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Based on medical staff bylaws, medical record review and interview the hospital failed to ensure staff completed History and Physicals (H&Ps) prior to surgical procedures for four patients (#5, #6, #7 and #8) of four reviewed. These failures had the potential to affect the quality of care for all patients that presented for surgical procedures. The facility census was zero Acute Care patients, one Swing Bed patient and one Observation patient for a total census of two.

Findings included:

1. Review of the hospital's bylaws, last reviewed on 06/27/23, showed that except in emergencies, history and physical exams must be performed, documented, and entered into the patient's medical record before surgical procedures may be performed.

2. Review of Patients' Electronic Medical Surgical Records (EMSR) showed:
- Patient #5's EMSR dated 08/14/23, showed Staff P, General Surgeon, failed to authenticate with a signature, date and time, the patient's H&P prior to left inguinal hernia surgical repair.
- Patient #6's EMSR dated 08/04/23, showed Staff R, Ear, Nose and Throat Surgeon, failed to authenticate with a signature, date and time, the patient's H&P prior to a tonsillectomy surgical procedure.
- Patient #7's EMSR dated 07/12/23, showed Staff Q, Gastroenterologist, failed to authenticate with a signature, date and time, the patient's H&P prior to a colonoscopy surgical procedure.
- Patient #8's EMSR dated 06/06/23, showed Staff O, Orthopedic Surgeon, failed to authenticate with a signature, date and time, the patient's H&P prior to a right knee arthroscopy surgical procedure.

3. During an interview on 09/12/23 at 11:00 AM, Staff N, Manager of Surgical Services, stated that the physicians should have signed, dated and timed the H&Ps.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection control policies and infection prevention standards when staff failed to dispose of soiled waste into biohazard red bags for two patients (#1 and #24) of two observed. These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The facility census was zero Acute Care patients, one Swing Bed patient and one Observation patient for a total census of two.

Findings included:

1. Review of the hospital's policy titled, "Master Plan for Hazardous Waste Storage, Disposal and Management," last reviewed on 09/27/22, showed that infectious waste (waste contaminated by blood or body products) was to be placed in red hazardous waste bags by the staff, where generated.

2. Observation on 09/11/23 at 2:35 PM, in the outpatient wound care clinic, Staff O, Nurse Practitioner, placed Patient #24's soiled dressing and 4x4 pads (soiled with exudate) into a regular trash can.

Observation on 09/12/23 at 9:05 AM, in pre-op bay at bedside of Patient #1, Staff B, Registered Nurse, placed blood soaked 4x4s and blood soaked pads (used to clean blood off of the floor), into a regular trash can.

3. During an interview on 09/13/23 at 9:38 AM, Staff P, Infection Preventionist, stated that any items with blood or body fluids should be placed into red hazard bags.

Based on policy review, record review, and interview the facility failed to:
- Complete a comprehensive quality of life activities assessment, which identified specific individualized activity interest for two of two current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#9 and #12) and for two of two discharged Swing Bed patients (#21 and #22) reviewed for a comprehensive quality of life activities assessment.
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for two of two current Swing Bed patients (#9 and #12) and for two of two discharged Swing Bed patients (#21 and #22) reviewed for specific individualized activity interests of the patient.
- Develop a comprehensive activity care plan, which included activity interests and interventions for two of two current Swing Bed patients (#9 and #12) and for two of two discharged Swing Bed patients (#21 and #22) reviewed for a comprehensive activity care plan.
These failed practices had the potential to affect all Swing Bed patients admitted to the facility's Swing Bed program by failing to stimulate their minds, body and social interests. The facility census was zero Acute Care patients, one Swing Bed patient and one Observation patient for a total census of two.

Findings included:

1. Review of the facility's policy titled, "Swing Bed Chart," dated 06/2012, showed staff directive: Activity Assessment - Can be performed by Activity Rep, Social Services or OT (Occupational Therapy).

Review of the facility's policy titled, "Swing Bed Assessment, Care Planning and Discharge Planning," dated 06/28/22, showed staff directives in part:
- It is the policy of Carroll County Memorial Hospital (CCMH) to provide a comprehensive assessment, comprehensive care plan and discharge plan to all patients who receive skilled care services (Swing Bed) in the hospital setting.
- Every patient admitted to Swing Bed will have a comprehensive assessment completed by a Registered Nurse (RN) within 12 hours of admission. Elements of the assessment include in part: Customary routine; cognition; communication abilities; mood, behavior patterns and psychosocial well-being; and physical functioning and structural problems.
- A comprehensive person-centered care plan is developed after nursing and other discipline individual assessments.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #9 was admitted to the facility's Swing Bed program on 09/07/23, for intravenous (IV, in a vein) antibiotic therapy and rehabilitative services;
- Patient #12 was admitted to the facility's Swing Bed program on 09/11/23, for IV antibiotic therapy and rehabilitative services;
- Patient #21 was admitted to the facility's Swing Bed program on 08/23/23, for rehabilitative services status post stroke; and
- Patient #22 was admitted to the facility's Swing Bed program on 08/17/23 for rehabilitative services status post stroke.

Patient #9's, #12's, #21's and #22's EMHR showed staff failed to conduct a comprehensive quality of live activity assessment of the patients to assist in identifying the patients' activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility's Swing Bed program.

3. During an interview on 09/12/23 at 9:30 AM, Staff G, Registered Nurse (RN), Director of Inpatient (Acute Care, Swing Bed, and Observation) and Nursing Services, acknowledged the facility's Swing Bed program does not include neither an activity assessment nor an activity Care Plan for patients admitted to the facility's Swing Bed program. Staff G stated the facility was under the impression the element for activity assessment and Care Plan for activities for Swing Bed patients had been removed from the regulations for Swing Bed programs.

During an interview on 09/12/23 at 9:45 AM, Staff H, Occupational Therapist (OT), stated in the past she performed activity assessments on all patients admitted to the facility's Swing Bed program, however, she was informed the Swing Bed patients no longer required an activity assessment or activity Care Plan. Staff H stated since she was informed the activity assessment was no longer required, she has not been performing assessments for patients' activity interest or formulating an activity Care Plan.