HospitalInspections.org

Based on observation, interview and record review, the facility failed to maintain a maximum of 25 inpatient beds. The hospital census was 16 which included seven Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's Bed Count Sheet dated 12/02/14 showed the total number of beds on the Medical-Surgical Unit to include pediatric and ICU/CCU (Intensive Care Unit/Critical Care Unit) beds equaled 23 inpatient beds and the total number of Obstetrical (OB) Unit beds equaled two inpatient beds for a total of 25 available inpatient beds.

2. Observation during a tour on 02/26/15 at 3:50 PM, of the facility with Staff N, Director of Medical Records, to count the number of beds throughout the facility showed the bed count on the Medical-Surgical Unit was 23 beds identified for inpatient use.

During tour on 02/26/15 at 4:00 PM of the OB Unit showed two rooms used for labor, delivery and recovery (rooms used to labor, deliver and post partum use) and three post partum beds/rooms used for patients after they labored and delivered an infant for a total of five beds identified for inpatient use.

During an interview on 02/26/15 at 4:00 PM, Staff UU, Registered Nurse (RN), Assistant OB Supervisor, stated that the two labor beds/rooms are used as inpatients rooms and patients will stay in the bed after they deliver. Staff UU stated that a patient in a labor bed/room will only be moved if the room is needed for a labor patient.

During an interview on 02/26/15 at 4:40 PM, Staff N, Director of Medical Records confirmed/stated that the facility had 23 inpatient beds on the Medical-Surgical Unit and five inpatient beds on the OB Unit for a total of 28 inpatient beds. Staff N stated that the facility had three inpatient beds over the 25 bed limit for Critical Access Hospitals.

Based on interview, record review and policy review the facility failed to follow established medical staff criteria for the credentialing of medical staff by failing to ensure the credentialing files were complete and contained medical staff training for four (ZZ, BBB, CCC, FFF) of 11 medical staff credentials reviewed and review of the quality of services provided for 11 (RR, ZZ, AAA, BBB, CCC, DDD, EEE, FFF, GGG, HHH, III) of 11 medical staff credentials reviewed; and failed to ensure physicians providing patient care services were a member of the medical staff for one (III) of 11 medical staff credentials reviewed.
These failed practices placed all patients seeking care at the facility at risk for substandard care and care in an unsafe environment. The facility census was 16.

Findings included:

1. Review of the facility's "Medical Staff Bylaws," dated 02/27/14 showed the following:
- Recognizing that the Medical Staff is the appropriate body for overseeing the quality of medical care in the facility, and Staff assumes this responsibility subject to the ultimate authority of the Hospital Board of Directors.
- Physician applicants for membership on the staff shall be graduates of a school of Medicine or Osteopathy;
- Dentist applicants shall be graduates of a dental school accredited by the American Dental Association's Commission on Dental Accreditation.
- Every member of the medical staff must demonstrate adequate experience, education, training, and current professional competence.
-In addition to completion of the application form, the applicant shall provide satisfactory evidence of education, training, professional qualifications and licensure.
- A review of the professional practice of each member of the Medial Staff shall be performed no less than every two years in order to evaluate current competency and identify professional practice trends that may impact quality of care and patient safety.
A Member's failure to timely submit a completed renewal application shall be deemed a resignation from the Staff effective as of the expiration date of their then current membership/privileges.

Record review of the Medical Staff Credentialing files showed the following:
- There was no diploma or record of medical school completion on file for Staff ZZ, Doctor of Osteopathy (DO), Medical Director Emergency Services;
- There was no diploma or record of medical school completion and no record of ongoing education for re-credentialing on file for Staff BBB, Doctor or Medicine (MD), Medical Director Radiology;
- There was no diploma or record of medical school completion on file for Staff CCC, DO, Chief of Staff;
- There was no diploma or record of medical school completion and no record of ongoing education for re-credentialing on file for Staff FFF, MD, Orthopedic Surgeon (a branch of medicine that tries to prevent and correct problems that affect bones and muscles);
- The credentialing file for Staff III, Doctor of Dental Surgery (DDS, Dentist) showed an expiration date of 12/10/13.

During an interview on 02/24/15 at 9:45 AM, Staff N, Manager of Health Information Services (HIM), stated that:
- The facility did not have a record of medical school completion for Staff ZZ and Staff CCC;
- There was no record of medical school completion or continuing medical education on file for Staff BBB and Staff FFF;
- The Medical Staff re-credentialing process did not include a quality review of the services provided;
- The privileges for Staff III had expired effective 12/10/13.

2. During concurrent record review and interview on 02/26/15 at 10:30 AM, the Operating Room (OR) Register showed Staff III had performed abstraction (removal) of eight teeth, on 04/23/14. Staff K, OR Manager, stated that she remembered she had checked the OR privileges roster for Staff III which showed they were expired and she had called Staff N, HIM manager to verify that Staff III had current privileges to perform the operation.

3. Medical record review of the closed record for Patient #19 showed an operative note dated 04/23/14 for removal of remaining natural teeth signed by Staff III.

During an interview on 02/26/15 at 3:30 PM, Staff N stated that:
- Staff III did not respond when the application to renew his Medical Staff privileges was sent.
- She was not aware that a patient had been scheduled for surgery by Staff III since his privileges had expired.
- She did not remember being called by the surgery staff to check Staff III's privileges.
- When credentials expired a letter was sent to the practitioner and they no longer had privileges to practice at the facility.

During an interview on 02/26/15 at 5:00 PM, Staff PPP, President of the Board, stated that the board met monthly and received a lot of different data to review and approve. He stated that he was not aware that one of the medical staff was not privileged.



27727

Based on observations, interviews, record reviews and policy reviews, the facility failed to ensure that:
- Staff assessed and reassessed the potential for falls for two of two current patients and two of two discharged patients reviewed who had fallen. Three patients of the four sustained broken bones from the falls. (Refer to C-0294).
- Staff followed their policy for fall prevention assessment for two of two current patients and for two of two discharged patients who were at risk for falls. (Refer to C-0294).
- Staff developed and implemented a care plan to identify patients at risk for falls and to prevent further falls and injuries for two of two current patients and for two of two discharged patients. All four patients sustained injuries from falls while in the facility. (Refer to C-0294)
The facility census was 16, which included seven Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services.

The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 02/25/15, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients' health and safety.

As of 02/26/15, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Fall Prevention Program and Policy and Procedure was developed and implemented.
- All current inpatients within the facility had a Morse Fall Risk Assessment (a method of assessing a patients' likelihood of falling) completed and fall risk intervention implemented according to the Morse Fall Scale paper chart.
- Paper Care plans were initiated on each patient [for fall risk patients].
- The Marianjoy Fall Risk Assessment Tool (a method of assessing a patients' likelihood of falling) was removed from the electronic health record (EMR).
- Flagging system was implemented by utilizing a star attached outside the patient's door. Yellow for moderate risk and red for high risk [for falls].
-Physical Therapy completed a therapy screening on all current patients who were at high risk for falls.
- Pharmacy completed a medication review on current patients who were at high risk for falls. Recommendations were to be suggested to primary care physician, per procedure.
- Fall risk intervention forms were laminated and posted in patient care areas.
- Fall Prevention Program and Policy was developed and implemented to outline the nursing management of patients who are at risk for falling and initiate safety precautions for patients. Paper documentation was utilized until format can be built into current EMR.
- Nursing House Supervisors and Director of Nursing provided education to employees on the Morse Fall Scale, change in condition, stars, policy and procedure for Fall Prevention.
- Incident reports for each patient fall will be completed and transmitted to Risk Management for investigation.
-Every shift the DON or House Supervisor were responsible for monitoring compliance with alarm policy, including battery function.
- Every shift the DON or House Supervisor were responsible for confirming that each patient's assessment matches their star placement.
- Fall prevention policy was integrated into the hospital Quality Assurance and Performance Improvement program and will be reviewed by the Chief Executive Officer.
- DON or designated Nursing Supervisor will do daily monitoring to ensure compliance with these implementations and will continue to monitor to ensure continued compliance.




32280

Based on observation, interview and record review, the facility failed to ensure the integrity of the contents of three of three crash carts (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medications/equipment for life saving protocols) and two of two Obstetrical (OB) emergency kits. This had the potential to allow unauthorized persons to access medications in the crash carts and OB emergency kits. The facility census was 16.

Findings included:

1. Record review of the facility's policy titled, "Emergency Cart" dated 05/13/13, showed directives for the integrity of lock and lock number shall be checked and documented daily.

2. Observation on 02/24/15 at 10:45 AM in the Emergency Room showed a crash cart which was secured with a plastic key/lock. In an unlocked drawer of the nursing station was an opened package of approximately 50 plastic numbered keys/locks used for securing the crash cart.

During a concurrent interview, Staff JJJ, Registered Nurse (RN) stated that the package of key/locks were obtained from Central Supply. She stated that the package held approximately 100 keys/locks with identifying concurrent numbers on each but she did not know where the numbers began or ended. She stated that it could be possible for someone to remove a key/lock from the crash cart and remove medications and then replace the key/lock with one obtained from the unlocked drawer.

3. Observation on 02/23/15 at 1:55 PM of the Medical/Surgical unit crash cart showed the cart was secured with a plastic key/lock.

During an interview on 02/24/15 at 1:30 PM, Staff C, RN, House Supervisor, stated that the replacement keys/locks for the crash cart were located in the medication room. She stated that staff obtained replacement keys/locks from the medication room after the crash cart was opened.

Observation on 02/26/15 at 4:43 PM of the Medical/Surgical medication room showed an open plastic container with approximately 50 plastic keys/locks used to secure the crash cart in an unlocked cabinet.

4. Observation on 02/26/15 at 1:50 PM of the OB crash cart showed the cart was secured with a plastic key/lock.

During an interview on 02/26/15 at 1:50 PM, Staff UU, RN, Assistant OB Supervisor, stated that the plastic keys/locks for the crash cart and the two OB emergency kits were kept unlocked in the newborn nursery.

Observation on 02/26/15 at 2:00 PM showed the plastic keys/locks were located in the newborn nursery in a cardboard box in a plastic bag. The plastic bag contained 66
plastic keys/locks. The plastic keys/locks were left in open view and unsecured on a desk in the newborn nursery.

The unsecured plastic keys/locks had the potential to allow staff, patients, and visitors to tamper with the OB crash cart and the two OB emergency kits.


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32280

Based on observation, interview and policy review, the facility failed to ensure staff performed hand hygiene and changed gloves when indicated for three (#10, #13 and #18) out of four current patients observed during care and when dietary staff failed to perform hand hygiene or change gloves per facility policy. This had the potential to expose all patients, staff, volunteers and visitors to hospital acquired infections and communicable diseases. The facility census was 16.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene Plan," dated 05/2014 showed the following direction for staff: All personnel will use the handwashing techniques set forth in the following procedure after coming on duty, when hands are soiled and after each patient encounter.

2. Observation on 02/23/15 at 3:40 PM showed Staff T, Emergency Room (ER) Physician, entered Patient #18's room and did not perform hand hygiene. Staff T shook hands with the patient, lifted the head of the bed up, listened to his heart sounds by stethoscope and palpated his chest and abdomen. Staff T did not perform hand hygiene upon leaving the room.

During an interview on 02/23/15 at 3:55 PM Staff T stated that he did not perform hand hygiene because he forgot.

3. Observation on 02/24/15 at 9:30 AM showed Staff S, ER Physician, entered Patient #13's room and did not perform hand hygiene. Staff S proceeded to examine the patient by listening to her heart sounds by stethoscope and examine her ears by Otoscope (a medical device use to look into ears). Staff S did not perform hand hygiene upon leaving the room.

During an interview on 02/24/15 at 10:55 Staff S, stated that he forgot to do that (hand hygiene) because he was thinking about something else.

4. Observation on 02/24/15 at 9:55 AM showed:
- Staff I, Registered Nurse (RN) and Staff G, Certified Nursing Assistant (CNA) entered Patient #10's room to provide perineal care (peri care-washing of the genital and rectal areas of the body) and urinary catheter (a tube placed into the bladder to drain urine) care (to clean around the insertion site of the foley catheter).
- Both staff performed hand hygiene and put on non-sterile gloves.
- Staff I cleansed the patient's peri area and applied moisture barrier (ointment used to protect the skin from excessive moisture) to the patient's buttocks.
- Staff I removed her gloves and put on another pair of gloves without performing hand hygiene.
- Staff I removed the patient's soiled brief, performed catheter care and cleansed down the urinary catheter tubing.
- Staff I removed her left (L) glove and put another glove on her (L) hand without performing hand hygiene.
- Staff I applied Nystatin powder (medication used to treat fungal infections) to the patient's groin (crease of the inner part of each thigh).
- Staff I removed the (L) glove after she applied the powder to the patient's groin and put another glove on her (L) hand without performing hand hygiene.
- Staff I applied Nystatin powder under the patient's breast.
- Staff I wore the same pair of gloves, repositioned the patient in bed, clipped the call light to the patient's gown and repositioned the patient's head on the pillow.
- Staff I removed her gloves but did not perform hand hygiene, picked up the trash and left the patient's room.
- Staff G removed her gloves but did not perform hand hygiene before she left the patient's room.

During an interview on 02/24/15 at 10:30 AM, Staff I, RN, stated that staff are to foam in and out (going into patient rooms and when leaving) and when they remove gloves. Staff I stated that she did not perform hand hygiene after she removed her gloves and she should have.

5. Record review of the facility's policy titled, "Dietary Policy and Procedure," reviewed 02/17/15, showed directives for staff to perform hand hygiene after touching anything which was contaminated.

6. Observation on 02/25/15 at 11:25 AM showed Staff GG, Cook, wearing gloves opened a door to a lower cabinet; then left the kitchen dietary tray line and walked approximately 20 feet to the serving line in the dining room and dipped pureed food onto a plate and brought it back into the kitchen. She repeated this three times without changing her gloves or performing hand hygiene.

During an interview on 02/25/15 at 1:45 PM, Staff GG stated that she had never previously changed gloves or performed hand hygiene while performing these functions.

7. Observation on 02/25/15 at 11:45 AM showed Staff EE, Dietary Aide, placed food on the patient trays with gloved hands and placed the food in the movable dietary cart. When the cart was full on one side, she placed her gloved hands on the outside of the cart and turned it around to place trays on the second side. She did not change gloves and perform hand hygiene between handling the food and moving the cart.

During an interview on 02/25/15 at 1:55 PM Staff EE, stated that she wasn't aware that she needed to change gloves and perform hand hygiene after she moved the dietary cart.








27727

Based on observation, interview and record review, the facility failed to ensure foods were labeled with the common name, covered, dated when opened and removed after expiration. These deficient practices placed all patients at risk for unsanitary food service and cross contamination of food. The facility census was 16.

Findings included:

1. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code, Chapter 3-302.12 Food Storage showed direction for facility dietary staff to label foods with common name.

2. Observation on 02/25/15 at 11:55 AM in the kitchen cooler showed the following opened food containers that were not labeled with their name and dated when opened.
- Two cup cakes in an open box;
- A gallon jar of pickles;
- A gallon jar of salad dressing;
- A gallon jar of mustard; and
- A gallon jar of pickle relish.

Observation on 02/25/15 at 1:35 PM in the kitchen walk in freezer showed the following
food containers that were not covered or labeled with the date when opened or an expiration date:
- A tray of 40 frozen biscuits, which were uncovered with no date of when they were placed on the tray;
- A second tray of 36 frozen biscuits, which were uncovered with no date of when they were placed on the tray;
- An opened, plastic bag of two dozen frozen pancake bites with an expiration date of 08/14 but no date of when it was opened;
- An opened, plastic bag of frozen cooked bacon with an expiration date of 07/13 but, no date of when it was opened;
- An opened, plastic bag of six pancakes with an expiration date of 11/12 but no date of when it was opened; and
- An opened, plastic bag of French toast with an expiration date of 10/14 but no date of when it was opened.

During an interview on 02/25/15 at 11:40 AM, Staff FF, Dietary Manager, stated that all opened items should be identified as to the contents, covered with plastic wrap or tin foil and have the date the food was opened written on the package. He also stated that expired items should be thrown away.

Based on observations, interviews, record reviews and policy reviews, the facility failed to ensure that:
- Staff assessed and reassessed the potential for falls for two (#1 and #3) of two current patients and two (#15 and #16) of two discharged patients reviewed who had fallen. Three patients (#3, #15 and #16) of the four sustained broken bones from the falls.
- Staff followed their policy for fall prevention assessment for two (#1 and #3) of two current patients and for two (#15 and #16) of two discharged patients who were at risk for falls.
- Staff developed and implemented a care plan to identify patients at risk for falls and to prevent further falls and injuries for two (#1 and #3) of two current patients and for two (#15 and #16) of two discharged patients. All four patients sustained injuries from falls while in the facility. This had the potential to affect all patients admitted to the facility assessed at risk for falls to experience a fall and sustain an injury. The facility census was 16, which included seven Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

Findings included:

1. Record review of the facility's policy titled, "Admission of the Adult Patient Guide for Physical Assessment," revised 08/15/14, showed direction for staff to complete a physical assessment following a careful comprehensive or problem-related history.

Record review of the facility's policy titled, "Fall Prevention Assessment Policy," revised 05/06/13, showed the following:
- Promote patient safety.
- Identify patients at risk for falls.
- Implement a fall prevention plan of care for patients identified at risk for falls.
- Prevent further injury and/or falls.
- Analyze fall data for trends and patterns.
- Patients will be assessed by a Registered Nurse (RN) at the time of admission to determine their risk for falling by using the Morse Fall Risk Assessment Scale (a tool used to identify patients at risk for falls).
- A fall prevention reassessment is recommended in the event the patient's condition changes during the course of the hospital stay, after transfer to another unit, and/or every 24 hours.
- Stars (magnetic star shapes placed on patient doorways to indicate fall risk) will be color coded to match the Morse Fall Risk Assessment. (No risk for falling: blue; low risk for falling: yellow; and high risk for falling: red.)
- Document the measures to be implemented from the plan of care in the narrative areas on the daily nursing care record by each shift.
- If in the event a patient falls, staff to ensure patient safety and update the fall prevention assessment and fall prevention plan of care.

Record review of the facility's policy titled, "The Nursing Process-Care Planning Process," dated 05/2013, showed the following direction for staff:
- To provide each patient with an individualized plan of nursing care.
- To assist the nursing staff in determining priorities.
- To provide for effective communication among the nursing staff about the patient's care.
- All patients shall be assessed on admission, and a written plan of care developed and initiated within 24 hours of admission by an RN (Registered Nurse). The plan of care shall reflect those Standards of Care applicable to that individual.
- The plan of care reflects integration of information from various disciplines involved in care of the patient, provides for identification and prioritization of individualized patient needs, and serves as the basis for patient care decisions, based on identified needs and care prioritization.
- The patient's plan of care shall be reviewed and updated at least daily by an RN on the day shift. The plan of care may be reprioritized as needed on other shifts as a result of ongoing assessment and interdisciplinary rounds.
- Evaluate and revise the nursing plan of care as needed and adds problems/needs based on reassessment of the patient.

Record review of the facility document, "Marianjoy Fall Risk Assessment Tool" (a tool used to identify fall risk) showed questions that gave one point for a yes and zero points for no. The questions included:
- Communication deficits;
- Impaired cognition;
- Altered bowel/bladder elimination;
- Sensory deficits (deficits in hearing, sight or touch);
- History of falls in the past three months; and
- Impulsive behavior.

If the total score was four or more the patient was rated as high risk for falls. This scoring system was incorporated into the electronic medical record (EMR) and was used for fall risk assessments on each patient admitted to the facility.

2. Record review of the facility document titled, "Patient Fall Summary," showed the facility had 14 patient falls between 06/2014 and 02/2015. Three patients sustained broken bones and two of the three patients expired within four weeks of their fall.

During a telephone interview on 03/12/15 at 12:47 PM, Staff A, Director of Nursing (DON) stated that the facility's average monthly census was 10.95 patients.

3. Record review of Patient #3's History and Physical (H&P) dated 02/16/15, showed:
- The patient was 94 years old.
- She was admitted to acute care on 02/10/15 following a fall at her home.
- She had lower back pain, lower extremity (leg) swelling and weeping (fluid drainage from a wound) of her legs.
- She was discharged from acute care and admitted to the facility's Swing Bed program on 02/13/15 for continued physical therapy and occupational therapy for improvement in strength and ambulation.
- She was noted by staff to have increased periods of confusion on 02/15/15.
- She crawled out of bed falling onto her left shoulder which resulted in a humerous (top of the long bone in the upper arm) fracture on 02/15/15.
- The Orthopedist (doctor specializing in bones) was consulted but it was determined that the patient was not a surgical candidate.
- Plan: Apply a shoulder immobilizer and try to keep patient comfortable.
- She was at great risk for deterioration now from her increased immobility.

Review of the patient's Marianjoy Fall Risk showed a score of three for the assessment completed on 02/15/15 at 9:00 AM.

Record review of the patient's EMR showed no evidence of a care plan for falls after she experienced a fall on 02/15/15. The facility failed to follow their fall risk assessment policy and update the care plan after a fall had occurred.

Record review of the patient's Nurse's Notes showed Staff LL, Graduate Nurse (GN) documented:
- On 02/13/15 at 10:15 PM, the patient ambulated to the bathroom.
- On 02/14/15 at 2:50 AM, patient assisted to the bathroom in a wheelchair due to complaints of weakness and feeling dizzy.
- On 02/15/15 at 11:30 AM, the patient was confused and reoriented easily.
- On 02/15/15 at 3:00 PM, the patient was becoming more confused and reoriented easily.
- On 02/15/15 at 5:00 PM, the patient was confused and reoriented easily.
- On 02/15/15 at 7:30 PM, the patient tried to climb out of bed and assisted to the bedside commode (chair like toilet that can be positioned close to the bed for safety).
- On 02/15/15 at 7:40 PM, call light to patient's room on and nurse answered. As nurse entered room the roommate yelled for someone to help. The patient was found lying on the floor beside the bed with upper body leaning against a chair. The patient complained of left shoulder pain. The patient's bed alarm was in place on the bed (bed alarm is a fall prevention system, which consists of a battery pack and a sensor pad. The alarm sounds to alert the staff when the patient attempts to exit the bed.)

Record review of the patients' x-ray report dated 02/15/15 showed an acute left proximal humeral fracture (fracture at the top of the arm bone.)

During a telephone interview on 02/25/15 at 7:47 PM, Staff LL, GN stated that:
- She had cared for Patient #3 on 02/15/15.
- During morning assessment the patient was alert and oriented to person, place and time but as the day progressed she became increasingly confused and disoriented but was easily reoriented.
- Sometime later in the day she answered the call light for the patient's room and the patient was slightly confused and was trying to climb out of bed.
- The patient was not making any sense but did answer yes to the need to use the bathroom.
- Earlier in the day she ambulated to the bathroom but due to weakness a bedside commode was ordered.
- Staff LL went to shift report and stated to the next shift that she felt like a bed alarm was warranted.
- She retrieved a bed alarm from the supply room and stated that she verified the existing batteries were in place and functioning. She placed it on the patients' bed.
- Later she heard someone yell for help and found Patient #3 on the floor in her room.
- She stated that the bed alarm was not alarming when she entered the room.
- She had never heard of the Marianjoy Fall Risk Assessment but stated that patient rooms were to have magnetic stars on the outside of the doorway to indicate that the patient was a fall risk.
- She was unsure if the patient had been assessed as a fall risk prior to this event.

Observation on 02/23/15 of the patient's doorway showed no signs (magnetic star) or indication the patient was a fall risk.

During an interview on 02/23/15 at 3:10 PM, the patient's family stated that:
- The patient was admitted approximately two weeks ago after she had fallen at her home.
- Prior to this admission she had lived in her own home, alone, ambulated with a walker and was able to take care of her finances with minimal assistance.
- She climbed out of bed on 02/15/15 and fell onto the floor and broke her shoulder, which was now non-repairable.
- A urinary catheter (a tube placed in the bladder to drain and collect urine) was inserted because of her inability to get out of bed.
- She was placed on palliative (comfort) care with a goal to keep her pain free and comfortable.
- She was alert while awake and ate meals with assistance.

During an interview on 02/25/15 at 5:00 PM, Staff KK, Physician, stated that:
-He had cared for the patient for the past two years.
- Prior to this admission, the patient lived alone and was limited with her mobility but was able to do so with a walker and was also able to take care of her colostomy (a surgical opening into the intestines to remove stool from the body and collected in a bag attached to the abdomen) by herself.
- The patient was admitted to Swing Bed status on 02/13/15 for rehabilitation for lower back fractures from a previous fall at home.
- He felt the patient had a good chance for rehabilitation and possibly going back home or to an assisted living prior to the recent fall that resulted in the shoulder fracture but now he felt this would not occur.
- He was aware that the patient had attempted to get out of bed earlier on the day of the fall.
- He informed the patient that he "hoped she would not die from this injury but felt she may within a month."
- A day or two later palliative care was initiated.

During a telephone interview on 02/25/15 at 8:15 PM, Staff MM, RN, stated that:
-She had worked on the evening shift when Patient #3 fell.
- She had been informed during report by Staff LL that the patient had been a little confused throughout the day when she had usually been alert.
- The patient was a fall risk due to her confusion.
- The use of bed alarms was at the discretion of the nurse if they felt it was needed.
- When she retrieved a bed alarm, batteries were usually already in it and she would
test them to make sure they functioned.
- Patients were to have a magnetic "yellow star" on their doorway to indicate they were a fall risk.
- She had not received any education regarding falls or fall risk assessments since the patient had fallen.
- She was unaware that staff was to replace the existing batteries when a bed alarm was implemented.

During an interview on 02/25/15 at 12:48 PM, Staff A, RN, DON, stated that:
- The Marianjoy Fall Risk Assessment was implemented on 05/2014.
- She expected staff to replace batteries when they implemented a bed alarm.
- The nurse had retrieved the bed alarm for Patient #3 and checked it to see if the existing batteries were functioning. The nurse stated that they were but the alarm did not sound when the patient got out of bed.
- Education regarding the need to replace batteries when implementing bed alarms was given to nursing staff at a recent staff meeting.

Record review of Nursing Staff Meeting Agenda and minutes from the 02/20/15 meeting showed fall assessment was listed on the meeting agenda. The meeting minutes showed no follow through for fall assessment or any information that referred to the need to change batterys when implementing bed alarms.

Record review of Patient #3's medical record, obtained on 03/03/15 (after the survey exit), showed the patient had expired, date unknown.

The facility failed to assess her as a fall risk knowing she had fallen prior to admission. They failed to reassess the patient for fall risk when she had exhibited increased confusion and impulsive behavior during the day and failed to implement interventions to promote her safety and prevent a fall. The patient fell and sustained a non-repairable broken humerous.

4. Record review of Patient #1's medical record showed the following:
- The patient was admitted for acute care on 01/28/15 for weakness and status post aneurysm (a ballooning or weakened area in an artery) and developed pneumonia, diarrhea and confusion shortly after admission.
- He was discharged from acute care to the Swing Bed program on 02/05/15.
- Review of the Swing Bed nursing admission assessment dated 02/05/15 showed he was admitted with continuation of one assist with transfers and ambulation.
- He continued on oxygen due to hypoxemia (abnormally low level of oxygen in the blood).
- He had diarrhea for several days.
- He may have had a hypotensive (low blood pressure) event at some time.

Record review of the patient's nurse's notes dated 02/07/15 at 10:34 PM, showed staff documented:
- The patient was found seated on the floor in front of the toilet.
- The patient stated that he had fallen to the floor on his knees.
- Bed alarm was placed on bed following the fall.

Record review of the patient's Marianjoy Fall Risk Assessment Tool dated from 02/05/15 to 02/08/15 showed staff assessed and documented the patient scored a three which included the time frame when he experienced a fall (02/07/15.)

Record review of the Marionjoy Fall Risk Assessment Tool from 02/09/15 to 02/24/15 showed the following:
- Impaired cognition - Yes
- Sensory deficit - Yes
- History of previous fall in the past three months - Yes
- High Risk for Fall - Yes

Record review of the patient's EMR showed no evidence of a care plan for falls.

Observation on 02/23/15 at 3:20 PM, of Patient #1's doorway showed no signs or indication the patient was a fall risk. A magnetic star should have been on the doorway to indicate fall risk per fall risk assessment policy.

During an interview on 02/23/15 at 3:20 PM, the patient's family stated that:
- The patient was admitted a few weeks ago following an aneurysm repair and pneumonia.
- The patient has been very weak.
- The patient fell (during this admission) hurting his knees either while getting out of bed or while he was in the bathroom, they weren't exactly sure.

The facility failed to assess the potential for fall risk per his diagnosis of hypoxemia, hypotensive event, diarrhea and generalized weakness. On 02/09/15 staff assessed him as a fall risk due to impaired cognition, sensory deficit, history of falls and a fall risk score of four (a high risk for falls.) The facility failed to follow their fall risk assessment policy and initiate a care plan after a fall had occurred (on 02/07/15.)

5. Record review of discharged Patient #15's Progress Note dated 06/09/14 showed:
- The patient was 84 years old and admitted with acute exacerbation (worsening or increased severity of a disease and or its symptoms) of chronic bronchitis (inflammation of the lining of bronchial tubes that carry air to and from the lungs).
- History of chronic obstructive pulmonary disease (COPD,a progressive disease that makes it hard to breathe) and dementia (a decline in the mental ability severe enough to interfere with daily life).
- Admitted to Swing Bed program on 06/09/14 for continued antibiotics, physical and occupational therapy.
- The patient was generally weak with increased complaints of chronic back pain.
- The patient continued to be treated for pneumonia and urinary tract infection (UTI.)
- The patient fell on 06/19/14 into the end of her roommate's bed and as a result of the fall sustained rib fractures and a large hematoma (a localized swelling filled with blood).
- She showed improvement in her general condition with good pain control from the chronic back pain prior to her fall.
- She was discharged back to the nursing home on 07/03/14 in stable condition with a poor prognosis.

Record review of the patient's Nurse's Notes showed Staff MMM, Licensed Practical Nurse (LPN) documented on 06/19/14 at 2:15 AM, the patient fell while ambulating to the bathroom.

During a telephone interview on 03/03/15 at 8:20 AM, Staff MMM, LPN, stated that:
- She assisted the patient to the bathroom on the night shift on 06/19/14.
- The patient used a walker but was impatient and she did not have time to put a gait belt (a device used to transfer people from one position to another or while ambulating people that have problems with balance) on the patient.
- The patient had on silky pajamas and she had a hold of the back of her shirt.
- The patient lost her balance and fell away from staff and fell into the end of the patient's roommate's bed.
- She could not remember if the patient was a fall risk or not.
- She was unaware if there was any signage or other visual cues to identify a patient as a fall risk.

Record review of the Patient #15's x-ray report dated 06/19/14 showed acute left seventh and eighth posterior (back) rib fractures.

Record review of the patient's Marianjoy Fall Risk Assessment showed a score of six (score four or above indicates high fall risk) for 06/09/14 and then no score documented until 06/28/14. Item Detail for the Marianjoy Fall Risk Assessment Tool, in the EMR, showed the interventions for frequency of this assessment had been changed from every shift to once (one time).

During an interview on 02/26/15 at 2:00 PM, Staff PP, RN, verified the patient's Marianjoy Fall Risk Assessment was missing for the dates from 06/10/14 to 06/27/14. Staff PP stated that if the frequency was changed to once, then the fall risk assessment would not have been viewable for staff to document.

During a telephone interview on 03/02/15 at 8:10 AM, Staff LLL, RN, stated that:
- He was the nurse assigned to care for the patient on the night of 06/19/14.
- He did not see the patient fall.
- He was unaware of what the Marianjoy Fall Risk Assessment scores meant and he would need to look at the policy and procedures to find the answer.
- The lower the number (score) given the higher the risk fall (actually the higher the score means the patient is at increased risk for falls).

During a telephone interview on 03/02/15 at 3:50 PM, Staff KKK, Physician stated that:
- The patient had frequent bouts of exacerbations of COPD that required hospitalizations.
- The patient was "bad" about not calling for assistance and that frequently got out of bed by herself.
- Prior to her fall on 06/19/14 the plan for the patient was to be discharged back to the nursing home.
- He was "pretty sure" the nurse that assisted the patient to the bathroom when she fell had not followed protocol when staff did not use a gait belt.
- The fall definitely threw a "monkey wrench" in her recovery.

Record review of the patient's EMR showed no evidence of a care plan for falls that included goals or interventions after staff assessed her as a fall risk and after she experienced a fall on 06/19/14. The facility failed to follow their fall risk assessment policy and initiate a fall care plan after patient fell and sustained broken ribs.

Record review of the patient's Discharge Summary dated 07/18/14 showed:
- The patient had been discharged back to the nursing home on 07/03/14 in stable condition but with a poor diagnosis.
- The patient developed a fever and was readmitted to the facility on 07/07/14 with pneumonia and sepsis (a life threatening complication of an infection) and exacerbation of her COPD.
- The patient expired on 07/13/14.

6. Record review of discharged Patient #16's H&P dated 06/19/14 showed:
- The patient was admitted to the Swing Bed program on 06/17/14 for skilled nursing and strengthening.
- The patient had a history of sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).
- The patient had a history of dementia, pneumonia and acute respiratory failure.

Record review of the patient's Marianjoy Fall Risk Assessment Tool showed no documented score from 06/18/14 to 06/27/14.

During an interview on 02/26/15 at 3:30 PM, Staff OO, Informatics Supervisor, verified the patient did not have a Marianjoy Fall Risk Assessment documented by staff from 06/18/14 to 06/27/14.

Record review of the patient's Nurse's Notes dated 06/19/14 showed Staff OOO, RN, documented:
- The patient was found seated on the toilet with his home continuous positive air pressure (CPAP) mask (used for sleep apnea patients) still in place with visible blood on the mask.
- The patient had blood on his face.
- The patient stated to the nurse that he had lost his balance and fell face first toward the shower while walking to the bathroom.

Record review of Patient #16's x-ray report dated 06/24/14 showed right seventh and eighth rib fractures.

Record review of the patient's EMR showed no evidence of a care plan for falls after he experienced a fall on 06/19/14. The facility failed to follow their fall risk assessment policy and initiate a care plan after a fall had occurred.

Staff did not assess and document a daily Marianjoy fall risk assessment for 06/18/14 to 06/27/14, per their policy, during the time in which the patient had a fall and sustained broken bones (on 06/19/14.) Staff did not identify through assessment to care plan for the potential for falls and did not implement any interventions to prevent a fall.

7. During an interview on 02/24/15 at 10:00 AM, Staff H, LPN, stated that:
- Patients at high risk for falls will have a bed alarm.
- A patient that scores a four or more will have a bed alarm and be as close to the nurses' station as possible.
- Staff received information about patients during bedside report and if a patient is at risk for falls an "orange sticker" is placed on the front of the medical record to alert staff a patient was at risk for falling.
- The patient will also have a "star" placed on the outside of the door when assessed at risk for falls.
- She would expect to either see a sticker on the patient's medical record and/or a star on the door if the patient has been assessed at risk for falls.
- Patient #3 was not at risk for falls now because she was unable to get out of bed.
- She did not know if a "yellow star" was different from a "red star."
Staff confirmed that none of the current patients medical records had an "orange sticker" on them to alert staff the patient was at risk for falls. Out of 16 current patients staff identified eight patients as fall risks.

During an interview on 02/24/15 at 1:00 PM, Staff A, RN, DON, stated that she expected staff to place a "star" on the patient's door after staff assessed the patient at risk for falls. Staff A stated that she would expect to see a care plan for the patient, especially after the patient had a change in condition. Staff A stated that yesterday (02/23/15) some patients' door frames did not have "stars" posted on them.

During an interview on 02/24/15 at 2:00 PM, Staff BB, Clinical EMR Specialist (CEMRS), stated that the facility did not have a care plan option for falls in the EMR system.

During an interview on 02/25/15 at 10:45 AM, Staff L, RN, Risk Manager, stated that in January 2015 she discovered the facility's EMR did not have an option listed for falls included in the problem list under care plans. Staff L stated that she talked to Staff A, RN, DON when she discovered (01/2015) that the EMR did not include falls in the problem list for care plans.

During an interview on 02/25/15 at 12:48 PM, Staff A, RN, DON stated that she did not initiate a "paper" care plan when she learned the EMR did not have an option listed for falls in the care plan section. Staff A stated that she did not think of having staff do a "paper" care plan for falls because she was focused on fixing the EMR.

During an interview on 02/25/15 at 9:35 AM, Staff CC, RN, stated that:
- When a patient gets a score from the fall assessment she did not know what fall interventions go with the fall assessment score.
- She did not know what the different "star" colors for falls meant.
- She did not know what the facility's policy and procedure was for falls or the interventions needed for different fall risk scores.

During an interview on 02/25/15 at 9:43 AM, Staff DD, RN, stated that:
- She did not know what interventions go with the fall risk score.
- She was not sure what the facility's policy and procedure said about falls.
- A high risk for falls did not mean the patient needed a bed alarm.
- A patient would need a care plan for falls when:
- The patient was assessed at high risk.
- The patient had a history of falls before admission.
- The patient had a diagnosis of syncope (fainting), changes in mental status and/or ambulatory status.

During an interview on 02/25/15 at 2:10 PM, Staff DD, RN, stated that:
- The facility had not done any re-education or in-service related to falls this month (02/2015).
- She received yearly re-education about falls in the fall.
- A nurse can make the decision if a patient needed a bed alarm or the physician can order one.
- The bed alarm needed a new battery when initiated.
- Staff are to check the bed alarm to make sure it worked.

During an interview on 02/25/15 at 2:20 PM, Staff SS, RN stated that:
- If a patient scored either a three or four (on fall assessment), she would initiate a bed alarm.
- She is not familiar with the entire facility's policy and procedure for falls.
- She has not received any additional re-education or in-service this month (02/2015) related to falls.
- A "red star" meant the patient was at high risk for falls and a "yellow star" meant the patient was at moderate risk for falls.
- The batteries are already in the bed alarm box and will alarm with a different sound to alert staff the battery needed to be changed.

During an interview on 02/25/15 at 2:40 PM, Staff TT, CNA, stated that:
- She has not received any in-service or re-education this month (02/2015) related to falls.
- Some of the bed alarms already had batteries in them and staff are to check to make sure the alarm worked.
- The bed alarm battery did not have to be changed after use, when moving a patient if the bed alarm did not sound staff would need to check to see if the battery needed to be changed or the bed alarm pad, the batteries are not removed after patient use and are used until they needed to be changed.
The expectation by Staff A, RN, DON, was for staff to insert new batteries each time a bed alarm was initiated by staff.

After four patient injuries from falls, the facility failed to educate staff on the Fall Prevention Assessment Policy to promote patient safety, identify patients at risk for falls and implement a fall prevention plan of care for patients identified as fall risks.








18018

Based on interview, record review and policy review, the facility failed to follow their Care Plan policy when staff failed to incorporate a nursing care plan based on patient assessment that addressed all patient needs that included measurable goals, interventions, and time tables for four (#1, #3, #10 and #17) of four current patients and for two (#15 and #16) of two discharged patients reviewed for nursing care plans. This failed practice had the potential to affect all patients admitted to the facility by not meeting individual needs identified from assessments. The facility census was 16 that included seven Swing Bed (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) patients.

Findings included:

1. Record review of the facility's policy titled, "The Nursing Process-Care Planning Process," dated 05/2013, showed the following direction for staff:
- To provide each patient with an individualized plan of nursing care.
- To assist the nursing staff in determining priorities.
- To provide for effective communication among the nursing staff about the patient's care.
- To assess all patients on admission, and a written plan of care developed and initiated within 24 hours of admission by an RN (Registered Nurse). The plan of care shall reflect those Standards of Care applicable to that individual.
- To ensure the plan of care reflects integration of information from various disciplines involved in care of the patient, provides for identification and prioritization of individualized patient needs, and serves as the basis for patient care decisions, based on identified needs and care prioritization.
- To ensure the patient's plan of care shall be reviewed and updated at least daily by an RN on the day shift. The plan of care may be reprioritized as needed on other shifts as a result of ongoing assessment and interdisciplinary rounds.
- To evaluate and revise the nursing plan of care as needed and add problems/needs based on reassessment of the patient.
- Ensure nursing interventions include actions or a series of actions performed by the nurse and the client to prevent illness (or its complications) and promote, maintain, or restore health.

Record review of the facility's policy titled, "Fall Prevention Assessment Policy," dated 05/2013 directed the following direction for staff:
- To promote patient safety by:
- Identifying patients at risk for falls.
- Implementing a fall prevention plan of care for patients identified as at risk for falls.
- To prevent further injury and/or falls by:
- Effectively managing patient who fall.
- Analyzing fall data for trends and patterns.
- Educating patients and families on measures to prevent falls and promote safety.
- Patients will be assessed by a Registered Nurse (RN) at the time of admission to determine their risk for falling by using the Morse Fall Risk Assessment (tool used to identify patients at risk for falling).
- A fall prevention reassessment is recommended in the event the patient's condition changes during the course of the hospital stay, after transfer to another unit, and/or every 24 hours.
- An individualized fall prevention fall plan will be developed for each patient assessed as a fall risk. The plan of care will be implemented by the registered nurse utilizing appropriate safety measures.
- Stars (magnetic star shapes placed on patient doorways to indicate fall risk) will be color coded to match the Morse Fall Risk Assessment. (No risk for falling: blue star; low risk for falling: yellow; and high risk for falling: red.)

2. Record review on 02/24/15 at 1:45 PM showed the following information in Patient #1's medical record:
- The patient was admitted to the facility on 01/28/15 for weakness and status post aneurysm and developed pneumonia, diarrhea and confusion shortly after admission.
- Staff documented on the Marianjoy Fall Risk Assessment Tool (a tool used to identify fall risk) from 02/09/15 to 02/24/15 the following:
- Impaired cognition - Yes
- Sensory deficit - Yes
- History of previous fall in the past three months - Yes
- High Risk for Fall - Yes

Observation on 02/23/15 at 3:10 PM of Patient #1's doorway showed no sign (star) or indication that patient was a fall risk. A sign was above the patient's bed that indicated patient was to have nectar thick liquids.

The patient's care plan did not include a fall care plan even though staff assessed that he had impaired cognition, sensory deficit, history of falls, a fall risk score of four and above was assessed at a high risk for falls and the patient had experienced a fall within the facility since his admission. The care plan also failed to address the patient's need for nectar thickened liquids.

During an interview on 02/23/15 at 3:20 PM Patient #1's family stated that:
- Patient was admitted a few weeks ago following an aneurysm (a ballooning or weakened area in an artery) repair and pneumonia.
- Patient has been very weak;
- Patient fell (during this admission) hurting his knees either while getting out of bed or while he was in the bathroom they weren't exactly sure.

3. Record review of Patient #3's medical record showed:
- The patient was admitted on 02/10/15 following a fall at the patient's home.
- The Marianjoy Fall Risk Assessment Tool dated 02/05/15 showed a score of three (a score of four or more indicates fall risk).
- The Marianjoy Fall Risk Assessment Tool dated 02/15/15 at 9:00 PM showed a score of five (following a fall in her room).

Observation on 02/23/15 of Patient #3's doorway and inside the room showed no sign (star) or indication the staff assessed the patient as a fall risk.

During an interview on 02/23/15 at 3:10 PM, Patient #3's family stated that the patient had fallen at home prior to admission and had fallen once since admission that resulted in a non-repairable broken shoulder.

The patient's care plan did not address falls even though staff had assessed that she was a five on the fall risk assessment tool and that she fell on 02/15/15.

4. Record review of Patient #10's medical record showed:
- The patient was admitted to the facility on 02/21/15 with complaints of acute mental status changes and hypothermia (a low body temperature below 95 degrees Fahrenheit)
- Staff documented on the Marianjoy Fall Risk Assessment Tool from 02/21/15 to 02/24/15 the following:
- Communication deficit-Yes;
- Impaired cognition-Yes;
- Altered bowel/bladder elimination-Yes;
- Sensory deficits-Yes;
- History of previous fall in past three months-No (staff documented no on 02/21/15 and 02/22/15) Yes (staff documented yes on 02/22/15, 02/23/15 and 02/24/14).
- Impulsive behavior-Yes;
- Special medications, for example, anitpsychotics-Yes;
- Fall Risk Total Score- six and seven; and
- High Risk for Fall-Yes.
The patient's care plan did not include a fall care plan even though staff assessed that she had communication deficit, impaired cognition, altered bowel/bladder elimination, sensory deficits, history of fall, impulsive behavior, special medications, fall risk score of six/seven and high risk for fall.

During an interview on 02/24/15 at 2:35 PM, Staff BB, RN, Clinical EMR (electronic medical record) Specialist (CEMRS), stated that Patient #10's EMR did not have a fall care plan because the EMR system did not have falls listed as an option in the care plan section.

5. Record review of Patient #17's medical record:
- The patient was admitted to the facility on 02/22/15 with complaints of dehydration (lack of sufficient water and fluids), confusion, and fall.
- Staff documented on the Marianjoy Fall Risk Assessment Tool from 02/22/15 to 02/24/15 the following:
- Impaired cognition-Yes;
- Sensory deficit-Yes;
- History of previous fall in the past three months-Yes;
- Fall risk total score- four; and
- High Risk for Fall-Yes.
- The patient's care plan did not address falls even though staff assessed that she had impaired cognition, sensory deficit, history of falls, a fall risk score of four and was assessed at high risk for falls.

Observation on 02/24/15 at 12:50 PM showed that Patient #17's medical record did not have an "orange" sticker on it to alert staff she was at risk for falls. The patient's door frame had a "red star" posted on it (a red star was not on the door frame the afternoon of 02/23/15).

During an interview on 02/24/15 at 2:00 PM, Staff BB, RN, CEMRS, stated that Patient #17's EMR did not have a care plan for falls. Staff BB stated that the facility did not have a care plan option for falls in the EMR system.

6. Record review of discharged Patient #15's medical record showed:
- The patient was admitted to the facility on 06/05/14 for acute exacerbation of chronic bronchitis (worsening or increase in severity of the inflammation of the lining of bronchial tubes that carry air to and from the lungs). This makes her short of breath easily.
- Staff documented on the Marianjoy Fall Risk Assessment Tool from 06/05/14 to 06/09/14 a score of six (which indicated fall risk). No documentation for this assessment from 06/10/14 through 06/27/14 was found. The patient had a fall on 06/19/14 that resulted in fractured ribs.

The patient's medical record did not include a fall care plan to help prevent the potential for any additional falls.

7. Record review of discharged Patient #16's medical record showed:
- The patient was admitted to the facility on 06/12/14 for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly starts and stops). He also had a history of dementia, recent respiratory failure and pneumonia.
- Staff documented on the Marianjoy Fall Risk Assessment Tool from 06/05/14 through 06/09/14 scores ranging from five to seven (which indicated fall risk). No documentation for this assessment from 06/10/14 through 06/27/14 was found. The patient had a fall on 06/19/14 that resulted in fractured ribs.
The medical record did not include a fall care plan to help prevent the potential for any additional falls.

During an interview on 02/24/15 at 9:45 AM, Staff G, Certified Nursing Assistant (CNA) stated that nursing staff reports to CNAs what patients are fall risk. Staff G stated that she did not know how the facility identified patients at risk for falls. Staff G stated that she did not know the facility's policy and procedure for falls.

During an interview on 02/24/15 at 10:00 AM, Staff H, Licensed Practical Nurse (LPN) stated that:
- Patients at high risk for falls (scores a four or more) will have a bed alarm (a fall prevention system, which consists of a battery pack and a sensor pad. The alarm sounds to alert the staff when the patient attempts to exit the bed) and be as close to the nurses' station as possible.
- The patient will also have a "star" placed on the outside of the door when assessed at risk for falls.
- Staff received information about patients during bedside report and if a patient is at risk for falls an "orange" sticker is placed on the outside of the medical record to alert staff they are a fall risk.
- She would expect to either see a sticker on the patient's medical record and/or a star on the door if the patient has been assessed at risk for falls.
- Patient #3 was not at risk for falls now because she was unable to get out of bed.
- She did not know if a "yellow star" was different from a "red star".
- Staff H confirmed that none of the current inpatients' medical records had "orange" stickers on them to alert staff the patient was at risk for falls.

During an interview on 02/24/15 at 1:00 PM, Staff A, RN, Director of Nursing (DON) stated that she expected staff to place a star on the patient's door after the patient had been assessed at risk for falls. Staff A stated that she would expect to see a care plan for the patient, especially after the patient had a change in condition. Staff A stated that yesterday (02/23/15) some patients' door frames did not have "stars" posted on them.

During an interview on 02/24/15 at 1:45 PM, Staff F, RN, stated that she would expect a patient that had incurred a fall while at the facility would have a care plan for falls. She stated that the system (EMR) does not give the option for potential for fall risk.

During an interview on 02/25/15 at 9:43 AM, Staff DD, RN, stated that:
- She did not know what interventions go with the fall risk score.
- She was not sure what the facility's policy and procedure said about falls.
- A high risk for falls did not mean the patient needed a bed alarm.
- A patient would need a care plan for falls when:
- The patient was assessed at high risk.
- The patient had a history of falls before admission.
- The patient had a diagnosis of syncope (fainting), changes in mental status and/or ambulatory status.

During an interview on 02/25/15 at 10:45 AM, Staff L, RN, Risk Manager, stated that in January 2015 she discovered the facility's EMR did not have an option listed for falls included in the problem list under care plans. Staff L stated that she talked to Staff A, RN, DON when she discovered (01/2015) that the EMR did not include falls in the problem list for care plans.

During an interview on 02/25/15 at 12:48 PM, Staff A, RN, DON stated that she did not initiate a "paper" care plan when she learned the EMR did not have an option listed for falls in the care plan section. Staff A stated that she did not think of having staff do a "paper" care plan for falls because she was focused on fixing the EMR.

During an interview on 02/25/15 at 2:10 PM, Staff DD, RN, stated that:
- The facility had not done any re-education or in-service related to falls this month (2/2015).
- She received yearly re-education about falls in the fall.
- A nurse can make the decision if a patient needed a bed alarm or the physician can order one.

During an interview on 02/25/15 at 2:20 PM, Staff SS, RN, stated that:
- If a patient scored either a three or four she would initiate a bed alarm.
- She is not familiar with the entire policy and procedures for falls for the facility.
- She has not received any additional re-education or in-service this month (02/2015) related to falls.
- A "red star" meant the patient was at high risk for falls and a "yellow star" meant the patient was at moderate risk for falls.

During an interview on 02/25/15 at 2:40 PM, Staff TT, CNA stated that she had not received any in-service or re-education this month (02/2015) related to falls.






32280

Based on observation, interview and policy review, the facility failed to ensure staff logged off their COW (Computer on Wheels) before they left the workstation and positioned the computer screen so it was not in view of unauthorized individuals. This deficient practice had the potential to allow unauthorized individuals to view patients' confidential and sensitive information and impacted all that seek care at the facility. The facility census was 16.

Findings included:

1. Record review of the facility's policy titled, "Workstation Security Policy," dated 12/01/11, showed the following direction for staff:
- Workstations will be positioned such that the monitor screens and keyboards are not within view of unauthorized individuals.
- Users will log off prior to leaving their workstations.
- Workstations must ensure the confidentiality of sensitive information.

2. Observation on 02/25/15 at 2:30 PM showed a COW located behind the nurses' station on the Medical/Surgical Unit. The computer screen faced the hallway with several patients' information visible to all that walked by the nurses' station. The surveyor, standing in the hallway by the nurses' station could read from the computer screen several patients' name, sex, age and code status that was visible and easy to read from the hallway.

During an interview on 02/25/15 at 2:35 PM, Staff SS, Registered Nurse (RN), stated that the COW screen was facing the hall with patient information visible to all that passed by the nurses' station. Staff SS turned the computer off and stated that she did not know who was using the computer.

3. Observation on 02/26/15 at 6:05 PM showed a COW behind the nurses' station on the Medical/Surgical Unit. The computer screen faced the hallway and 12 patients' names were listed with information visible to all that walked by the nurses' station. The surveyor, standing in the hallway by the nurses' station could read from the computer screen the 12 patients' names, ages, sex, room numbers, next interventions (bladder scan as ordered, patient rounds, nothing by mouth, vital signs, Fall Risk Assessment ect.) and next meds (a list of medications was listed by each patient).

During an interview on 02/26/15 at 6:05 PM, Staff SS stated that the computer screen faced the hallway with visible patient information both yesterday (02/25/15) and today. Staff SS stated that staff are educated to have the computer screen locked when not in use. Staff SS stated that the computer screen should not be visible to the hallway. Staff SS stated that she did not know what staff had used the COW.

During an interview on 02/26/15 at 6:10 PM, Staff YY, Licensed Practical Nurse (LPN), stated that the COW facing the hallway with patient information visible was her computer. Staff YY stated that staff were to log off when finished with the computer. Staff YY stated that she did not log off when she left the computer to answer a call light because she did not want to lose information she had entered.

Based on policy review, interview and record review the facility failed to ensure Surgical Services were performed in a safe manner in accordance with applicable regulations and guidelines governing surgical services by:
- Failure to ensure current standard of practice for patient safety in Surgical Services for a current History and Physical (H&P) prior to surgery for five patients (#20, #21, #22, #25 ,#26) of seven patient records reviewed;
- Failure to ensure current policies and scope of services for surgical services;
- Failure to specify surgical privileges for each practitioner that performed surgical tasks including surgical assistants for four (J, K, NNN, OOO) of four surgical assistants (refer to C-0321); and
-Failure to ensure physicians performing surgical procedures were a current member of the medical staff for one (III) of 11 medical staff credentials reviewed (refer to C-0321).

The severity and cumulative effect of these deficient practices resulted in the facility's overall non-compliance with the requirements found at CFR 485.639 Condition of Participation: Surgical Services.

The facility performs an average of 37 surgical cases per month and 445 annually. These deficient practices put all patients receiving surgical care at the facility at risk for care in an unsafe environment. The facility census was 16.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," dated 02/27/14, showed an H&P examination which is completed no more than 30 days before admission may be utilized provided that the patient is reassessed and an update note is written, signed and dated to reflect the patient's status within 7 days prior to, or within 24 hours after admission. In the case of surgery or a procedure requiring anesthesia services, the update must be prior to the surgery or procedure.

2. Record review of the medical record for discharged Patient #20 showed a surgical H&P dated 01/29/15 at 2:35 PM. The patient had a surgical procedure on 02/12/15, which started at 8:24 AM. There was no update to the surgical H&P prior to the surgical procedure.

3. Record review of the medical record for discharged Patient #21 showed a surgical H&P dated 12/02/14 and a hand written update 02/03/15 at 9:00 AM. The patient had a surgical procedure on 02/03/15, which started at 8:24 AM. The update to the surgical H&P was performed after the surgical procedure ended.

4. Record review of the medical record for discharged Patient #22 showed a surgical H&P dated 02/02/15 at 10:17 AM. The patient had a surgical procedure on 02/16/15, which started at 11:44 AM. There was no update to the surgical H&P prior to the surgical procedure.

5. Record review of the medical record for discharged Patient #25 showed a surgical consent signed by the patient's mother and witnessed by the surgeon on 02/04/15 at 5:00 PM and the patient had an emergent (calling for prompt or urgent action) surgical procedure, which started at 6:45 PM. The surgical H&P was dated 02/04/15 at 7:51 PM, after the surgical procedure ended.

6. Record review of the medical record for discharged Patient #26 showed a surgical H&P dated 02/23/15 at 10:09 AM. The patient had a surgical procedure on 02/23/15, which started at 8:12 AM. The surgical H&P was performed after the surgical procedure ended.

During an interview on 02/24/15 at 2:40 PM, Staff K, Registered Nurse (RN), Surgical Services Supervisor, stated that an H&P had to be done within 30 days of the surgical procedure and be current within 24 hours. She stated that if the written H&P was more than 24 hours old it had to be updated by the surgeon prior to the patient being taken to the Operating Room (OR).

7. Record review of the Surgical Services Policies showed no written scope of services and no policies for conduct of surgical services related to the following:
- Identification of Infected and not-infected cases;
- Patient consents and releases; and
- Patient identification processes.

During an interview and concurrent review of Surgical Services policies on 02/26/15 at 10:30 AM, Staff K stated that there was no written Scope of Services for the Surgical Services Department and she did not have written policies for identification of infected and non-infected surgical cases, patient consents or patient identification processes.

32281

Based on interview and record review the facility failed to perform a written assessment of the practitioner's training, experience, health status and performance and to specify the surgical privileges for practitioners that performed surgical tasks including surgical assistants (non-physician assistant provides aid in exposure, hemostasis [stop bleeding], closure [surgical closing of a wound], and other intraoperative [during operation] technical functions to assist the surgeon) for two employed staff (J, K) and two non-employed Surgical Assistants (NNN, OOO) of four surgical assistants reviewed; and failed to ensure current medical staff privileging prior to surgery for one Surgeon (III) of five surgical credentials review. These deficient practices had the potential to adversely affect the safety and quality of care provided to patients who received surgical care. The facility performed an average of 37 surgical procedures per month. The facility census was 16.

Findings included:

1. Record review of the facility's "Medical Staff By-laws," dated 02/27/14 showed no medical staff category for privileging of surgical assistants that were not certified Physician Assistants (PA) or Advanced Practice Nurses (APN).

2. Record review of the facility's privileging files showed no current files for surgical assistants.

3. Record review of the facility's personnel files for Staff J, Registered Nurse (RN) and Staff K, RN, showed no written assessment of the staff's training and experience or privileges granted to perform as surgical assistants. There was no personnel file for Staff NNN, RN, and Staff OOO, Licensed Practical Nurse (LPN), non-employed surgical assistants.

4. Record review of the Surgical Services surgical privileges roster did not show privileges for surgical assistants.

Record review of the Surgery Roster for 01/22/15-02/23/15 showed the following:
- 24 surgical cases were performed.
- Non-physician surgical assistants were utilized for 21 of the 24 surgical cases.
- Staff J assisted on one case;
- Staff K assisted on five cases;
- Staff OOO assisted on six cases; and
- Staff NNN assisted on 10 cases.

During an interview on 02/23/15 at 2:30 AM, Staff K, RN, Operating Room (OR) Supervisor, stated that:
- The facility utilized surgical first assistants to assist the surgeons during cases.
- The facility employed two staff that could function in the surgical assistant role; her and Staff J.
- Some of the surgeons employed first assistants through their clinics.
- To her knowledge the facility did not have a process for privileging of surgical assistants.
- She did not have any files for surgical assistants.
- She did not know who had training, competency and health records for non-employed surgical assistants.

During an interview on 02/24/15 at 9:45 AM, Staff N, Manager of HIM, stated that:
- She had been responsible for the credentialing and privileging files until recently.
- The facility did not have files for surgical assistants.
- Human Resources would maintain personnel files for employed staff.
- She did not know who had assessment, training and health files for non-employed surgical assistants.

During an interview on 02/26/15, Staff FFF, Doctor of Medicine (MD) Orthopedic Surgeon, (a branch of medicine that tries to prevent and correct problems that affect bones and muscles), stated that to her knowledge she had not been asked for training, competency or health files for the surgical assistants she employed through her clinic.

5. During concurrent record review and interview on 02/26/15 at 10:30 AM, the Operating Room (OR) Register showed Staff III had performed teeth abstraction (removal) of eight teeth, on 04/23/14. Staff K, OR Manager, stated that she remembered she had checked the OR privileges roster for Staff III which showed they were expired and she had called Staff N, HIM manager to verify that Staff III had current privileges to perform the operation.

6. Medical record review of the Operative Note for discharged Patient #19 showed an operative note dated 04/23/14 for removal of remaining natural teeth signed by Staff III.

During an interview on 02/26/15 at 3:30 PM, Staff N stated that:
- Staff III did not respond when the application to renew his Medical Staff privileges was sent.
- She did not catch that a patient had been scheduled for surgery by Staff III.
- She did not remember being called by the surgery staff to check Staff III's privileges.
- When credentials expired a letter was sent to the practitioner and they no longer had privileges to practice at the facility.

7. During an interview on 02/26/15 at 5:00 PM, Staff PPP, President of the Board, stated that the board met monthly and received a lot of different data to review and approve. He stated that he was not aware that one of the medical staff was not privileged.

Based on interview, record review and policy review the facility failed to specify in the statement of privileges for each category of operating practitioner the type and complexity of procedures they may supervise for the Certified Registered Nurse Anesthetist (CRNA) administering anesthesia. This deficient practice failed to ensure anesthesia care was monitored by qualified medical staff and failed to ensure a safe environment for all patients presenting to the facility for surgical care. The facility performed an average of 37 surgical procedures per month. The facility census was 16.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," dated 02/27/14, showed the following:
- The Board, upon the recommendations of the Executive Committee, shall approve the specific privileges for each CRNA, addressing the type of supervision required.
-When a CRNA administers anesthesia, the CRNA shall be under the supervision of the physician, dentist or podiatrist performing the procedure.
-All applications for appointment and reappointment submitted shall contain a statement specifically identifying the clinical privileges requested by the applicant and shall provide documentation of the applicant's education, training, experience and competency to perform the requested privileges.
-The Medical Staff Bylaws did not stipulate limitations to medical staff categories to supervise the administration of anesthesia by the CRNA or the specific privileges required to supervise the CRNA.

Record review of the facility's document titled "Register of Operations (surgical roster of cases)," dated 01/22/15 through 02/23/15 showed 24 surgical cases were performed where a CRNA was listed as the anesthetist (a medical specialist who administers anesthetics, which is a substance that causes loss of sensation or consciousness).

2. During concurrent review of medical staff credentialing files and interview on 02/24/15 at 9:45 AM, Staff N, Manager of Health Information Management (HIM), stated that until recently she had been responsible for medical staff credentialing. Staff N Stated that the following surgeons had not been privileged to supervise CRNA administering anesthesia:
- Staff RR, General Surgeon;
- Staff DDD, Obstetrics and Gynecological Surgeon (OB/GYN, OB physician who delivers babies/GYN, physician who specializes in treating diseases of the female reproductive organs);
- Staff FFF, Orthopedic Surgeon (trained to deal with problems that develop in the bones, joints, and ligaments of the human body); and
- Staff GGG, Podiatric Surgeon (treatment of disorders of the foot, ankle, and lower extremity).
Staff N stated that the facility had not developed criteria for privileging surgeons to supervise CRNA administering anesthesia.

During an interview on 02/26/15 at 9:30 AM, Staff HHH, CRNA, stated that anesthesia services for the facility was provided by CRNAs. She stated that there was no anesthesiologist (a physician specializing in anesthesiology) on staff and that the Medical Staff Rules and Regulations stipulated that the operating practitioner was responsible for the oversight of the CRNA administering anesthesia for all surgical cases.

Based on interview and record review the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) Program that included problem identification and prevention, identification and implementation of corrective actions and evaluation of the effectiveness of correction actions. These deficient practices had the potential to adversely affect the safety and quality of care provided for all patients. The facility census was 16.

Findings included:

1. Record review of the facility's "QAPI Program," dated 2015, showed the following:
- On a monthly basis the QAPI Committee reports findings, conclusions, recommendations, actions and results of actions related to all patient care and other clinical services.
- The scope of the QAPI program covers the measurement and assessment activities of the Medial Staff, Nursing and ancillary or support services. All clinical and non-clinical departments are included.
- Quality improvement activities will address both clinical and organization functions. These activities are designed to assess key functions of patient care and to identify, study and correct problems and improvement opportunities found in the processes of care delivery.
- Accumulated data are analyzed in such a way that current performance levels, patterns or trends can be identified.
- The assessment process will incorporate four basic comparisons in relation to an established benchmark (process of comparing one's business processes and performance metrics to industry bests or best practices) or goal:
- With self over time, through assessment for variations, patterns and trends;
- With others, including the use of data bases
- With standards such as practice guidelines/parameters;
- With best practices.
- The effectiveness of the QAPI program will be evaluated at least annually.

Record review of the facility's policy titled, "Fall Prevention Assessment Policy," revised 05/06/13, showed the following direction:
- To promote patient safety;
- Identify patients at risk for falls;
- Implement a fall prevention plan of care for patients identified at risk for falls.
- To prevent further injury and/or falls; and
- Analyze fall data for trends and patterns.

2. Record review of the facility's document titled "Patient Fall Summary," dated 06/2014 to 02/2015 showed 14 patient falls with three patients that sustained broken bones.

During an interview on 02/24/15 at 10:45 AM, Staff L, RN, Manager Quality and Risk, stated that she was unaware the number of falls was so high for this time frame. She stated that she had investigated all patient incidents/events including falls but she did not trend the data or identify patterns. She was unable to answer what was done with this information after it was collected.

During an interview on 02/25/15 at 3:30, Staff DDD, Chief Executive Officer (CEO), stated that he was unaware of the number of patient falls that had occurred over the past seven months. He stated that he had not been made aware of this information.

During an interview on 02/26/15 at 1:30 PM, Staff L stated that the Medical Surgical (Med- Surg) department had selected only two Quality Indicators that were monitored; scanning of medications and charting of IV (intravenous, administered thru a small tube inserted into a vein) medications.

3. Record review of the Medical-Surgical Unit's QAPI report titled, "QI Med- Surg Department," dated 01/15 showed the problem identified was a decline in percent of medications and patients scanned at beside and a goal of 80% for all medications given and patient's wrist bands scanned. The assessment process did not include benchmarks identified for the measures.

4. Record review of the Pharmacy's QAPI report titled, "Medication & Patient Scanning" dated 01/06/15, showed for the same issue the Medical Surgical Department was tracking for medication scanning and patient arm band scanning the goal was inconsistent and set for a 5% increase in compliance each quarter until a goal of 95% was obtained. The data was not trended to show variations or patterns over time or comparison to benchmarks.

5. Record review of the QAPI report titled, "SNF" (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility) Patients Admitted to Palliative Care (comfort care given to a patient who has a serious or life-threatening disease)," dated 05/14/14, showed the issue was to assess the process of admitting Palliative Care patients to SNF level of care. There were no measurable goals or interventions with follow-up for compliance and no benchmarks identified for comparison.

6. Record review of the Dietary Department's QAPI report titled, "Test Tray Review," dated 01/12/15, showed a task of Test Tray Review because test trays had not been meeting the required temperature guidelines. There was no measurable goal identified. Data review consisted of generalized statements "there were days in the beginning of the quarter where the trays did not include beverages or a copy of the types of items being served to patients" and "there were occasions where the test tray was left sitting out in the kitchen after being filled instead of being placed in the hot cart like the patient trays." There was no data analysis or trending and no measurable follow-up to evaluate corrective actions.

7. During an interview on 02/24/15 at 9:40 AM, Staff L, Registered Nurse (RN), Manager Quality and Risk, stated that:
- Each Department decided the performance improvement indicators they were going to monitor and determined the threshold for goals.
- She did not have anything in writing that showed the QAPI indicators the departments had selected and the department indicators were not included in the facility's overall Quality Improvement Plan.
- The departments did not document interventions when the monitoring of their indicators showed their quality goals were not met.
- She was aware the reporting of the quality data by each department was inconsistent and did not contain written conclusions, recommendations, interventions or results of interventions.







32280

Based on interview and record review the facility failed to ensure an effective Quality Assessment Performance Improvement (QAPI) Program that included the evaluation of contracted services affecting patient health and safety. This deficient practice had the potential to adversely affect the safety and quality of care provided for all patients. The facility census was 16.

Findings included:

1. Record review of the facility's "QAPI Program," dated 2015, showed the following:
- On a monthly basis the QAPI Committee reports findings, conclusions, recommendations, actions and results of actions related to all patient care and other clinical services.
- The scope of the QAPI program covers the measurement and assessment activities of the Medial Staff, Nursing and ancillary or support services. All clinical and non-clinical departments are included.
- Accumulated data are analyzed in such a way that current performance levels, patterns or trends can be identified.
- The assessment process will incorporate four basic comparisons in relation to an established benchmark (process of comparing one's business processes and performance metrics to industry bests or best practices) or goal:
- With self over time, through assessment for variations, patterns and trends;
- With others, including the use of data bases
- With standards such as practice guidelines/parameters;
- With best practices.

2. Record review of Radiology's QAPI report dated 08/2014, showed the following:
- The report for "Turnaround Time Study" evaluating the contracted services for reading radiology studies was presented in a total number with no comparison study for trending or benchmarking and no identified goals or interventions.
- The QAPI report for contracted CT (computed tomography, a radiological imaging that uses computer processing to generate an image of tissue density in slices) services consisted of a quality control (QC, mandated equipment functioning tests) report for the evaluation of the imagining equipment and a report of dose averages for monitoring radiation exposures during CT exams. The dose average report stated "an exact comparison cannot be made as each patient is different due to body habitus (body build characteristics) and age of patient."
- A QAPI report measuring IV infiltration (inadvertent administration of fluid or medication into the surrounding tissues that was intended to flow into the blood stream through a small tube inserted into a vein) involving CT scans with contrast injection was reported in total numbers for a three month period 05/2014 to 07/2014 with a percentage of infiltrates. The data was not presented in a method that could be trended; there was no identified goal or interventions.
- The QAPI report for contracted Mammography services consisted of an equipment inspection QC report and a report for "Repeat and Reject Analysis" in total numbers without identified goals or interventions based on findings.

3. Record review of the contracted Wound Care Services's report titled, "Quality Statistics," dated 07/2014 - 09/2014, showed data for wound resolution, amputation and wound exclusion trending. There were no goals identified, no measurable interventions and no benchmarking.

4. There were no QAPI reports for the contracted services of reference laboratory (laboratory that receives a specimen from another laboratory and that performs one or more tests on such specimen), blood products, bone densitometry (bone density test determines if you have osteoporosis - a disease that causes bones to become more fragile and more likely to break), lithotripsy (a treatment using ultrasound shock waves to break up a kidney stone into small particles that can be passed out by the body), or sonography (diagnostic imaging technique utilizing reflected high-frequency sound waves to delineate, measure, or examine internal body).

During an interview on 02/25/15 at 9:40 AM, Staff L, Registered Nurse (RN), Manager of Quality and Risk, stated that:
- All contracted services were required to report QAPI.
- She did not receive reports for contracted laboratory services;
- Some of the services reported total numbers of procedures or encounters with no trending or performance improvement initiatives identified.
- She had no opportunity to validate the QAPI reports by contract services.

Based on observation, interview, record review and policy review, the facility failed to identify and/or provide activities of individualized interests for two current patients (#6 and #7) of four Swing Bed patients (a specific type of reimbursement for patients that need a skilled service, such as therapy, but don't need the level of care in a regular patient bed) patients reviewed. This had the potential to deny all Swing Bed patients their actual interests in activities. The total facility census was 16. The Swing Bed census was seven.

Findings included:

1. Record review of the facility's policy titled, "Activity Program," revised 06/14/14 directed that the Activity Director:
- Was responsible for planning, coordinating, implementing, and documenting participation in all activities.
- Was to offer activities that were to consist of arts and crafts; walks; puzzles/games; books/magazines; music; any approved activity suggested by the patient.
- Provide documentation that would include Activity assessment; activity care plan relating to the individual interest and abilities; activity participation or needs/concerns were to be documented in activity notes.

Record review of the facilities policies showed no policy specific for care plans for the Swing Bed patient.

2. Observation and concurrent interview on 02/23/15 at 3:50 PM, showed no activity calendar available/posted for Patient #6. Patient #6 stated that she enjoyed working puzzles and would like a deck of cards. Patient #6 stated that she stayed in bed most of the time because she was cold and there was nothing else to do.

Record review of Patient #6's Activity Assessment dated 02/17/15 at 1:11 PM, showed the patient was alert and oriented but depressed and that she enjoyed sewing and quilting.

Record review of the patient's medical record showed no documentation of activity notes. The absence of this was verified by Staff NN, Licensed Practical Nurse (LPN).

3. Observation and concurrent interview on 02/23/15 at 4:00 PM, showed no activity calendar available/posted for Patient #7. Patient #7 stated she liked puzzles. Patient #7 stated that she walked twice daily with the therapists but mostly remained in bed due to room being cold and nothing to do other than watch TV. She also stated she would love to work on a puzzle or play cards.

Record review of Patient #7's Activity Assessment dated 02/10/15 at 1:10 PM, showed the patient was alert and oriented and that assistance was needed with ambulation. The patient enjoyed music, playing games, TV, reading and puzzles.

4. Record review of patient's activity participation documentation showed eight entries for routine activities from 02/11/15 to 02/24/15 that were offered to all patients on specific days. No activity participation documentation that showed individualized activities was offered to this patient.

During an interview on 02/24/15 at 11:00 AM, Staff D, Activities Director, stated that:
- She had a standardized activity calendar, located in her office that showed the activities provided to Swing Bed patients.
- Specific activities were offered on specific days.
- Monday - one on one day. She would discuss what the patient did over the weekend.
- Tuesday - prayer day.
- Wednesday - paper day.
- Thursday - She did not work on Thursdays.
- Friday - Offer puzzles/magazines.
- The therapists did the patient activities in her absence.
- Both Patient #6 and #7 mainly watched TV.
- The patients were able to go to the Residential Care Facility that was attached to the building for hair appointments if they wished.

During an interview on 02/24/15 at 1:15 PM, Patient #6 and #7 both stated that they were unaware of the availability to have their hair done.