPR Cart Maintenance and Inspection," last revision date 4/2019, showed:

" ...3. Monthly

a. The CPR cart will be opened, and all drawers will be checked against the inventory list to ensure that all medications, supplies and equipment are present and not outdated.

...c. If supplies are missing or outdated, nursing will request replacement from central supply. The nurse will then replace the item once obtained from Central Supply. The outdated supplies will be returned to Central Supply. ..."

Based on observation and interview, the facility dietary staff failed to label food items when food packages were opened and partially used for meal preparation. This deficient practice had the potential to affect all patients and residents within the facility. Findings include:

During an observation and interview on 1/29/24 at 4:05 p.m., staff member K said the items stored in the dry storage room were usually dated when the item was opened but it depended on who was working at the time.

The following items were found to be opened and not dated:

Bread stuffing- top of package rolled closed and taped, not dated
Potato chips- top of package rolled closed and taped, not dated
Walnut package- top of package rolled closed and taped, not dated
Sliced almonds bag- top of package rolled closed and taped, not dated
Orange jello package- corner of package open, not dated
Krusteaz pancake mix- box top closed, not dated
Worcestershire sauce- ¼ full gallon container, not dated
Balsamic Vinegar- ½ full gallon container, not dated

During an interview on 1/30/24 at 7:50 a.m., staff member E said items had not been labeled with open dates. Staff member E said the items should have been dated when they were opened.

Based on interview and record review, the facility failed to ensure the residential rights acknowledgement signatures form was filled out completely and correctly upon admission for 3 (#s 2, 6, and 13) of 14 sampled swing bed patients. This deficient practice has the potential to affect patients admitted to a swing bed within the facility. Findings include:

1. Review of patient #2's paper medical record showed a form acknowledging resident rights. The form was signed by patient #2's representative. Underneath the signature line the form stated, "...If a Resident's Representative Signed, Complete the Following: Printed name and relationship to resident." This portion of the form was not completed. The form also did not include the patient's name or identify their attending physician. This area was not completed.

2. Review of patient #6's paper medical chart showed a form acknowledging resident rights. The form was signed by patient #6's representative. Underneath the signature line the form stated, "...If a Resident's Representative Signed, Complete the Following: Printed name and relationship to resident." This portion of the form was not completed. The form also did not identify thier attending physician. This area was not completed.

3. Review of patient #13's paper medical record, dated 7/1/21, showed an acknowledgment of resident rights signed by someone other than the patient. However, the form was not completed appropriately. The form did not have the relationship to the patient, the date of the signature, or the signature of a witness. It was not possible to determine when the form was signed and if it was completed at the time of the patient's admission on 7/1/21.

During an interview on 2/1/24 at 9:45 a.m., staff member T stated she was responsible for completing the admission paperwork and getting all of the appropriate signatures.

During an interview on 2/1/24 at 9:55 a.m. staff member B stated it was her responsibility to make sure the documentation in the charts was completed correctly and she had not had the time to make sure it was done. Staff member B stated, "It's my fault things are not done correctly. I have not properly trained staff member T."

Based on interview and record review, the facility failed to ensure all patient records contained a properly executed informed consent for care for 6 (#s 13, 14, 15, 16, 17, and 18) of 35 sampled patients. This deficient practice has the potential to affect all patient choices when consenting for care in the facility. Findings include:

1. Review of patient #13's medical record, with an admission date of 7/1/21, failed to show a signed consent for care was executed on the date of admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #13 was admitted to swing bed status on 7/1/21.

A request was made, on 1/30/24, for patient #13's consent for care for his swing bed admission on 7/1/21. The consent for care provided showed patient #13 signed his first name only and no date for the patient's signature was shown. The staff member's signature was dated 11/15/20. No other documentation which showed the correct admission date was provided prior to the end of the survey.

2. Review of patient #14's medical record, with an initial admission date of 5/2/22, failed to show a signed consent for care was executed on the date of admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #14 was admitted to the emergency department on 4/22/22 and transfered to another hospital. Staff member R stated patient #14 was initially admitted to a skilled swing bed on 5/2/22.

A request was made, on 1/30/24, for patient #14's consent for care for her skilled swing bed admission on 5/2/22. The consent for care provided was dated 5/17/22. No other documentation was provided prior to the end of the survey.

3. Review of patient #15's medical record, with an admission date of 11/21/23, failed to show a signed consent for care was executed on the date of admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #15 was in an observation bed from 11/8/23 to 11/10/23, and in a respite care bed from 11/10/23 to 11/21/23.

A request was made, on 1/31/24, for patient #15's consent for care for his swing bed admission on 11/21/23. The consent for care provided was dated 11/8/23. No other documentation was provided prior to the end of the survey.

4. Review of patient #16's medical record, with an admission date of 7/1/22, failed to show a signed consent for care was executed for the 7/1/22 swing bed admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #16 was admitted to swing bed status on 7/1/22.

A request was made, on 1/31/24, for patient #16's consent for care for the 7/1/22 admission. The consent provided was dated 3/25/22. No other documentation was provided prior to the end of the survey.

5. Review of patient #17's medical record, with an admission date of 11/20/20, failed to show a signed consent for care was executed for the 11/20/20 admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #17 was admitted to swing bed status on 11/20/20. Staff member R stated the patient was a regular nursing home patient prior to the 11/20/20 admission to swing bed.

A request was made, on 1/31/24, for patient #17's consent for care for the 11/20/20 admission. The consent provided was dated 11/30/19. No other documentation was provided prior to the end of the survey.

6. Review of patient #18's medical record, with an admission date of 3/25/21, failed to show a signed consent for care was executed for the swing bed admission.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated patient #18 was a respite patient from 2/26/21 through 3/25/21 and was admitted as a swing bed patient on 3/25/21.

A request was made, on 1/31/24, for patient #18's consent for care for the 3/25/21 admission. The consent provided was dated 2/26/21. No other documentation was provided prior to the end of the survey.

During an interview on 2/1/24 at 9:45 a.m., staff member B stated staff member T was responsible for obtaining signed consent for care forms for patients admitted to a swing bed. Staff member B stated she failed to train staff member T regarding this responsiblility, which had resulted in a number of swing bed patients who did not have properly executed consents for care for their current swing bed stays.

Based on interview and record review, the facility failed to ensure all medical provider signatures were dated for 8 (#s 1, 2, 3, 4, 13, 17, 18, and 19) of 35 sampled patients; and the facility failed to ensure the signature authentication document was current and contained all medical practitioners authorized to provide health care services to patients of the CAH. This deficient practice has the potential to affect all documents requiring provider signatures within the patient medical records. Findings include:


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1. A review of patient #1's physician's orders, dated 12/19/23, 1/2/24, 1/15/24, and 1/22/24, showed a provider signature, but no date indicating when the order was signed.

A review of patient #2's physician's order, dated 12/19/23, showed a provider signature but no date indicating when the order was signed.

A review of patient #3's physician's order, dated 11/7/23, showed a provider signature but no date indicating when the order was signed.

A review of patient #4's physician's orders, dated 8/24/23, 8/25/23, 9/26/23, 10/6/23, 10/30/23, 12/30/23, and 1/2/24, showed a provider signature but no date indicating when the order was signed.

Review of patient #13's provider orders, dated 6/18/22, 7/19/22, 8/31/22, and 12/14/23, showed the handwritten provider orders contained a provider signature without the date the signature was entered into the record.

Review of patient #17's provider orders, dated 12/21/23 and 1/25/24, showed the handwritten provider orders contained a provider signature without the date the signature was entered into the record.

Review of patient #18's provider order, dated 1/24/24, showed the handwritten provider order contained a provider signature without the date the signature was entered into the record.

Review of patient #19's provider order, dated 9/24/23, showed the handwritten provider order contained a provider signature without the date the signature was entered into the record.

During an interview on 1/30/24 at 10:22 a.m., staff member B stated, "Ultimately it is my responsibility to make sure the chart documentation is complete, and I just haven't had time to make sure it was completed."

During an interview on 2/1/24 at 8:12 a.m., staff member R stated it was not part of her process to check provider orders for completeness regarding the date the provider signed a verbal or telephone order written by someone else.

2. Review of the active provider list, dated 1/29/24, showed the facility had six onsite providers.

Review of the signature authentication log, last dated 10/20/16, failed to show the signature for four (staff members W, X, Y, and Z) of the six medical providers who provided services onsite at the facility.

Review of the facility's policy titled, "Medical Record Content," dated June of 2012, showed all reports of procedures and test results were to be documented and authenticated in the patient medical record. The policy also showed handwritten provider orders and verbal (or telephone) orders written by someone other than the provider must be authenticated by the provider giving the order.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated the facility had a signature authentication log for medical practitioners. Staff member R stated the log was not current as she had gotten "lax" because of the computer. Staff member R stated she should have been keeping it updated because swing bed patient charts are still paper.

Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their swing bed program. This deficient practice had the potential to affect all patients with a requested organ donor or imminent death. Findings include:

During an interview on 1/30/24 at 12:30 p.m., staff member B stated the facility's OPO program did not currently include swing-bed patients. Staff member B stated, "Since most of the swing-bed patients are private pay, they are not included in the OPO."

Review of a facility document titled, "Organ and Tissue Donation," not dated, showed:

" ...the Donor Referral Line must be contacted of ALL deaths and imminent deaths, regardless of age, or medical/social history, to determine medical suitability for donation."

Based on interview and record review, the facility failed to ensure patients admitted to swing bed status were made aware of their rights upon admission for 3 (#s 15, 16, and 17) of 35 sampled patients. This deficient practice has the potential to affect the patient's ability to exercise their rights. Findings include:

1. Review of patient #15's medical record, dated 11/21/23, failed to show a signed and dated acknowledgment of the receipt of the facility's patient rights form.

A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 11/21/23, The form provided was dated 11/11/23, which was during the patient's respite care stay. No acknowledgment, dated 11/21/23, was provided prior to the end of the survey.

2. Review of patient #16's medical record, dated 7/1/22, failed to show a signed and dated acknowledgment of receipt of the facility's patient rights form.

A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 7/1/22, The form provided was dated 3/25/22, which was four months prior to the patient's swing bed stay. No acknowledgment, dated 7/1/22, was provided prior to the end of the survey.

3. Review of patient #17's medical record, dated 11/20/20, failed to show a signed and dated acknowledgment of receipt of the facility's patient rights form.

A request was made, on 1/31/24, for the signed acknowledgment of rights for the admission which started on 11/20/20, The form provided was dated 12/4/19, which was a nursing home stay which occurred almost one year prior to the swing bed stay. No acknowledgment, dated 11/20/20, was provided prior to the end of the survey.

During an interview on 2/1/24 at 8:12 a.m., staff member R stated the resident was given a new chart when they became a swing bed patient. Staff member R stated there should have been a signed acknowledgment in each medical record.

During an interview on 2/1/24 at 9:45 a.m.,, staff member B stated it was staff member T's responsibility to complete the paperwork for swing bed admissions. Staff member B stated she did not ensure staff member T understood what her responsibilities were when completing admission paperwork for swing bed patients.

Based on observation and interview, the facility failed to post signs in a public area, specifying the rights of individuals to receive examination and treatment for emergency medical conditions and women in labor. This deficient practice had the potential to affect patients entering the emergency department for services. Findings include:

During an observation on 1/31/24 at 7:40 a.m., the entrances to the emergency department were inspected. No EMTALA signs were present at either entrance of the emergency department, or the main entrance to the facility's admission desk.

During an interview on 1/31/24 at 7:52 a.m., staff member B said the facility had signs posted at the entrance of the emergency room. Staff member B said the signs were removed for painting and were not replaced. Staff member B was unable to locate the postings within the facility.

Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care for 10 (#s 9, 10, 12, 29, 30, 31, 32, 33, 34, and 35) of 35 sampled patients. This deficient practice has the potential to affect all patients receiving care in the facility the ability to acknowledge their patient rights. Findings include:

A review of patient #9's medical record showed an admission date of 1/19/23. No acknowledgement of patient rights was in the medical record.

A review of patient #10's medical record showed an admission date of 11/13/23. No acknowledgement of patient rights was in the medical record.

A review of patient #12's medical record showed an admission date of 6/24/23. No acknowledgement of patient rights was in the medical record.

A review of patient #29's medical record showed an admission date of 9/26/23. No acknowledgement of patient rights was in the medical record.

A review of patient #30's medical record showed an admission date of 1/15/24. No acknowledgement of patient rights was in the medical record.

A review of patient #31's medical record showed an admission date of 1/2/24. No acknowledgement of patient rights was in the medical record.

A review of patient #32's medical record showed an admission date of 10/11/23. No acknowledgement of patient rights was in the medical record.

A review of patient #33's medical record showed an admission date of 8/27/23. No acknowledgement of patient rights was in the medical record.

A review of patient #34's medical record showed an admission date of 8/17/23. No acknowledgement of patient rights was in the medical record.

A review of patient #35's medical record showed an admission date of 1/3/24. No acknowledgement of patient rights was in the medical record.

During an interview on 1/30/24 at 1:33 p.m., staff member B said the facility did not provide a written form for acknowledgement of patient rights for inpatient stays, emergency room visits, or outpatient testing.

Record review of a facility policy, "Patient Rights," dated 9/2008, showed:

"Policy: It is the policy of [facility name] that all hospital patients be informed of their rights and responsibilities.

...1. Upon admission to the hospital, the facility will inform the patient and/or representative both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing patient conduct and responsibilities during the stay at the facility.

2. Receipt of this information will be acknowledged in writing and placed in the patient's medical record. "

Based on interview and record review, the facility failed to provide a safe enviornment for 1 (#8) of 2 sampled patients. This deficient practice resulted in an elopement from the facility. Findings include:

Review of a Facility Reported Incident, reported to the State Survey Agency, dated 9/1/23 at 2:00 a.m., showed patient #8 was a respite patient. Staff on the floor confirmed patient #8 was in her room at 1:00 a.m. During the freshwater pass at 2:00 a.m., the patient was not in her room or bathroom. Staff searched room to room in the nursing home, attached critical access hospital, and clinic without success. The immediate grounds were searched by two staff members without success. Law enforcement was contacted, and a staff member used a vehicle to search the local streets and fairgrounds. At 5:00 a.m., patient #8 was still missing and law enforcement was contacted again. Patient #8 was found after sunrise, two blocks from the facility, laying in a yard. Emergency Medical Services were notified and patient #8 was taken to the Emergency Room via ambulance.

Review of patient #8's medical records showed patient #8 was admitted as a respite patient on 8/8/23. Nursing notes dated, 8/9/23 at 5:42 p.m., showed patient #8 stated, "I just want to go home."

Review of patient #8's Resident Kardex, undated, showed the box marked elopement risk was checked. "Special instructions: * elopement risk*, *wander-guard ordered, -Confused oriented to son." [sic]

Review of patient #8's medical record showed no further interventions were placed to prevent an elopement at the time of admission.

A review of patient #8's Emergency Room visit, dated 9/1/23 showed:

"... 1. Environmental exposure
1. Cool lower extremities, core temperature from initial presentation. With warm IVF and bear-hugger cool extremities warmed.

...7. Skin laceration to LLE, right elbow
1. ABD to the left leg, reported copious clear drainage.

...Patient ultimately discharged from the ED to the NH as a respite patient."

During an interview on 1/31/24 at 11:10 a.m., staff member E stated she was head of emergency preparedness and had initiated the code yellow with the disaster plan as soon as she was notified of the incident. Staff member E stated she had not been notified of the incident until after 6:00 a.m., but when she was notified and "activated the call tree, people were here within four minutes." Staff member E stated she was unsure why she was not notified right away, but had been educating staff on the importance of timely notification to the appropriate administrative personnel. Staff member E stated she did not think there had been any documentation of the education that she had provided during the staff meeting.

During an interview on 1/31/24 at 1:12 p.m., staff members A and B both stated there should have been some other type of interventions started upon patient #8's admission since a wander-guard was not readily available.

During an interview on 1/31/24 at 4:50 p.m., staff member A stated, "There was no difference in policies between the long-term care residents and the swing bed patients. We use the same policies and procedures for everyone."

A request was made on 1/31/24 at 1:50 p.m., for patient #8's wandering and elopement admission assessment. No assessment was provided prior to the end of the survey.

During an interview on 2/1/24 at 7:40 a.m., staff member B stated there was not an elopement assessment completed for patient #8.

A review of a facility document titled, "Risk of Wandering and Elopement," with an effective date of 8/27/19, showed:

"Policy: It is the policy of [Facility Name] to assess all Long Term Care residents for risk of wandering and elopement on admission, quarterly, and as needed to ensure the safety of the resident ..." [sic]