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Based on hospital document review, record review, personnel file review, observations and staff interviews, the Critical Access Hospital (CAH) failed to ensure Emergency Services:

1. provided adequate, experienced, and trained nursing staff in the emergency department (ED);

2. provided proper Emergency Medical Treatment and Labor Act (EMTALA) signage and all required components regarding EMTALA signage;

3. were reviewed and included as part of the Performance Improvement and Quality Assessment program (Compliance);

4. developed ED policies and procedures currently based on national standards of practice.

Findings:
1. On the afternoon of March 19, 2015, surveyors made the following observations in the ED:

~Nurses (Staff J and Staff Q) in the ED taking care of patient #19.

~Staff Q started patient #19's intravenous catheter (IV).

~Staff J hooked patient #19 to a cardiac monitor to monitor the patient's heart rate.

~Staff Q did not follow the 5 rights of medication administration (basic fundamentals of nursing). Staff Q did not verify the right patient, right drug, right time, right dose, and right route all which are regarded as a standard for safe medication practices.

~Staff Q administered morphine sulfate 8 milligrams (mg) IV push over a period of approximately 30 seconds to patient #19.

Lippincott Nursing Drug Handbook documented, "I.V. for direct injection...give slowly over 4 to 5 minutes..." and "...Adverse Reactions...cardiac arrest...apnea (temporary cessation of breathing), respiratory arrest..."

According to the Oklahoma State Board of Nursing (OSBN), licensed practical nurses (LPNs), "...authorized by institutional policy to monitor moderate (conscious) sedation patients..." and "...Administration of medications to and management of the moderate (conscious) sedation patient remains the responsibility of the Registered Nurse, licensed physician or dentist..."

~Staff J placed a blood pressure cuff and pulse oximetry on to patient #19 after the morphine sulfate IV push had been completed. Patient #19's oxygen saturation level was 88% and declining (normal oxygen saturation levels are between 95% to 100%. Oxygen levels falling below 90% are typically seen as abnormal indicating cause for concern).

~Staff J left the room while monitoring patient #19 during a conscious sedation procedure to obtain the patient's chart. According to the OSBN, "...The Registered Nurse administering, managing and/or monitoring moderate (conscious) sedation shall have no other responsibilities during the procedure that would leave the patient unattended or compromise continuous monitoring..."

2. On the afternoon of March 19, 2015, surveyors reviewed personnel files. The ED nursing personnel files did not include skills specialized for working in the ED.

Staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room:

-Triage Assessment using the emergency severity index (ESI);

-Respiratory treatments, assessing, performing, and documenting;

-Accessing, assembling, and delivering oxygen cylinders with regulators for patient use;

-Neurological assessment using Glasgow coma scale;

-IV conscious sedation, rapid sequence intubations (RSI), and airway management based on American Society of Anesthesiologists guidelines;

-Restraint training (crisis intervention protection);

-Restraint application, use, monitoring, and documenting;

None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

3. On the morning of March 18, 2015, surveyors toured the CAH with the hospital Administrator and the chief nursing officer (CNO). There was no EMTALA signage posted in the ED or hallway area leading to the ED.

4. The hospital Administrator and CNO verified that there was no EMTALA signage posted in the ED or hallway area leading to the ED.

5. Meeting minutes for Compliance, Medical Staff and Governing Body did not reflect services provided in the ED were reviewed, evaluated/analyzed with corrective action taken when indicated through the quality program. The CNO verified the findings at the time of review.

6. There were policies and procedures listed in the emergency department (ED) manual on amputations, surgical and invasive procedures, endometrial biopsies, etcetera.

7. On the afternoon of March 18, 2015, the CNO told surveyors that the CAH did not perform amputations, surgical and other invasive and special procedures, and endometrial biopsies.

8. ED policies and procedures did not have documented evidence that the ED Medical Director, Medical Staff and Governing Body had approved/signed all ED policies and procedures.

Based on Critical Access Hospital (CAH) document review, observation, and staff interview the CAH failed to maintain the physical plant and environment to ensure care of the patients in a safe setting and failed to:

a. ensure there was a preventative maintenance program in place to maintain the safety of radiology equipment. See Tag C-0222;

b. ensure drugs and biologicals were stored appropriately. See Tag C-0224;

c. ensure there was a system in place to provide emergency fuel and water if needed. See Tag C-0229;

d. maintain written evidence of regular inspection and approval by State or local fire control agencies. See Tag C-0234.

Based on document review, observation and staff interviews, the Critical Access Hospital (CAH) failed to ensure patient care equipment is maintained in safe operating condition.

Findings:
1. On the morning of March 18, 2015, surveyors toured the radiology department. There was a Vistron CT Power Injector that was last inspected March 2012.

2. Staff G told surveyors that he did not know when the power injector was inspected last and did not know if the power injector was safe for patient use.

3. Surveyors requested physicist reports, radiation safety reports, biomedical maintenance reports from January 1, 2014 through current. None was provided.

4. There were no policies and procedures in place to ensure that periodic inspections of radiology equipment were conducted and problems identified were corrected in a timely manner.

Based on document review, observation, and staff interviews, the critical access hospital (CAH) failed to ensure drugs and biologicals were appropriately stored.

Findings:
1. On the morning of March 18, 2015, surveyors toured the CAH with the Hospital Administrator and the Chief Nursing Officer (CNO). There was expired medications in various areas of the CAH. The following observations were made:

Emergency Department
In the Braslow's Cart (a cart that contains life saving equipment and medications specific to pediatrics) there was expired life saving equipment and medications.

Expired 1 March 2015 - Four (4) Boxes 8.4% Sodium Bicarb injections
Expired November 2014 - Two (2) Vials Magnesium Sulfate two milliliters (ml)

The CNO verified that the life saving medications and equipment were expired.

Radiology Department
In the Computed Tomography (CT) building there was an emergency drug box that contained expired life saving medications.

Expired 1 January 2015 - Two (2) vials Epinephrine 1:1000 one (1) milligram (mg)/ml
Expired November 2014 - Three (3) vials Diphenhydramine 50 mg/ml
Expired November 2014 - Three (3) vials promethazine 25 mg/ml

The radiology department manager verified that the life saving medications were expired.

2. On the afternoon of March 18, 2015, the drug room technician verified that the medications were expired.

Based on document review and staff interviews, the critical access hospital (CAH) failed to ensure that there was a system in place to provide emergency gas and water.

Findings:
1. On the morning of March 18, 2015, surveyors requested the CAH's emergency preparedness plan. Staff C provided the emergency preparedness manual. The emergency preparedness manual did not document that the CAH had a system in place for providing emergency gas and water.

2. On the morning of March 18, 2015, surveyors requested governing body, medical staff, and QAPI (Quality Assessment Performance Improvement) meeting minutes 2014 through current. Staff B provided governing body, medical staff,and QAPI meeting minutes for 2014 through current. There was no documented evidence that the CAH had arrangements with utility companies and other companies for emergency provisions.

3. There was no documented evidence that the CAH's emergency preparedness plan included all the components required by CMS (Center for Medicare and Medicaid Services).

4. Staff B and Staff C verified that there is no current emergency preparedness plan that included all components required by CMS.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to coordinate with Federal, State, and local emergency preparedness and health authorities to develop and implement a comprehensive plan to ensure the safety of patients during local emergency situations.

Findings:
1. On the morning of March 18, 2015, surveyors requested the CAH's emergency preparedness plan. Staff C provided the emergency preparedness manual. There was no documented evidence of participation with Federal, State, and local emergency preparedness.

2. There was no documented evidence that the CAH's emergency preparedness plan included all the components required by CMS (Center for Medicare and Medicaid Services).

3. On the morning of March 18, 2015, surveyors requested governing body, medical staff, and QAPI (Quality Assessment Performance Improvement) meeting minutes 2014 through current. Staff B provided governing body, medical staff,and QAPI meeting minutes for 2014 through current. There was no documented evidence that the CAH had participated in any emergency preparedness drills with Federal, State, and local agencies.

4. Staff B and Staff C verified that the CAH has not contacted and participated in any emergency preparedness drills with Federal, State, and local agencies.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure there was regular inspections by State or local fire control agencies.

Findings:
On the morning of March 18, 2015, surveyors requested inspections completed by State or local fire agencies. There was documented evidence that the last fire inspection was 2011.

On the afternoon of March 18, 2015, Staff C told surveyors that there had not been a fire inspection since 2011.

Based on document review and staff interviews, the governing body failed to monitor, evaluate, and ensure the services of the hospital. The governing body failed to:

a. ensure the organizational structure of the hospital was effective in providing quality health care in a safe environment;

b. ensure a preventative maintenance program for the buildings physical plant, fixed building equipment, and clinical equipment to assure a safe environment of care;

c. ensure education, training, and assessment of competency for all staff (clinical and non-clinical) was completed;

d. review, revise, approve, and implement (orientation and training) of hospital policies and procedures;

e. ensure there were trained and competent staff for the care and safety of patients;

f. review, analyze, and have oversight of quality monitors, incident reports, risk management reporting, and safety monitoring to improve patient safety and minimize risk to patients; and

g. take actions to implement measures to assure quality of care and safety resulting in Condition Level Deficiencies.

Based on Critical Access Hospital (CAH) document review, and staff interview, the CAH failed to:

a. ensure the pharmacist is responsible for developing, supervising, and coordinating all the activities of the CAH (Critical Access Hospital) pharmaceutical service. See Tag C-0276;

b. ensure that outdated and unsuable drugs are not available for patient use. See Tag C-0276;

c. maintain an active, ongoing infection control program. See Tag C-0278;

d. designate in writing an Infection Control Practitioner (ICP) who is qualified through training and experience. See Tag C-0278;

e. ensure staff were screened and evaluated for communicable diseases. See Tag C-0278;

f. ensure dietary policies and procedures were current and approved by the dietician. See Tag C-0279;

g. ensure the dietary manual was approved by the dietician. See Tag C-0279;

h. ensure a staff member was granted the authority, and delegated responsibility for the day to day operation of the dietary services. See Tag C-0279.

Based on document review, observation, and staff interviews, the critical access hospital (CAH) failed to ensure that outdated and unusable drugs are not available for patient use. The pharmacist failed to supervise and coordinate all activities of the CAH's pharmaceutical services.


Findings:
1. On the morning of March 18, 2015, surveyors toured the CAH with the Hospital Administrator and the Chief Nursing Officer (CNO). There was expired medications in various areas of the CAH. The following observations were made:

Emergency Department
In the Braslow's Cart (a cart that contains life saving equipment and medications specific to pediatrics) there was expired life saving equipment and medications.

Expired 1 March 2015 - Four (4) Boxes 8.4% Sodium Bicarb injections
Expired November 2014 - Two (2) Vials Magnesium Sulfate two milliliters (ml)

The CNO verified that the life saving medications and equipment were expired.

Radiology Department
In the Computed Tomography (CT) building there was an emergency drug box that contained expired life saving medications.

Expired 1 January 2015 - Two (2) vials Epinephrine 1:1000 one (1) milligram (mg)/ml
Expired November 2014 - Three (3) vials Diphenhydramine 50 mg/ml
Expired November 2014 - Three (3) vials promethazine 25 mg/ml

The radiology department manager verified that the life saving medications were expired.

2. On the afternoon of March 18, 2015, the drug room technician verified that the medications were expired.

3. On the afternoon of March 18, 2015, surveyors requested the CAH crash cart checks policy and procedure. Staff B provided a document titled, "Crash Cart Checks."

4. The CAH's crash cart policy and procedure documented, "...Pharmacy should check all drugs on the emergency cart at the beginning of each month. Expired drugs should be replaced by Pharmacy..."

5. On the afternoon of March 18, 2015, surveyors requested pharmacy policies and procedures for outdated and unusable medications, unit inspections, and the pharmacist's responsibilities. Staff B provided documents titled, "Non Scheduled, Outdated and Unusable Drugs, Unit Inspections and Consultant Pharmacist" policies and procedures.

6. The CAH's Non Scheduled, Outdated and Unusable Drugs policy and procedure documented, "...Visual inspections shall be made by the drug room technician of all drug areas...for the purpose of removing stock that has outdated, or is unusable..."

7. The CAH'S Unit Inspections policy and procedure documented:

"To ensure proper storage of medications the consulting pharmacist shall inspect all drug storage areas within the hospital at least once a month..."

"The Pharmacist will direct the monthly inspection of all drug storage areas in the hospital. A written record of these inspections will be maintained..."

"...Drugs shall not be kept in stock after the expiration date on the label..."

8. The consultant pharmacist's reports for multiple months documented, "Discontinued medications removed from drawers...satisfactory."

The drug room technician told surveyors she was unaware if the pharmacist checked all areas of the hospital for outdates.

9. The Consultant Pharmacist policy and procedure documented, "...The pharmacist will be responsible for full compliance with all state and federal regulations governing the operation of the drug room..."

10. There was no documented evidence that the pharmacist supervised and coordinated all activities of the CAH's pharmaceutical services.

Based on infection control policy and procedure review, infection control meeting minutes review, infection control surveillance data, personnel file review, Governing Body meeting minutes review, and Medical Staff meeting minutes review, the Critical Access Hospital (CAH) failed to:

a. designate in writing an individual qualified through education, training, and experience as the Infection Control Practitioner (ICP).

b. maintain an active, ongoing, infection control surveillance program that included specific measures for prevention, control, and investigation of infections and communicable diseases in the CAH.

c. perform screening and evaluation of all health care workers for communicable diseases.


Findings:

1. On the morning of March 18, 2015, administrative staff told surveyors that Staff E was the Infection Control Practitioner (ICP).

2. On the afternoon of March 18, 2015 and the morning of March 19, 2015, surveyors reviewed Governing Body meeting minutes and Medical Staff meeting minutes. There was no documentation that Staff E had been designated in writing as the ICP.

3. On the afternoon of March 19, 2015, surveyors reviewed the personnel file for Staff E. The personnel file contained no documentation that Staff E had been trained in maintaining an active, ongoing infection control program.

4. Review of Infection Control meeting minutes, Governing Body meeting minutes and Medical Staff meeting minutes contained no documentation of review and approval of all the chemicals and disinfectants used in the CAH. Staff E told surveyors she had not reviewed and approved all chemicals and disinfectants used in the CAH.

5. On the afternoon of March 18, 2015, surveyors reviewed nine (B, E, G, K, M, O, P, R, & Y) employee health files.

There was a health form in the employee files for immunization documentation. The health file documented the Measles Mumps and Rubella (MMR) vaccine on the same line as the Varicella (chicken pox) vaccine. In all 9 employee health personnel files reviewed it was unclear if the employee had the MMR vaccine or the Varicella vaccine or both.

6. On the morning of March 18, 2015, surveyors reviewed the infection control policies and procedures. There was no policy for reporting communicable diseases and there was not a list of the reportable communicable diseases. This was verified with Staff E at the time of review.

7. Staff E told surveyors that the CAH did not have a current TB risk assessment and the CAH did not have a current hospital risk assessment.

8. Review of infection control surveillance data documented environmental rounds but the documentation of environmental rounds was not department specific. Staff E told surveyors that surveillance occurs in the main hospital but not all departments of the hospital.

9. Review of infection control meeting minutes and infection control surveillance data did not contain documentation that employee illnesses were investigated. Staff B and Staff E told surveyors that employee illnesses are documented.

A policy titled, "Reporting Personal Illness or Absences," documented "...the manager/supervisor in conjunction with the HR department will track and trend absences caused by illness..."

10. Staff B told surveyors that the linen service was an out sourced contract service. There was no documentation that the ICP had visited the out sourced linen service for infection control practices.

Based on policy and procedure review, review of the Critical Access Hospital's (CAH) dietary manual, review of governing body meeting minutes, review of medical staff meeting minutes, and staff interview, the CAH failed to:

a. ensure dietary policies and procedures were current and approved by the dietician.

b. ensure the dietary manual was approved by the dietician.

c. ensure a staff member was granted the authority, and delegated responsibility for the day to day operation of the dietary services.

Findings:

1. On the morning of March 18, 2015, administrative staff told surveyors that staff W was the consulting dietician and staff R was the Certified Dietary Manger (CDM) responsible for the day to day operation of the dietary services.

2. On the morning of March 18, 2015, surveyors reviewed the dietary manual that is used at the CAH. There was no documentation the dietician approved the dietary manual. The dietary manual had been approved by the medical staff for a period up to 5 years. The dietary manual should be reviewed and approved on an annual basis.

3. On the morning of March 18, 2015, surveyors reviewed the dietary policies and procedures. The dietary policies and procedures were last approved in 2013. There was no documentation the dietician had reviewed and approved the dietary policies and procedures.

4. Review of Governing Body meeting minutes and Medical Staff meeting minutes contained no documentation that the CDM had been designated in writing as the staff member responsible for the day to day operation of the dietary services. This was confirmed with Staff B.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure that policies were reviewed annually.

Findings:
1. On the morning of March 18, 2015, surveyors requested governing body and medical staff meeting minutes from 2014 through current. Surveyors also requested policies and procedures from multiple departments/services offered throughout the CAH.

2. Surveyors reviewed governing body meeting minutes, medical staff meeting minutes, and CAH policies and procedures. There was no documented evidence that all department policies and procedures were reviewed and approved on an annual basis.

3. There were policies and procedures listed in the emergency department (ED) manual on amputations, surgical and invasive procedures, endometrial biopsies, etcetera.

4. On the afternoon of March 18, 2015, the CNO told surveyors that the CAH does not perform amputations, surgical and other invasive and special procedures, and endometrial biopsies.

5. On the afternoon of March 18, 2015, surveyors requested all radiology policies and procedures including ultrasound and magnetic resonance imaging (MRI) contracting services policies and procedures. None was provided.

6. On the afternoon of March 18, 2015, Staff G told surveyors that he did not have the contracted services policies and procedures.

7. On the morning of March 19, 2015, the CNO told surveyors that all policies and procedures needed to be reviewed, revised, updated, and approved.

Based on radiology policy and procedure review, and staff interview, the hospital failed to ensure radiology services were provided in accordance with acceptable standards of practice.

Findings:

1. On the morning of March 18, 2015, Staff G told surveyors that the Critical Access Hospital (CAH) did not have a Radiologist appointed over radiology.

2. On the morning of March 18, 2015, surveyors toured the radiology department. There was a Vistron CT Power Injector that was last inspected March 2012. Staff G told surveyors that he did not know when the power injector was inspected last and did not know if the power injector was safe for patient use.

3. Radiology policies and procedures had not been updated and approved by a Radiologist, Medical Staff, and the Governing Body.

4. Radiology personnel were not oriented, trained, evaluated and deemed competent by a Radiologist, Medical Staff, and the governing body.

5. Surveyors requested physicist reports, radiation safety reports, biomedical/maintenance reports from January 1, 2014 through current. None was provided.

6. There was no documented evidence which studies required interpretation by a radiologist.

7. There were no policies and procedures in place to ensure that periodic inspections of radiology equipment were conducted and problems identified were corrected in a timely manner.

Based on hospital document review and staff interview, the hospital failed to ensure that a list of all services provided through arrangements, contracts, and or agreements were maintained describing the nature and scope of the services provided.

Findings:
1. On the morning of March 18, 2015, surveyors requested a list of contracted services. A list that was not complete was provided by the CEO.

2. The CEO verified that the list of contracted services was not complete. The list was missing several contractors (organ procurement organization, credentialing, telemetry, biomedical service, etc.)

3. The CEO verified that the list of contracted services did not contain nature and scope of services provided.

Based on nursing personnel file review and staff interview, the Critical Access Hospital (CAH) failed to ensure the nursing services meet the needs of the patient.

Findings:

1. On the afternoon of March 18, 2015, surveyors requested nursing personnel files to include all training and education.

2. Nursing personnel files were provided. The nursing personnel files provided contained evidence of current licensure but there was no evidence of any skills training and or competencies. The nursing personnel files contained no evidence of orientation to the hospital and the policies and procedures.

3. On the afternoon of March 18, 2015, Staff B told surveyors that the CAH accepts patients of all ages. There was no documentation of any nursing staff having age specific competencies and or training. Staff B told surveyors that age specific training had not been done.

4. On the afternoon of March 18, 2015, Staff B told surveyors that the nursing staff provide respiratory therapy treatments to the patients and had been trained by a Respiratory Therapist. No documentation of Respiratory training was provided to the surveyors.

5. On the morning of March 19, 2015, Staff B told surveyors that the nursing staff did not perform conscious sedation. On the afternoon of March 19, 2015, surveyors observed a procedure in the Emergency Room where conscious sedation medication was administered by nursing personnel. There was no documentation of conscious sedation training and competencies.

6. On the morning of March 18, 2015, Staff B told surveyors that all nursing staff work and assist in the Emergency Room. There was no documentation of any Emergency Room training and competencies.

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to maintain medical records that were complete and accurately documented.

Findings:

1. On the afternoon of March 19, 2015, surveyors reviewed medical records.

2. Four (#14, 18, 20, and #21) of four swing bed resident's medical records reviewed did not contain physician's orders to discharge the patient from acute care.

3. Four (#14, 18, 20, and #21) of four swing bed resident's medical records reviewed did not contain a history and physical from the physician for the swing bed admission.

4. Four (#14, 18, 20, and #21) of four swing bed resident's medical records reviewed did not contain a complete initial nursing assessment upon admission to swing bed status.

5. In seven (#4, 7, 10, 12, 14, 20, #21) of seven medical records reviewed where respiratory therapy treatments were given there was no documentation of a complete pre and post respiratory therapy assessment. All seven medical records contained a respiratory flow sheet to document pre and post lung sounds but pre and post lung sounds were not documented.

6. In eleven (#2 through 7, #9 through 12, and #16) of eleven medical records reviewed, the emergency department nursing documentation did not contain clear/informative documentation. Nursing documentation did not contain notifications to the provider/physician for abnormal vital signs and interventions carried out in the ED.

Patient medical record # 3 contained documentation that the patient presented to the ED for chest pain. The medical record did not contain documented evidence of heart sounds.

Patient medical record #5 contained documentation that the patient presented to the ED for abdominal pain and weakness. The medical record did not contain documented evidence of an abdominal assessment and bowel sounds. The medical record documented abdomen "N/A" and appetite as "N/A." Basic nursing fundamental are to assess the area of concern.

Patient medical record #4 and #7, # 10, #12 contained documentation that the patients presented to the ED for shortness of breath. The medical record did not contain documented evidence of lung sound reassessments.

Based on record review and interviews with hospital staff, the hospital did not ensure that the hospital performed a periodic evaluation and quality assurance review as required with the Critical Access Hospital (CAH) conditions of participation. The hospital has not conducted an annual periodic evaluation and did not have an effective and ongoing quality assurance program.

Findings:

1. The hospital did not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

2. The hospital did not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies.

3. The hospital did not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

4. The hospital did not have an effective Quality Assurance Performance Improvement (QAPI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished.

5. The hospital did not have a functioning QAPI system is implemented so that remedial action can address deficiencies found through the QAPI program.

Based on Swing Bed Admission packet review and staff interview, the Critical Access Hospital (CAH) failed to notify each swing bed resident of the items and services that are included in the nursing facility services and the items and services that the facility offers for which the resident may be charged.

Findings:

1. On the morning of March 19, 2015, Staff B told surveyors that the CAH did not notify all swing bed residents of the items and services that are included in the nursing facility services and the items and services for which the resident may be charged.

2. On the morning of March 19, 2015, surveyors reviewed the swing bed admission packet. There was no documentation of the items and services that are included in the nursing facility services and the items and services for which the resident may be charged.

Based on staff personnel file review and staff interview, the Critical Access Hospital failed to have a system in place to ensure the safety of the residents.

This occurred in 11 of 11 (B, E, G, H, K, M, N, O, P, R, & W) personnel files reviewed.

Findings:

1. On the morning of March 19, 2015, surveyors reviewed staff personnel files of employees who were involved in direct resident care. Eleven of eleven (B, E, G, H, K, M, N, O, P, R, & W) Staff files reviewed did not contain a current nurse aide registry check.

2. Six of eleven (E, G, H, N, O, & W) personnel files reviewed contained no nurse aide registry check.

3. Five of eleven (B, K, M, P, & R) personnel files reviewed did not contain a current nurse aide registry check.

2. On the afternoon of March 19, 2015, staff B verified the findings. Staff B told surveyors that she was not sure what the process was for nurse aide registry checks.

Based on swing bed resident medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that all swing bed residents were assessed upon admission to swing bed status.

This occurred in 2 of 2 closed swing bed resident medical records (# 18 & # 14) reviewed and in 2 of 2 open swing bed resident medical records (# 20 & # 21) reviewed.

Findings:

1. On the afternoon of March 19, 2015, surveyors reviewed medical records. Two of two closed swing bed resident medical records (#18 & # 14) reviewed did not contain a comprehensive nursing assessment upon admission to swing bed status. Two of two open swing bed resident medical records (#20 & #21) reviewed did not contain a comprehensive nursing assessment upon admission to swing bed status.

2. At the time of record review Staff B verified that the nursing staff used the initial nursing assessment from the patient's acute care medical record as the initial swing bed nursing assessment.