HospitalInspections.org

Based on record review and interview the Governing Body failed to determine, implement and monitor policies governing the CAH (critical Access Hospital) by not ensuring the Governing Body conducted quarterly meetings
Findings:

A review of the Governing Body Meeting Minutes revealed there were no meetings conducted since 09/26/2018.

In an interview on 07/08/19 at 2:00 PM Staff #A, the Director of Nursing Services (DON) stated the Governing Body suppose to meet quarterly. Additionally, she confirmed that the Governing Body had not met this year.

Based on record review and interview the critical access hospital failed to evaluate the quality and appropriateness of services affecting patient and safety by not documenting action plans for each problem or potential problem that the hospital identified.
Findings:

A review of the Quality Assurance/Performance Improvement QA/PI from 11/2018 through 05/2019 revealed there were no action plans for each identifier.

On 07/08/19 at 12:45 PM Staff #I stated she was the quality coordinator and had begun her job in 05/2019. She also stated she was unaware she was suppose to document action plans for each identifier.

Based on record review and interview the critical access hospital failed to provide therapeutic activities for swing bed patients by not having documented evidence that patient's were participating in therapeutic activities.
Findings:

1. A review of the medical record for patient #2 revealed the certified occupational therapy Assistant (COTA) performed an activity screening on 07/02/19. Further review revealed no documented evidence that the activity was conducting activities for patient #2.

2. A review of the medical record record revealed patient #8 was admitted to the critical access hospital on 06/25/19 at 6:26. Continued review revealed on 06/25/19 an activity assessment was performed by the Staff K. Further review failed to reveal documentation that the activity director was conducting activities.

In an interview on 07/08/19 at 9:00 AM patient #8, stated he not engaged in activities at the critical access hospital.

On 07/08/19 at 9:30 AM patient #9 stated he was in the hospital waiting for a wound closure to be performed. Patient #9 also stated he staff does not talk to him about activities.