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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.618 Emergency Services, was out of compliance.

C-0888 Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. Based on observations, interviews and document review, the facility failed to ensure emergency equipment was available in emergency situations. Specifically, the facility failed to ensure expired emergency equipment and medications were removed and replaced to provide usable equipment in an emergency situation in two of three code carts observed.

Based on observations, interviews and document review, the facility failed to ensure emergency equipment was available in emergency situations. Specifically, the facility failed to ensure expired emergency equipment and medications were removed and replaced to provide usable equipment in an emergency situation in two of three code carts observed.

Findings include:

Facility policies:

The Supply Expiration Process policy updated 9/20 read, the purpose was to ensure medical supplies were not used after the marked expiration date. Materials management personnel are to record and reconcile monthly the expiration date for all medical supply inventory products. Each hospital department is responsible to check for outdated supplies. Items that have that have reached the marked expiration date will immediately be removed from patient care areas.

References:

The BD Vacutainer read, the vacutainer tubes are used as a system for the collection of venous blood. Tubes should not be used after the expiration date.

The GlucaGen IFUs read the medication is an anti-hypoglycemic agent and is used for the treatment of hypoglycemia (low blood sugar). GlucaGen should not be used after the expiration date on the vials of medication.

The EasyCap II adult colorimetric CO2 detector is used to assist with verification of tube placement during endotracheal intubation (when a tube is placed in the mouth and into the trachea to assist a patient to breath).

The PediCap pediatric end-tidal CO2 detector is used to assist with verification of a tube placement during endotracheal intubation of a pediatric patient.

The BD Insyte Autoguard BC shielded IV Catheter instructions for use read, the catheter is inserted into a patient's vascular system for the administration of fluids.

1. The facility failed to ensure emergency medical supplies and medications were removed from use after the supplies had expired.

A. Observations revealed expired medications and supplies in two of three code carts (a cart stocked with supplies to be used in a medical emergency) observed.

a. On 7/19/21 at 1:45 p.m., observations were conducted in the emergency department. Upon observation of the code cart, numerous supplies were found to be expired. The expired supplies included:

i. One 18 gauge intravenous (IV) catheter expired 5/31/21.

ii. Two 20 gauge IV catheters expired 2/28/21.

iii. One 21 gauge safety needle (used for intramuscular or subcutaneous injection of medication) expired on 2/21.

iv. One pediatric colorimetric CO2 detector expired on 1/29/21.

v. One adult colorimetric CO2 detector expired 4/14/21.

b. On 7/20/21 at 9:00 a.m., observations were conducted of the medical surgical unit. Upon observation of the code cart, numerous supplies were found to be expired. The expired supplies included:

i. Three 0.9% sodium chloride injections which expired on 5/1/21.

ii. One pediatric colorimetric CO2 detector expired on 4/13/21.

iii. One 20 gauge IV catheter expired 3/31/21.

iv. One 18 gauge IV catheter expired on 5/31/21.

v. One Blue lab tube buff Na citrate 0.109 M, 3.2 % ( a blood collection tube used to check a patient's coagulation (blood clotting) status), expired on 4/30/21.

vi. One arterial blood gas (ABG) kit expired on 2/8/21.

vii. One glucagon kit (medication administered to a patient when they had extremely low blood sugar) expired on 5/30/21.

The IFUS above read, the equipment should not be used if expired.

B. Review of the facility's code cart checks revealed lack of consistency with facility staff checking code carts for accuracy.

a. Review of the inpatient code cart checks for June and July revealed the column which read, outdates checked and seal replaced on the first day of each month, was only completed three days out of two months.

b. Review of the emergency department code cart checks for June and July revealed the column which read, outdates checked and seal replaced on the first day of each month, was only completed three days out of two months.

C. Interviews revealed expired supplies should not be used and should be removed from use once expired.

a. On 7/20/21 at 9:20 a.m., an interview was conducted with Physician Assistant (PA #12). PA #12 was present during the observations of the inpatient code cart. PA #2 stated expired supplies should not be used and should be removed from the code cart. PA #2 further stated expired supplies should not be used because there was a concern for the lack of integrity of the supplies.

b. On 7/20/21 at 4:29 p.m., an interview was conducted with Pharmacist (#4). Pharmacist #4 stated expired medications should not be administered to a patient due to the lack of knowledge whether the medication was still potent and would be effective.

c. On 7/21/21 at 10:43 a.m., an interview was conducted with Infection Preventionist (IP #5). IP #5 stated expired equipment should not be used on patients because there was a risk the package was contaminated. IP #5 further stated it was important to follow the IFUs for equipment since the manufacturer knows the product's functions the best.

Based on interviews and document review, the facility failed to ensure nursing care plans were completed for all patients. Specifically, the facility failed to ensure patients who were admitted to the inpatient unit after surgical procedures received a nursing care plan in two of three surgical records reviewed (Patients #16, #18) and three of five records reviewed where patients were admitted to the inpatient unit and discharged home (Patients #17, #19 and #20).

Findings include:

Facility policy:

The Nursing Care Plan policy read, the care plan must be entered into the patient's chart within 24 hours of admission. Additionally, the care plan should be documented once a shift. The care plan should include goals and interventions based on assessment of the patient. The care plan should be resolved or completed upon discharge.

1. The facility failed to ensure a care plan was created for five surgical patients based on assessments of the patients.

A. Medical record review

a. A review of Patient #16's medical record revealed the patient had a lumbar surgical procedure on 7/20/21. There was no evidence in the record a care plan had been created and documented during the patient's admission.

b. A review of Patient #18's medical record revealed the patient had a total knee arthroplasty procedure on 5/12/21. There was no evidence in the record a care plan had been created and documented during the patient's admission.

c. Review of Patients #17, #19, and #20's medical records resulted in no evidence care plans were created or documented.

The review of medical records was in contrast to the facility's policy which read a care plan should be created upon admission and should include goals and interventions based on assessment of the patient.

B. An interview with the facility case manager (CM) revealed all patients admitted to the inpatient unit should have a care plan created based on assessments of the patients.

a. On 7/28/21 at 3:12 p.m., an interview was conducted with CM #3. CM #3 stated a care plan should be created after admission of the patient to the inpatient unit and should be updated every 12 hours while the patient was admitted. CM #3 stated the purpose of the care plan was to evaluate patients and create goals based on the evaluation. CM #3 stated if a care plan was not created, there was a risk vital concerns obtained through assessment of the patients could be missed and not addressed.

Based on medical record review and interviews, the facility failed to ensure the medical records for three of 20 medical records reviewed (Patient #1, #6, and #8) included an informed consent signed by patients upon their admission in order to make an informed decision on their care.

Findings include:

Facility policy:

The Informed Consent policy read, informed consent is an ethical obligation and a legal requirement that health care providers disclose the benefits, risks and alternatives to treatment. An informed consent form is a legal document verifying that the informed consent conversation occurred between the health care provider and the patient, that the patient understands treatments, why it's needed, the risks and benefits and alternative treatment methods.

Facility Document:

The patient rights document provided to patients read, the patient has the right to consent to or refuse treatment throughout their hospital stay.

1. The facility failed to ensure patients signed an informed consent prior to receiving treatment at the facility.

A. Medical Record Review

a. A review of Patient #1's medical record revealed the patient had been admitted on 6/18/21 and was discharged from the facility on 6/19/21. Further review revealed the patient was readmitted to the facility on 6/24/21. Patient #1 had signed a consent for treatment for the 6/18/21; however, there was no evidence in the medical record an informed consent was signed by the patient for the 6/24/21 admission.

b. A review of Patient #6's medical record revealed Patient #6 was admitted to the facility on 7/9/21 for diabetes and chest pain. There was no evidence in the medical record an informed consent was signed by the patient upon admission or throughout the patient's stay.

c. A review of Patient #8's medical record revealed Patient #8 was admitted to the facility for swing bed placement. There was no evidence in the medical record the patient signed an informed consent for treatment.

B. Interviews revealed all patients must sign an informed consent for treatment in order to ensure patients were aware of their rights and were able to consent or refuse treatment options.

a. On 7/28/21 at 3:12 p.m., an interview was conducted with Case Manager (CM #3). CM #3 stated all patients should sign an informed consent upon admission and it was the responsibility of the primary nurse at the time of admission to ensure an informed consent was signed. CM #3 stated an informed consent was to be signed by the patient each time the patient was admitted to the facility. CM #3 further stated it was important for the informed consent to be completed so there was evidence the patient had been notified of their rights and treatment and the patient was notified of their right to refuse treatment.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation, §485.640 Infection Prevention and Control and Antibiotic Stewardship Programs, was out of compliance.

C-1206 The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; Based on observations, interviews and document reviews, the facility failed to ensure methods to prevent and control the transmission of infections. Specifically, the facility failed to ensure equipment was decontaminated and reprocessed per facility policy and the instruments' instructions for use (IFUs).

C-1208 The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; Based on observations, interviews and document review, the facility failed to ensure infection prevention and control measures were implemented in order to maintain a clean and sanitary environment to avoid transmission of infection. Specifically, the facility failed to ensure hospital grade laundry was conducted by trained staff.

C-1231 (c)(2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. Based on interviews and document review, the facility failed to ensure the infection preventionist implemented systems for tracking all infection surveillance throughout the facility. Specifically, the facility failed to ensure the infection preventionist had complete oversight of all entities of the facility requiring infection control oversight. (Cross reference C-1206; C-1208).

Based on observations, interviews and document reviews, the facility failed to ensure methods to prevent and control the transmission of infections. Specifically, the facility failed to ensure equipment was decontaminated and reprocessed per facility policy and the instruments' instructions for use (IFUs).

Findings include:

Facility policies:

The high-level disinfection of flexible endoscopes updated 9/20 read, flexible endoscopes should be reprocessed before being used if unused for more than seven days. The manufacturer's recommendations should always be followed.

The cleaning, disinfection and sterilization policy updated 9/20 read, all reusable instruments, equipment and used services should be decontaminated, disinfected or sterilized. Manufacturers' directions and facility policies for reprocessing reusable instruments should be available to staff at all times. The manufacturers' specifications for the quality of water used for cleaning should be followed. All jointed instruments must be open and/or unlocked.

References:

The V.Mueller Products and Services General Surgical Instrument Cleaning and Sterilization Guide read, all devices must be processed in the completely open position to allow solution to contact of all surfaces.

ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities (page 40-41) read, the device's current written IFUs should be accessible, reviewed and followed. To help ensure effective decontamination of devices, open all jointed instruments.

The Olympus CF-HQ190L/I colon Videoscope IFUs read, medical literature reports incidents of cross-contamination due to improper reprocessing. It is strongly recommended that facility policies and instructions in this manual are used. Disinfectant solution is only effective when used according to the disinfectant manufacturer's instructions. Follow the manufacturer's instructions regarding activation, concentration and contact time to achieve disinfection. 1. The facility failed to ensure IFUs were followed when reprocessing endoscopes and surgical instruments.

A. Observations of the decontamination area revealed IFUs were not followed when decontaminating jointed instruments.

a. On 7/21/21 at 11:15 a.m., observations of the decontamination area were conducted. Hinged instruments were noted in a wash basket and noted to not be fully open while waiting to be placed into the instrument washer.

b. On 7/21/21 at 12:30 p.m., and interview was conducted with Registered Nurse (RN) #9. RN #9 stated she was a scrub nurse, however, she occasionally worked in the sterile processing department (SPD). RN #9 stated the SPD followed AAMI national guidelines and standards. RN #9 stated the facility followed IFUs for decontamination of instruments because national standards and guidelines required facilities to follow manufacturers' IFUs.

However, the process observed on 7/21/21 at 11:15 a.m. was in contrast to the instrument cleaning and sterilization guide referenced above which read, all devices must be processed in the completely open position to allow solution to contact of all surfaces.

B. Observations of the GI scope room indicated the potential for endoscopes to not be reprocessed appropriately.

a. On 7/21/21 at 11:20 a.m., observations were conducted of the endoscope reprocessing area. The sink used to manually clean the endoscope was not marked to ensure the amount of water needed to dilute the enzymatic used was met.

i. During the observation, RN #9 was present. RN #9 stated it was important to ensure the sink was marked and the correct concentration was used. She stated if the correct concentration of enzymatic and water was not used, there was a risk the scope would not be decontaminated as required and had the potential to cause the spread of infection between patients.

Based on observations, interviews and document review, the facility failed to ensure infection prevention and control measures were implemented in order to maintain a clean and sanitary environment to avoid transmission of infection. Specifically, the facility failed to ensure hospital grade laundry was conducted by trained staff.

Findings include:

Facility policy:

The Infection Prevention and Control Laundry policy, updated 9/20 read, to remove significant quantities of microorganisms, water temperatures of at least 160 degrees F and 50-150 ppm of chlorine bleach should be used. Water temperatures of less than 160 degrees F with laundry chemicals suitable for low-temperature washing used at proper concentrations per the manufacturer may also be used.

References:

According to Background G. Laundry and Bedding: Guidelines for Environmental Infection Control in Health-Care facilities (2003), the antimicrobial action of the laundering process results from a combination of mechanical, thermal and chemical factors. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160°F for a minimum of 25 minutes is commonly recommended for hot-water washing. The use of chlorine bleach assures an extra margin of safety. A total available chlorine residual of 50-150 ppm is usually achieved during the bleach cycle. Chlorine bleach becomes activated at water temperatures of 135°F-145°F.

The laundry personnel job description read, the primary purpose of the job is to provide laundry/linen service to all areas of the facility, in accordance with established procedures, as directed by your manager, to assure the highest degree of linen cleanliness is maintained at all times.

1. The facility failed to ensure laundry personnel received adequate training in order to process hospital grade laundry.

A. Observations

a. On 7/19/21 at 2:00 p.m., the laundry processing area was observed. During the observation, Laundry Technician (LT) #6 was interviewed. LT #6 stated she had received training how to process and clean linen from the previous laundry technician. LT #6 stated she did not know the required settings of the washer and dryer to ensure microorganisms were removed from the linen. Additionally, LT #6 was unable to state the nationally recognized guidelines for hospital grade laundry.

B. Interviews
a. On 7/21/21 at 10:43 a.m., an interview was conducted with Infection preventionist (IP) #5. IP #5 stated it was important for laundry staff to ensure cross contamination did not occur while processing hospital laundry. IP #5 stated as the IP, she did not oversee the laundry process.

C. Document Review

a. A review of LT #6's personnel file revealed she had prior laundry technician experience at a hotel, however she did not have laundry personnel experience performing hospital grade laundry. Additionally, review of the personnel file revealed there was not a competency or education present provided by the facility to LT #6 which indicated she was deemed competent to perform hospital grade laundry

Based on interviews and document review, the facility failed to ensure the infection preventionist implemented systems for tracking all infection surveillance throughout the facility. Specifically, the facility failed to ensure the infection preventionist had complete oversight of all entities of the facility requiring infection control oversight. (Cross reference C-1206; C-1208).

Findings include:

Facility policies:

The Surveillance of Infections policy updated January 2020 read, house wide surveillance will be conducted.

The Infection Prevention Program policy updated 7/29/20 read, the program will maintain a continual surveillance program to obtain, analyze and manage data and information, including surveillance for infection.

References:

The Infection Control RN Job description read, the staff member shall coordinate activities related to the monitoring, prevention, and control of infections.

The Infection Prevention and Control 2020 Performance Improvement and Surveillance Plan, approved November 24, 2020 read, the goal was to identify and reduce the risks of acquiring and transmitting infections among patients, residents, employees, providers, visitors, and the community. Surgical site infection (SSI) prevention will include surgical, SPD, and EVS process review.

1. The facility failed to ensure the infection preventionist had oversight of all entities of the facility.

A. An interview with Infection Preventionist (IP) #5 revealed lack of oversight of all areas of the hospital.

a. On 7/21/21 at 10:43 a.m., an interview was conducted with IP #5. IP #5 stated one of her roles was to conduct surveillance of the entire hospital. IP #5 stated she had conducted an audit in the SPD department a few years ago, but had not done one within the past year. IP #5 stated she was unaware if anyone had oversight of the SPD department or if audits were being conducted to confirm appropriate infection prevention processes.

i. In addition to the lack of oversight of the SPD department, IP #5 was not able to fully explain the process for tracking Surgical Site Infections (SSIs). IP #5 stated infection rates for SSIs were tracked but she was not the staff member who reviewed the medical records or followed up with surgical patients. IP #5 further explained she was unaware of the process for surgical patient followed up for SSI tracking.

The lack of oversight by the infection preventionist in the SPD area and tracking of post-operative SSIs was in contrast to the infection preventionist's job description and facility policy, as well as the requirement to develop and implement facility-wide infection prevention procedures.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.643 Organ, Tissue, and Eye Procurement was out of compliance.

C-1503 Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the CAH. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the CAH, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the CAH for this purpose; Based on interviews and document review, the facility failed to ensure it met the obligations of its written agreement with the Organ Procurement Organization. Specifically, the facility failed to ensure a staff member was trained in organ procurement and had oversight of the facility's organ procurement program.

Based on interviews and document review, the facility failed to ensure it met the obligations of its written agreement with the Organ Procurement Organization. Specifically, the facility failed to ensure a staff member was trained in organ procurement and had oversight of the facility's organ procurement program.

Findings include:

Facility policy:

The Death-Organ and Tissue Donation policy updated 8/16/20 read, the purpose was to establish criteria after death has occurred and to provide the option of organ donation to families of patients who have made the decision to withdraw life-sustaining procedures.

References:

The Donor Alliance organ and tissue donation contract with the facility was initiated March 25, 2013. The contract defines a designated requester as a hospital representative who has completed training by Donor alliance regarding the methodology for approaching potential donor families. This training is conducted for tissue donation only. Duties of the donor hospital include adopting policies and protocols concerning the organ and tissue donation program. Additionally, the hospital shall designate a senior staff member physician or nurse champion who will collaborate with Donor Alliance and facilitate the development and implementation of an effective organ and tissue donation program.

1. The facility failed to ensure a staff member was designated and trained as the organ procurement requestor as well as the person with oversight of the organ procurement program.

A. Interviews revealed the facility did not have a designated staff member to collaborate with the Organ Procurement Organization and to facilitate the implementation of the organ procurement program.

a. On 7/21/21 at 10:27 a.m., an interview was conducted with Quality Director (Director #10). Director #10 stated there was not a staff member who had oversight of the facility's organ procurement program and was not assigned as the facility's designated requestor for organ donation.

i. On 7/21/21 at 10:30 a.m., Director #10 returned and stated the Chief Nursing Officer (CNO #7) oversaw the facility's organ procurement program and was a designated requestor.

b. On 7/21/21 at 11:23 a.m., however, an interview was conducted with Compliance Director (Director #8). Director #8 stated the facility did not participate in organ collection since those patients were transferred to a higher level of care. Additionally, the facility did not have a designated organ requestor due to the lack of participation in organ collection.

B. Review of documents indicated lack of training for CNO #7 to be a designated requestor.

a. A review of CNO #7's personnel file revealed there was no evidence of training received in order for CNO #7 to be a designated requestor. Additionally, there was no evidence in the CNO's signed job description about her duties as a designated requestor.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of §485.645 Special Requirements for CAH Providers of Long-Term Care Services ("SwingBeds"), was out of compliance.

§485.645(d)(5) Comprehensive assessment, comprehensive care plan, and dischargeplanning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that theCAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least thefollowing: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive ersoncentered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (1) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (2) In consultation with the resident and the resident's representative(s) (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident's written plan of care. (iii) Be culturally-competent and trauma-informed. §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. Based on Interviews and document review the facility failed to ensure the patients admitted to swing bed status met the standards of treatment for swing bed admissions. Specifically the facility failed to perform comprehensive assessments, provide comprehensive care plans and activities specific to the patients needs in 3 of 3 records reviewed (Patients #5, #14 and #15).

Based on interviews and document review, the facility failed to ensure the patients admitted to swing bed status met the standards of treatment. Specifically, the facility failed to perform comprehensive assessments, provide comprehensive care plans and activities specific to the patient's needs, affecting 3 of 3 patients (Patients #5, #14 and #15) whose records were reviewed.).

Findings include:

Facility policies:

The Care Planning policy for patients read, a care plan would be established and individualized and include an interdisciplinary plan for each patient. The Registered Nurse (RN) was responsible to generate a plan of care within four hours of admission or one hour for direct admits or patients on a postoperative "23-hour" hold admitted to the medical-surgical unit. The plan should be individualized based on patient diagnosis and assessment. The plan should address learning needs of both the patient and the patient's family. Consulting disciplines should contribute to the nursing plan of care. The plan of care should be updated daily based on reassessment of patient needs and ability. All interdisciplinary staff were responsible for collaboration, goal setting, interventions and ongoing evaluations and revisions of the plan of care.

The Swing Bed Provision of Services policy read, the facility will provide swing bed services. The patient would be kept in the same bed on the nursing unit however would be reallocated to a swing bed patient status. The policy defines swing beds as a hospital bed which can be used either for acute care needs or for skilled nursing as conditions dictate. The policy holds Nursing leadership, nursing staff, rehabilitation staff including physical, occupational, speech or respiratory therapists, physicians or hospitalists, nurses, CNA's, social workers, case managers and dietitians responsible for the policy.

The Swing Bed Activities policy read, the facility's swing bed program was used to provide activities designed to meet the interest of and in support of the physical, mental and psychosocial well-being of each patient/resident. Each patient/resident's interests and needs will be assessed at admission to the swing bed and as needed. The assessment should include a care plan, discharge planning, the patient/resident's interests, preferences, adaptation needs and social history. The intent of the activities were to enhance the patient/resident's sense of emotional well-being and promote or enhance physical activity. The various activities may be offered through one-to-one programs, use of volunteers for an activities program, or activities preferred by the patient/resident such as watching television, talking with visitors or chaplains. Scheduled activities must be posted in the patient/resident's room, patient/resident's will be encouraged, not forced to attend scheduled activities. All staff will assist patients/residents wishing to attend activities both to and from their rooms as necessary. Dietary restrictions and needs will be accommodated for patients/residents on an individual basis. The staff members responsible for the policy included nursing leadership, nursing staff and social services.

1. The facility failed to ensure activities, comprehensive assessments and care plans were in place to enhance the patient's sense of emotional well-being and promote or enhance physical activity of patients in their care who been admitted to swing bed status.

Record review

a. Review of Patient #5's medical record revealed the patient was admitted on 6/24/21 with worsening confusion at home and weakness. The patient transitioned to swing bed status on 6/29/21 as noted in the record by Physician Assistant (PA) #1. The record revealed a comprehensive assessment was not performed to identify the patient's interests and needs and a care plan was not created to establish activities compatible with Patient #5's interests and designed to promote her physical activity.

b. Review of Patient #14's medical record revealed the patient was admitted on 7/7/21 with multiple sclerosis, generalized pain and a headache. The patient transitioned to swing bed status on 7/14/21 as noted in the record by PA #1. The record revealed a comprehensive assessment was not performed to identify the patient's interests and needs and a care plan was not created to establish activities compatible with Patient #14's interests and designed to promote her physical activity

c. Review of Patient #15's medical record revealed the patient was admitted on 6/7/21 with intractable thoracic back pain due to an acute/subacute compression fracture of T10. The patient transitioned to swing bed status on 6/11/21 as noted in the record by PA #1. The record revealed a comprehensive assessment was not performed to identify the patient's interests and needs and a care plan was not created to be used to establish activities compatible with Patient #15's interests and designed to promote her physical activity

The record reviews contrasted with the facility policy that read, based on a comprehensive assessment, an individual care plan would be established for each patient and patients admitted to swing bed status would be provided activities to promote physical activity and their interest.

Interviews

a. An interview was conducted on 7/20/21 at 2:09 p.m., with Infusion RN #2. RN #2 stated swing beds were used for patients not safe to discharge, who needed extra help and were without home health services. RN #2 stated the facility only offered swing bed patients three activities, a walk outside with staff, a book or puzzle. RN #2 reviewed the record of Patient #5. RN #2 was not able to locate a comprehensive assessment to identify the Patient #5's interests and needs and a care plan was not created to establish activities compatible with the patients' interests and designed to promote her physical activity after admission to swing bed status.

b. A second interview was conducted on 7/20/21 at 3:31 p.m., with RN #2. RN #2 stated a comprehensive assessment was used to anticipate the patient needs for the next level of care, for placement, social, psychosocial, financial and support needs. A comprehensive assessment was important to ensure items did not fall through the cracks and cause patients to fail due to lack of support. RN #2 stated a comprehensive care plan allowed all caregivers to be on the same page and planning would guide the patient to the best outcome. The risk of not establishing a comprehensive care plan could cause confusion and anger with the patient and the family. The staff need to be consistent to provide the best care and outcome. RN #2 stated her understanding was the hospital initial assessment was used as the comprehensive assessment, and said it seemed redundant to perform an additional assessment if a patient transferred to swing-bed status.

RN #2's interview contrasted with facility policy which outlined the changes in the level of care expected as a hospitalized inpatient was transferred into swing-bed status. This included comprehensive assessments, care plans and specialized activities.

c. An interview was conducted on 7/21/21 at 9:42 a.m., with RN Case Manager (CM) #3. CM #3 stated she had been in her current role since September of 2020. CM #3 stated she had just learned about comprehensive assessments today, as it would be her responsibility to ensure the comprehensive assessments were now documented for each patient transitioned to swing bed status. CM #3 stated case management would also implement how to document the comprehensive care plans. CM #3 stated when a patient started out in observation, moved to inpatient and then became a swing bed resident, the record throughout the stay was one record. It was only when a patient arrived from outside the inpatient units that an initial assessment was completed on the new swing bed resident. CM #3 stated she provided swing bed residents with puzzles or books; however, she said she does not document those activities in the patient record or on a care plan. CM #3 stated the facility did not post a list of scheduled activities for the swing bed residents and would need to review the policy for those specifics. CM #3 stated she had not been trained on swing beds; rather, she had conversations regarding swing beds but no official training.

CM #3's interview contrasted with facility policy which read activities would be individualized to meet patient interests and to promote physical, mental and psychosocial well-being of each patient.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined §485.625 Establishment of the Emergency Program (EP), was out of compliance.

E-0013 (b) Policies and procedures. CAH must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. Based on interviews and document review, the facility failed to develop and implement emergency preparedness policies and procedures. Specifically, the facility failed to ensure emergency preparedness policies were created and updated every two years.

E-0036 (d) Training and testing. The CAH must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. Based on interviews and document review, the facility failed to implement a training and testing program based on the facility's emergency preparedness plan and program.

Based on interviews and document review, the facility failed to develop and implement emergency preparedness policies and procedures. Specifically, the facility failed to ensure emergency preparedness policies were created and updated every two years.

Findings include:

1. The facility failed to develop and implement emergency preparedness policies for staff to reference and follow during an emergency.

A. Review of the facility's emergency preparedness plan and policies revealed required emergency preparedness policies were not a part of the program. Specifically, the following required policies were missing from the facility's emergency plan and program:

i. A policy and procedure for how to track staff on-duty and patients under the facility's care in an emergency.

ii. A policy and procedure for a means to shelter in place for patients and staff who cannot leave or evacuate from the facility.

iii. A policy for how the facility was to share patient documents and protect confidentiality of patient information during an emergency.

iv. A policy for the facility's role under a waiver declared by the Secretary.

B. On 7/28/21 at 3:20 p.m., Chief Executive Officer (CEO #11) was interviewed. CEO #11 acknowledged the policies had not been created and stated the facility had been working to complete their emergency preparedness program. CEO #11 stated it was important for the facility to have a complete emergency preparedness plan and program in order to provide needed resources and organization needed during an emergency. CEO #11 further stated it was important for staff to be aware of the emergency plan and policies in order to respond quickly and effectively.

Based on interviews and document review, the facility failed to implement a training and testing program based on the facility's emergency preparedness plan and program.

Findings include:

References:

The Hospital Emergency Operations Plan (EOP) updated in 2020 read, the facility will rehearse the incident plan at least annually. Drills should include an after-action debrief and an evaluation of the drill.

1. The facility failed to ensure staff received emergency preparedness training and conducted the required exercises every two years.

A. Document review revealed the facility had not provided required training to staff members and had not conducted testing of the emergency program.

i. Review of staff personnel files revealed a lack of evidence the facility provided emergency preparedness training every two years.

ii. Review of the facility's emergency preparedness program documents revealed the facility had not conducted an exercise to test the emergency preparedness program in the past two years.

B. On 7/28/21 at 3:20 p.m., Chief Executive Officer (CEO #11) was interviewed. CEO #11 stated training and testing had not been performed according to the facility's EOP and required regulations. CEO #11 stated the facility had been working to complete its emergency preparedness program. CEO #11 stated it was important for the facility to have a complete emergency preparedness plan and program in order to provide resources and the organization needed during an emergency. CEO #11 further stated it was important to provide training and perform exercises in order to ensure staff members were competent with the emergency preparedness program. Additionally, she stated testing of the emergency preparedness program was important to check for any gaps or changes needed to the program.