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Based on observation and interview, the facility failed to prevent the use of portable heating devices in resident/patient areas per NFPA 101, 2000 Edition, Section 19.7.8. The deficiency could affect all patients/residents in two of two smoke compartments.

Findings include:

The observation room was observed on 11/20/14 at 9:15 a.m. A portable space heater was in use in the room. A patient was in a hospital bed.

In an interview on 11/20/14 at 2:15 p.m., staff member J, maintenance supervisor, stated a facility staff must have placed the heater in the room. Staff member J removed the space heater.

Based on observation, record review, and staff interview, the facility nursing, medical record, and administrative staff members failed to retrieve vital medical documentation for residents electronically or with a hard copy. The deficiency could affect all patients/residents in the hospital and swing bed program. The cumulative effect of these systemic problems resulted in staff not able to explain where medical documents were filed and incomplete medical records. Refer to citations C0302, C0303, and C0306.

Based on record review, and staff interview, the facility nursing, medical record and administrative staff failed to retrieved medical record documentation for 11 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) of 11 medical records selected for review.

Findings include:

In an interview on 11/20/14 at 9:00 a.m., staff member B, CEO, stated some medical records were electronic and some medical records were hard copy. Staff member B was unable to state which medical information was electronic and what was a hard copy.

In an interview on 11/20/14 at 1:00 p.m., staff member F, charge nurse, stated she was not sure what was charted electronically or what documentation was still a hard copy. "I am still learning." Staff member F was unable to retrieve documentation for residents via the computer or by hard copy.

A record review was conducted on 11/20/14 at 3:00 p.m. with staff member E, patient coordinator. She was unable to retrieve documentation via the computer. Staff member E stated "retrieving electronic health records was not easy," and she was still learning how to retrieve information. Staff member I, LPN, was asked by staff member E to retrieve hard copy documentation. Staff member I was unable to locate the hard copy documentation. Staff member I stated she was not sure if the hard copy was completed. Both staff member E and I stated the EHR was a new system started in July 2014. Both staff members E and I stated the medical records were a "mess." Staff member I stated "if the documentation was not located by computer or a hard copy it was not done or it was lost."

1. Resident #1's medical record reflected the following missing documentation:
- admitting orders for swing bed status;
-skin wound care;
-bed rail assessment;
-bed rail physician's orders;
-comprehensive assessment; and
-care plan.

2. Resident #2's medical record reflected the following missing documentation:
-comprehensive assessment;
-a physician's order for use of bed rails; and
-a care plan.

3. Resident #3's comprehensive assessment was missing from the medical chart.

4. Resident #4's medical record reflected the following missing documentation:
-bed rail assessment;
-physician's order for bed rails; and
-a care plan.

5. Resident #5's medical record reflected the following missing documentation:
-bed rail assessment;
-physician's order for bed rails; and
-a care plan.

6. Resident #6's medical record was missing a physician's order for bed rails.

7. Resident #7's medical record was missing a physician's order and assessment for a lap buddy.

8. Resident #8's medical record was a missing bed rail assessment.

9. Resident #9's medical record was missing a physician's order for bed rails.

10. Resident #10's medical record was missing a physician's order for bed rails.

11. Resident #11's medical record was missing a physician's order for bed rails.

The missing documentation could not be retrieved by the computer or by hard copy when requested.

Based on staff interviews, the hospital did not have a professional staff member responsible for maintaining medical records, ensuring the records are complete, readily accessible, and organized. The deficiency could affect all patients/residents of the hospital and swing beds.

Findings include:

In an interview on 11/20/14 at 9:00 a.m., staff member B, CEO, stated some medical records were electronic and some medical records were hard copy.

In an interview on 11/20/14 at 1:00 p.m., staff member K, medical record manager, stated the electronic medical record system was started in July 2014. There was training provided to the hospital staff members, but the staff members still could not operate the electronic system. There was confusion on what was documented as a hard copy or electronic. "I am confused on what is charted and how to retrieve medical documentation."

In an interview on 11/20/14 at 1:00 p.m., staff member F, charge nurse, stated she was not sure what was charted electronically or what documentation was still a hard copy.

In an interview on 11/20/14 at 3:00 p.m., staff member E, patient coordinator, stated "retrieving electronic health records was not easy."

Based on record review and staff interview the hospital failed to obtain physician's orders for 7 (#s 1, 2, 4, 6, 9, 10 and 11) of 11 medical records reviewed.

Findings include:

During an electronic health record review on 11/20/14 at 3:00 p.m., staff member E, patient coordinator, stated she was unable to retrieve the documentation electronically. Staff member I, LPN, stated the hard copy was not completed.

Resident #s 1, 2, 4, 6, 9, 10 and 11's physician's order for use of bed rails were not completed.

Based on record review and staff interview the hospital nursing staff failed to ensure 1 (#1) of 5 medical records reviewed had admission orders to swing-bed status.

Findings include:

Resident #1 was admitted to swing-bed status on 9/27/14. The EHR and the hard copy record reflected admission orders to swing-bed status, progress notes, and discharge summary from acute care were not completed.

In an interview on 11/20/14 at 3:00 p.m., staff member E stated the swing-bed admission orders were not completed on discharge from the acute care on 9/27/14.

Review of the facility's Admission To Intermediate Care policy showed residents were to be admitted to the swing bed by order of a physician.

Based on observation, record review, and staff interview, the hospital nursing staff implemented restraints (bed rails and lap buddy) daily without documented medical symptoms, a physician's order, assessment prior to the use of restraints, less restrictive interventions attempted prior to the use of the restraints, and failed to care plan the restraints for 11 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) of 11 charts selected for review. Two medical charts (#s 7 and 8) showed standing and/or PRN (as needed) restraint orders.

Findings include:

During the initial tour on 11/20/14 at 9:00 a.m. with staff member A, DON, the following were observed:

1. Resident #1 was in bed and two bed rails were in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

2. Resident #2 was in bed with two bed rails in the up position on the bed. The medical record reflected a lack of physician's order, a medical symptom, and a care plan for the restraint use.

3. Resident #3 was in her recliner, but her bed had two bed rails in the up position. The medical record reflected a lack of a physician's order, a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

4. Resident #4 was in bed and had two bed rails in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

5. Resident #5 was in bed and had four bed rails in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

6. Resident #6 had two bed rails in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

7. Resident #7 had four bed rails in the up position on the bed. Resident #7 was observed at this time to be in a wheelchair with a lap buddy. The medical record reflected an assessment for two bed rails to be used. The physician's order showed no guidelines for how many bed rails or when the bed rails were to be used. "May use side rails on bed FYI."

8. Resident #8 had four bed rails in the up position on the bed. A physician's order showed "ok to use w/c restraint." This physician's order did not clarify what restraint was to be used in the wheelchair. The physician's order for bed rails showed "bed rails for safety PRN." The medical record reflected a lack of a medical symptom, an assessment prior to the use of the bed rails, less restrictive interventions attempted prior to the bed rails, and a care plan for the restraint use.

9. Resident #9 had two bed rails in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, and a care plan for the restraint use.

10. Resident #10 was in bed and had two bed rails in the up potion on the bed. The medical record reflected a lack of a physician's order, a medical symptom, and a care plan for the restraint use.

11. Resident #11 was in bed and had two bed rails in the up position on the bed. The medical record reflected a lack of a physician's order, a medical symptom, and a care plan for the restraint use.

In an interview at this time with staff member A, DON, he stated bed rails are utilized for swing bed residents.

A review of the facility's Restraint policy showed bed rails where to be used in the following situations:
"1) All residents/patients under sedation,
2) All residents/patients who are unconscious,
3) All residents/patients admitted intoxicated,
4) For a medical condition that warrants side rails in order to provide Resident safety, such as patients with seizure disorders, or pediatric patients."

Guidelines
"The use of restraints is a measure of last resort to protect the safety of the resident/patients or others and may be used only if the facility determines and documents less restrictive measures have failed."

Medical Provider
"The orders must meet the following criteria:
a. The order must be dated and timed.
b. The order includes the specific circumstance for implementation i.e. 'wrist restraint to prevent removal of NG.'
c. Standing and/or PRN orders for restraints will not be accepted."

Based on record review and staff interview the hospital nursing staff failed to complete a comprehensive assessment for 3 (#s 1, 2, and 3) and two comprehensive assessments (#s 4 and 5) were late of 5 sampled medical records. The hospital failed to actively identify through the required comprehensive assessment, health care concerns and needs for residents (#s 1, 2, 3, 4, and 5).

Findings include:

Review of medical records for residents #s 1, 2, 3, 4, and 5 on 11/20/14 at 3:00 p.m. with staff member I, LPN, showed comprehensive assessments were not completed. "If the documentation was not located by computer or a hard copy, it was not done." She further stated she knew the assessment was to be completed but just did not do it.

1. Resident #1 was admitted on 8/4/14 and as of 11/20/14, a comprehensive assessment was not completed.

2. Resident #2 was admitted on 3/14/14 and as of 11/20/14, a comprehensive assessment was not completed.

3. Resident #3 was admitted on 6/16/14 and as of 11/20/14, a comprehensive assessment was not completed.

4. Resident #4 was admitted on 8/13/14 and on 10/23/14, a comprehensive assessment was completed.

5. Resident #5 was admitted on 6/25/14 and on 10/23/14, a comprehensive assessment was completed.

Review of the facility's Nursing Assessment and Care Plan policy showed a comprehensive nursing assessment was to be completed within 14 days of admission and every 6 months.

Based on record review and staff interview, the hospital nursing staff failed to complete a comprehensive assessment within 14 days after admission for 5 (#s 1, 2, 3, 4, and 5) of 5 sampled medical records.

Findings include:

In an interview on 11/20/14 at 3:00 p.m., staff member I, LPN, stated she knew the assessments were to be completed on admission, but did not do them.

1. Resident #1 was admitted on 8/4/14 and as of 11/20/14, a comprehensive assessment was not completed.

2. Resident #2 was admitted on 3/14/14 and as of 11/20/14, a comprehensive assessment was not completed.

3. Resident #3 was admitted on 6/16/14 and as of 11/20/14, a comprehensive assessment was not completed.

4. Resident #4 was admitted on 8/13/14 and on 10/23/14, a comprehensive assessment was completed.

5. Resident #5 was admitted on 6/25/14 and on 10/23/14, a comprehensive assessment was completed.

Review of the facility's Nursing Assessment and Care Plan policy showed a comprehensive nursing assessment was to be completed within 14 days of admission and every 6 months. The facility failed to complete the comprehensive assessments within 14 days of admission to the swing bed program.

Based on record review and staff interview, the hospital nursing staff failed to complete care plans for 4 (#s 1, 2, 4, and 5) of 5 sampled medical records.

Findings include:

On 11/20/14 at 3:00 p.m., staff member I, LPN, could not retrieve an electronic or hard copy version of resident #s 1, 2, 4, and 5's care plans. Staff member I stated, "If the documentation was not located by computer or a hard copy, it was not done."

1. Resident #1 was admitted on 8/4/14 and as of 11/20/14, a care plan was not created.

2. Resident #2 was admitted on 3/14/14 and as of 11/20/14, a care plan was not created.

3. Resident #4 was admitted on 8/13/14 and on 11/20/14, a care plan was not created.

4. Resident #5 was admitted on 6/25/14 and on 11/20/14, a care plan was not created.

Review of the facility's Nursing Assessment and Care Plan policy showed a care plan was to start on admission into a swing bed. The care plan was based on the resident's needs through the comprehensive assessments and interventions developed to meet the health care needs of the resident.

Based on record review and staff interview, the hospital nursing staff failed to complete a care plan seven days after the completion of the comprehensive assessment for 4 (#s 1, 2, 4, and 5) of 5 sampled medical records.

Findings include:

In an interview on 11/20/14 at 3:00 p.m., staff member I, LPN, stated, "If the documentation was not located by computer or a hard copy it was not done."

1. Resident #1 was admitted on 8/4/14 and as of 11/20/14, a care plan was not created.

2. Resident #2 was admitted on 3/14/14 and as of 11/20/14, a care plan was not created.

3. Resident #4 was admitted on 8/13/14 and on 11/20/14, a care plan was not created.

4. Resident #5 was admitted on 6/25/14 and on 11/20/14, a care plan was not created.

Review of the facility's Nursing Assessment and Care Plan policy showed a care plan was to start on admission into a swing bed.

Based on record review, the hospital nursing staff failed to meet professional standards of quality care based on the lack of comprehensive assessments for 5 (#s 1, 2, 3, 4, and 5) and care plans for 4 (#s 1, 2, 4, and 5) of 5 sampled medical records.

Findings include:

1. Resident #1 was admitted on 8/4/14 and as of 11/20/14, a comprehensive assessment and care plan were not completed.

2. Resident #2 was admitted on 3/14/14 and as of 11/20/14, a comprehensive assessment and care plan were not completed.

3. Resident #3 was admitted on 6/16/14 and as of 11/20/14, a comprehensive assessment was not completed.

4. Resident #4 was admitted on 8/13/14 and on 10/23/14, a comprehensive assessment was completed. A care plan was not completed as of 11/20/14.

5. Resident #5 was admitted on 6/25/14 and a comprehensive assessment was completed on 10/23/14. A care plan was not completed as of 11/20/14.

Review of the facility's Nursing Assessment and Care Plan policy showed a care plan was to start on admission into a swing bed. The care plan was to be based on the resident's needs and interventions needed to meet the health care needs of the resident.