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Based on record review, staff interview, observation and review of the CAH (Critical Access Hospital) Policy and Procedures, the facility failed to ensure that 6 of the 40 patient records (Patients 5, 7, 11, 17, 34 and 36) reviewed contained complete physician/provider orders when the patient changed from Acute Inpatient Status to Swingbed (SNF-Skilled level of care) Status. The total sample was 40 and the CAH census was 1 observation patient, 4 acute inpatients and 3 swingbed patients. The total patients served for fiscal year 2014 (10/1/13 to 9/30/14) included 277 medical/surgical inpatients and 130 swingbed patients. This failed practice has the potential to affect all patients admitted to swingbed status from acute inpatient status at the CAH.

Findings are:

A. Review of Patient 5's medical record dated 7/23/14-8/12/14 revealed the patient had been admitted on 7/23/14 to Acute Inpatient Status.

On 7/27/14 the physician/provider wrote the following orders at 11:30 AM:
1) "Admit SNF"
2) "CBC W/ Auto Diff" (complete blood count with auto differential-a laboratory test used to identify the number of cells in the blood, especially red blood cells and white blood cells).
3) "Basic Metabolic Profile"- (a laboratory test that measures your sugar level, electrolye and fluid balance level and kidney function).

The 7/27/14 Swingbed/SNF medical record for Patient 5 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

B. Review of Patient 7's medical record dated 9/16/14-9/23/14 revealed the patient had been admitted on 9/16/14 in Acute Inpatient Status.

On 9/19/14 the physician/provider wrote the following orders at 10:02 AM:
1) "Admit SNF"
2) "Discontinue IVF [intravenous fluids] to Saline Lock" (a cap device applied to an indwelling venous catheter that can be accessed intermittently)"

The 9/19/14 Swingbed/SNF medical record for Patient 7 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

C. Review of Patient 11's medical record dated 7/9/14-7/17/14 revealed the patient had been admitted on 7/9/14 in Acute Inpatient Status.

On 7/13/14 the physician/provider wrote the following order at 8:30 AM:
1) "To SNF"

The 7/13/14 Swingbed/SNF medical record for Patient 11 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

D. Review of Patient 17's medical record dated 12/13/14-12/18/14 revealed the patient had been admitted on 12/13/14 in Acute Inpatient Status.

On 12/16/14 the physician/provider wrote the following order at 9:30 AM:
1) "SNF"

The 12/16/14 Swingbed/SNF medical record for Patient 17 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

E. Review of Patient 34's medical record dated 12/16/14-12/22/14 revealed the patient had been admitted on 12/16/14 in Acute Inpatient Status.

On 12/20/14 the physician/provider wrote the following orders at 11:32 AM:
1) "Admit SNF"
2) "Discontinue Telemetry" (remote monitoring of the patients heart rhythm)

The 12/20/14 Swingbed/SNF medical record for Patient 34 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

F. Review of Patient 36's medical record dated 9/16/14-9/22/14 revealed the patient had been admitted on 9/16/14 in Acute Inpatient Status.

On 9/19/14 the physician/provider wrote the following orders at 8:38 AM:
1) "Admit SNF"
2) "CBC W/ Auto Diff"
3) "Basic Metabolic Profile"
4) "INR/Protime" (a laboratory test to measure the time for blood to clot)

The 9/19/14 Swingbed/SNF medical record for Patient 36 did not indicate the specific physician/provider orders to continue in the Swingbed/SNF Care Status. The record lacked current diagnoses, what medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

G. Review of the "Acute to SNF Admission" policy dated review/revision 10/10 revealed the following:
"4) Physician to evaluate current orders and update to reflect what is to continue for SNF care. The SNF admission are then written to clarify exactly what medications and treatments etc. are ordered for SNF status."

H. An observation on 1/14/15 of the patient meal tray pass from 11:10 AM to 11:34 AM of 6 patients (2 Acute Inpatient, 3 SNF/Swingbed patients and 1 Short Stay Surgery patient) was completed. During diet verification of the meals passed to the 6 patients on 1/14/15, 2 swingbed patient's diet orders were not available on the nursing cardex. Registered Nurse A (RN-A) checked the SNF/Swingbed EHR (Electronic Health Record) for the diet order, the order was not available in the SNF/Swingbed EHR. RN-A then closed out of the SNF/Swingbed EHR and entered the Acute Inpatient EHR and searched for the diet order at the time of Acute Inpatient discharge to determine the diet orders for these 2 swingbed patients.

I. An interview with the Informatics Nurse on 1/13/15 at 3:30 PM while reviewing electronic records revealed when asked about the SNF admission orders, "No, this is what the doctors write (To SNF, Admit SNF or SNF) in the Swingbed record. We just know that they want us to continue the orders from the Acute Inpatient stay unless they add other orders at the same time. But you are right, there isn't any documentation that indicates what all the orders are to continue. Before we went to the EHR the doctors would always write all that out. We will have to work on that, we just didn't incorporate it all into the EHR when we started it."

J. An interview with the CNO (Chief Nursing Officer) on 1/20/15 at 2:15 PM revealed, "I guess it is understood that if the doctor doesn't write anything but that (Admit to SNF) that we just continue all the orders from the Acute Care orders. I guess I look at it like charting by exception."

K. An interview with the Medical Records Director on 1/20/15 at 2:45 PM revealed, "I can see what you are saying, we don't have all the orders listed on the admission to swingbed. I just didn't catch it. I know that they continue the previous orders from the acute chart."