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Based on observation and staff interviews. the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-12)-Fire proofing missing
(K-18)-Corridor doors not latching and closing
(K-25)-Smoke wall penetrations not sealed
(K-27)-Smoke barrier doors not closing and latching
(K-29)-Hazardous rooms not properly enclosed
(K-38)-Exit path not maintainable
(K-46)-Battery powered emergency lights not tested
(K-48)-No written fire safety plan
(K-50)-Fire drills at similar times
(K-51)-Smoke detector installation
(K-56)-Obstructions and missing Sprinklers
(K-61)-Sprinkler valve not supervised.
(K-62)-Sprinkler maintenance
(K-154)-Wrong information in fire watch plan
(K-155)-Wrong information in fire watch plan

Based on observation, record review and interview, the facility failed to ensure biohazard rooms are secured from unathorized access in 1 of 12 areas observed (Emergency Department)

Findings include:

Examples in Emergency Department:

During tour of the Emergency Department on 2/22/16 at 9:45 AM with Manager A, the soiled room that contains biohazards is not locked and the gynecological examination room has sexual assault evidence bags and brochures stored under the sink. This was confirmed during tour with Manager A, who was unaware the soiled room should be secure.

Based on observation and interview the facility failed to provide ongoing maintenance and monitoring for 1 or 1 blanket warmers on the medical/surgical unit.

Findings include:

On 2/22/16 at 12:30 PM, observed blanket warmer on the medical/surgical unit with the temperature dial set at the highest setting of 180 degrees which was in the red zone of the settings dial. DON G stated the blanket warmer has an automatic alarm should it get too hot.

Per interview on 2/23/16 at 3:00 PM with DON G, the facility does not have a policy related to the blanket warmer. DON G stated the blanket warmer is not currently monitored for temperature and does not have an automatic alarm as previously thought. DON G stated the manufacturer recommendation is not to exceed 150 degrees and the facility has taken the blanket warmer out of use as staff reported it was not heating properly, which is why it was turned all the way up.

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:
(K-12)-Fire proofing missing
(K-18)-Corridor doors not latching and closing
(K-25)-Smoke wall penetrations not sealed
(K-27)-Smoke barrier doors not closing and latching
(K-29)-Hazardous rooms not properly enclosed
(K-38)-Exit path not maintainable
(K-46)-Battery powered emergency lights not tested
(K-48)-No written fire safety plan
(K-50)-Fire drills at similar times
(K-51)-Smoke detector installation
(K-56)-Obstructions and missing Sprinklers
(K-61)-Sprinkler valve not supervised.
(K-62)-Sprinkler maintenance
(K-154)-Wrong information in fire watch plan
(K-155)-Wrong information in fire watch plan

Based on observation, record review, and interview, staff at this facility failed to ensure that medications, syringes, and needles in emergency carts were secured and protected from unauthorized access during hours that the carts are not under staff supervision in 2 of 4 emergency carts observed on 2 of 12 units (Interventional Pain Management and Post-Anesthesia Care Unit). This deficiency potentially affects the 15 patients treated through surgical services on 2/22/16 and 2/23/16.

Findings include:
Per review of the facility's policy titled, "Crash Cart, Emergency Response Tote, and Defibrillators," #C0093, dated 4/15 states in part, "Breakaway locks to be obtained from pharmacy. Storage of additional pharmacy breakaway locks in clinical areas is prohibited."

A tour of the Intervention Pain Management unit was conducted on 2/22/2016 at 10:45 AM accompanied by Clinic Manager C. An emergency cart was observed to be in an alcove with a blue break away lock. The cart contained the following intravenous medications: Epinephrine, Amiodarone, Lidocaine, Atropine, Metroprolol, Flumazenil, Furosemide, Magnesium Sulfate, Calcium Chloride, Adenosine, Nalaxone, Dextrose, Sodium Bicarbonate, Diphenhydramine, Solu-cortef, Dopamine, Lidocaine, and Hydrocortisone. There were also bags of intravenous solutions, needles, and syringes in the cart.

Per interview with Clinic Manager C at the time of the observation, C stated that the housekeeping service cleans the department after hours when staff are not in the department and the cart is not put away or secured with a permanent locking device to avoid unauthorized access of medications or supplies.

At 11:00 AM Pharmacist R came to the unit and brought two replacement breakaway locks to resecure the emergency cart. One was red, the other yellow. Pharmacist R was not sure which to bring as R could not find blue locks in the pharmacy and stated, "These are what we use in [the parent hospital]." Upon investigation Pharmacist R found extra blue locks stored in the top drawer of the emergency cart and used one of these to resecure the cart. When Clinic Manager C was asked who would have access to these locks, Manager C replied that after opening the cart a new lock can be applied.

A tour of the Post Anesthesia Care Unit was conducted on 2/22/2016 at 2:37 PM accompanied by Surgery Manager J and Surgery Director L. An emergency cart with a break away lock was observed in the unit. The cart contained the same medications and supplies as above. Per interview with Director L at the time of the observation, L stated, "The department is locked but housekeeping has access and cleans after hours."

Based on observation, record review and interview, the facility failed to ensure supplies are not stored under sinks in 1 of 12 areas observed (Emergency Department); chairs, doors, cabinets and curtains are in washable condition and/or washed in 3 of 12 areas observed (Emergency Department, Outpatient Clinic and Medical/Surgical Unit); aseptic technique is used during blood draws and medication administration in 4 of 4 staff observed (B, D, K and O); personal protective equipment is worn properly in 3 of 3 staff observed in surgery (K, P and QQ); ultra sound gels are not topped off in 1 of 2 areas observed (Rehabilitation Department); and staff keep hair covered when working in the kitchen in 5 of 5 employees observed (T, U, V, W, X); and failed to properly store food and food supplies in 1 of 2 (medical/surgical unit kitchen) areas where food is stored. These deficiencies potentially affects all 154 patients treated at the facility during survey.

Findings include:

Observations in Emergency Department:

During tour of the Emergency Department on 2/22/16 at 9:45 AM with Manager A, the doors for the following rooms have gouges and scrapes: 1033, 1034, 1504, 1514, 1520 and 1525. This was confirmed during tour with Manager A, who acknowledged the items should not be under the sink and the door free from damage and/or contamination.

On 2/22/16 at 10:30 AM Lab Technician B performed a blood draw on Patient #1 in Emergency Room number 1533. Technician B cleansed the site, palpated the vein, and inserted the venipuncture needle without the benefit of recleaning the site. Per interview with Lab Manager SS on 2/22/16 at 3:30 PM, Manager SS stated it is expected to not palpate the site after cleansing.


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In an interview with Infection Preventionist RR and Director of Nursing G on 2/24/2016 at 7:30 AM regarding the standards of practice for infection prevention at this facility, RR stated they follow the World Health Organization, the Association for Professionals in Infection Control and Epidemiology, the Center for Disease Control, The Association of periOperative Registered Nurses, and the Association for the Advancement of Medical Instrumentation.

Observations in the Outpatient Clinic on 2/22/2016:
At 9:45 AM, accompanied by Clinic Manager C, the vinyl chair in room 107 was noted to have tears in the covering exposing a porous non-cleanable surface.

At 9:45 AM Laboratory technician D left room 107 to bring Patient #2 in for blood testing. Upon exiting room 107 and then returning to room 107 with Patient #2 Laboratory technician D did not perform hand hygiene. Laboratory technician D then applied gloves, inserted a needle for blood testing, removed gloves, and escorted Patient #2 out of the laboratory area without performing hand hygiene. This finding was discussed per interview with Regional Laboratory Manager Q on 2/23/2016 at 10:40 AM. During the interview Manager Q stated that they have the same hand hygiene policy in the clinic as in the hospital and stated, "Yes, I talked to [technician D] and [D] said [D] was so nervous [D] forgot to do hand hygiene at the end of the patient blood draw."

Per review of facility policy titled, "Hand Hygiene," dated IP [infection prevention] 3101, dated 3/2014 was reviewed on 7/23/2016 at 7:28 AM. The policy states in part, "Perform Hand Hygiene a the following times: A. WHO [World Health Organization] 5 Moments for Hand Hygiene...B. Before and after glove use.


Observations in Surgical Procedure 2/22/2016:
At 1:29 PM, Surgical Technician PP and Registered Nurse K were observed in the Endoscopy Procedure room and had surgical bonnets tucked behind their ears. Both also had earrings on.

At 1:55 PM Physician QQ was observed wearing a surgical skull cap leaving QQ's ears exposed.

At 2:00 PM Registered Nurse K accessed Patient #17's intravenous line, cleansed the port with an alcohol wipe, and then administered intravenous sedation with 2 syringes but failed to cleanse the port between administrations. Registered Nurse K repeated this again at 2:10 PM.

These findings were discussed per interview with Surgery Manager J on 2/24/2016 at 9:30 AM. Surgery Manager J stated, "We have been trying to do away with those skull caps."

In an interview with Infection Preventionist RR and Director of Nursing G on 2/24/2016 at 8:00 AM regarding cleansing of ports and intravenous access, RR stated that the port should be cleansed prior to each entry.

Per review of the facility policy titled, "Intravascular Therapy Guidelines," #IP [Infection Prevention]3301, dated 6/2014, was reviewed on 7/23/2016 at 7:25 AM. The policy states in part, "IV [intravenous] injection ports: a. Disinfect the port before each entry into IV system with either 70% isopropyl alcohol and 3.15% chlorhexidine gluconate swab or a 70% alcohol wipe or povidone iodine and FRICTION for at least 10 seconds."

Per review of the facility policy titled, "Invasive Procedures," #IP3312, dated 3/2014, was reviewed on 7/23/2016 a 9:25 AM. The policy states in part, "Earrings must be removed or totally confined in the scrub hat at all times in Restricted OR [operating room] and during procedures in other procedure areas."

Per review of the Association of periOperative Registered Nurses state under 2016 Guidelines Aseptic Technique Recommendation III "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair."


Observations in Interventional Pain Management 2/23/2016:
At 10:15 AM Registered Nurse O opened 3 medication vials for Patient #18's pain injection procedure. Registered Nurse O then held up the vials for Physician P, who accessed them with needles withdrawing the medication. The vials were not cleansed with alcohol prior to accessing them.

In an interview with Registered Nurse O on 2/23/2016 at 10:30 AM regarding cleansing medication vials prior to use, O stated that they do not use alcohol to wipe the vials, they are just opened and accessed right away.

In an interview with Infection Preventionist RR and Director G on 2/24/2016 at 8:00 AM regarding cleansing the septum of medication vials prior to access, RR stated that staff should clean the septum prior to access to vials."



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Examples on the Medical/Surgical Unit:

On 2/22/16 at 12:45 PM, observed a shelving cart in the Physical Therapy Closet containing betadine solution outdated on 9/2015, catheters outdated in 2011 and surgical wrapped pack outdated 2013. Per Director G at the time of discovery, the cart looked to hold outdated supplies and Director G was unaware it was being stored in the Physical Therapy Closet.

Review of facility policy on 2/23/16 at 7:00 AM, "Patient Care Supplies, Management of Clean and Sterile" dated 2/14 states "Immediately remove expired/contaminated items from inventory: 1. Discard disposable items, 2. return reusable items to Sterile Processing area or Supply Chain Operations, based on department of origin.

On 2/23/16 at 12:45 PM, accompanied by Director G, observed cabinet in the clean medication room damage with exposed wood at the bottom making that surface unwashable. Director G stated at the time of discovery that the damage cabinet needs to be replaced.

On 2/22/16 at 12:50 PM observed patient rooms on Medical/Surgical floor with fabric drapes. Per interview with Director G at the time of observation, Director G stated the window drapes are only washed or cleaned as needed.

On 2/22/16 at 1:30 PM reviewed facility contract titled "Environmental Cleaning and Disinfection" dated 5/13. It states under "Routine Maintenance/Cleaning; 5. Window drapes when visibly soiled."

On 2/22/16 at 3:00 PM conducted interview with Environmental Services Supervisor TT. Per Supervisor TT the privacy curtains are in the patient rooms on the Medical/Surgical floor are cleaned a minimum of every 6 months but the window drapes are only cleaned on an as needed basis. Supervisor TT agreed these are pull curtains and are subject to contact by staff, patients and family. Supervisor TT stated the drapes no special cleaning occurs with the drapes after a contact precaution patient has resided in the room.

Examples in Rehab:

On 2/22/16 at 2:00 PM observed partial bottles of ultrasound gel in the rehab department. Per interview with Case Manager Assisted/PTA UU the rehab department at the time of observation, has ultrasound gel that is topped off, rather than tossed or emptied, cleaned and refilled. Per Director G the facility does not have a policy related to the ultrasound gel refilling practices that allow for potential contamination.

Based on interview the facility failed to maintain a list of all contracted services for 1 of 1 interview with staff (G). This deficiency potentially affects all 154 patients treated at the facility during survey.


Findings include:

Per interview with Administrator Y and Director of Nursing G on 2/23/16 at 2:45 PM, the facility does not maintain a list of contracted services that includes the nature and scope of services provided. Per Y, the contracted services are not reviewed as part of their Quality Program at this time.

Based on record review and interview the facility failed to ensure records are complete including Advanced Directive information and signed consents, in 5 of 20 medical records reviewed (3, 4, 6, 7 and 8).

Findings include:

Per review of facility policy titled Advance Directive for Health Care last reviewed 12/11 states under Responsibilities of Members of the Health Care Team When the Patient Presents for Care: I. Nursing A. Ask patient if they currently have a Health Care Directive and document their response in the patient record...shall be given written information describing their right to prepare an Advance Directive.

Per review of facility policy titled General Consent and Authorization last revised 3/26/15 states under Procedure II. a. "...the date and time fields have been completed..."

Patient #3's medical record review revealed Patient #3 arrived in the Emergency Department with a complaint of chest pain, the General Consent and Authorization for treatment dated 1/7/16 is not timed. There is no documentation that Patient #3 was asked if s/he had an Advanced Directive, wanted information on one, or needed help completing an Advanced Directive.

Patient #4's medical record review revealed Patient #4 arrived in the Emergency Department with a complaint of abdominal pain. There is no documentation that Patient #4 was asked if s/he had an Advanced Directive, wanted information on one, or needed help completing an Advanced Directive.

Patient #6's medical record review revealed Patient #6 arrived in the Emergency Department with a complaint of abdominal pain. There is no documentation that Patient #6 was asked if s/he had an Advanced Directive, wanted information on one, or needed help completing an Advanced Directive.

Patient #7's medical record review revealed Patient #7 arrived in the Emergency Department with a complaint of sexual assault. There is no documentation that Patient #7 was asked if s/he had an Advanced Directive, wanted information on one, or needed help completing an Advanced Directive.

Patient #8's medical record review revealed Patient #8 arrived in the Emergency Department with a complaint of sexual assault. There is no documentation that Patient #8 was asked if s/he had an Advanced Directive, wanted information on one, or needed help completing an Advanced Directive.

The above findings are confirmed in interview during record review on 2/23/16 between 1:30 PM and 3:00 PM with Emergency Department Manager A, who stated Emergency Department staff do not ask about Advanced Directives.

Based on record review and interview, the facility failed to ensure staff that administer anesthesia are given privileges to perform those duties, in 39 of 39 Certified Registered Nurse Anesthetist credentialed for the facility (EE, WW, XX, YY, ZZ, AAA, BBB, CCC, DDD, EEE, FFF, GGG, HHH, III, JJJ, KKK, LLL, MMM, NNN, OOO, PPP, QQQ, RRR, SSS, TTT, UUU, VVV, WWW, XXX, YYY, ZZZ, AAAA, BBBB, CCCC, DDDD, EEEE, FFFF, GGGG, HHHH, IIII).

Findings include:

Per the facility's Medical Staff Bylaws, Rules and Regulations of the Medical Staff dated October 2013, it states under 5 Appointment and Reappointment 5.5-6 "...As soon as practicable, the Credentials Committee shall transmit to the Executive Committee a written report and its recommendations as to appointment and, if appointment is recommended, as to...Clinical Privileges to be granted...Article 6 Clinical Privileges 6.2-1 "Each application for appointment and reappointment to the Medical Staff...must contain a request for the specific Clinical Privileges desired by the applicant...6.2-2 Requests for Clinical Privileges shall be evaluated...6.4-1 Each department shall develop an application/request form delineating the Privileges for which an applicant my apply...."

Per interview with Certified Registered Nurse Anesthetist FFF and Surgery Manager J on 2/22/2016 at 1:10 PM regarding Anesthesia Services, Certified Registered Nurse Anesthetist FFF stated that an Anesthesiologist is always present in the facility when the Certified Registered Nurse Anesthetists are assisting in surgery.

Per review of Certified Registered Nurse Anesthetist EE on 2/23/16 between 9:45 AM and 10:45 AM, EE was not granted privileges for providing anesthesia to patients. Per interview with Human Resources Representative MM, while doing credential file reviews on 2/23/16 between 9:45 AM and 10:45 AM, the Certified Registered Nurse Anesthetists following job descriptions and are not given privileges.

Per interview with Administrator Y on 2/23/16 at 11:25 AM, Y was unaware the Certified Registered Nurse Anesthetists were not given privileges said considered them a part of the Medical Staff. Y confirmed the by-laws indicate they should have privileges. A list of 39 Certified Registered Nurse Anesthetists that are credentialed to work at the facility, was provided by Y, and Y confirmed none had privileges. These Certified Registered Nurse Anesthetists are: EE, WW, XX, YY, ZZ, AAA, BBB, CCC, DDD, EEE, FFF, GGG, HHH, III, JJJ, KKK, LLL, MMM, NNN, OOO, PPP, QQQ, RRR, SSS, TTT, UUU, VVV, WWW, XXX, YYY, ZZZ, AAAA, BBBB, CCCC, DDDD, EEEE, FFFF, GGGG, HHHH and IIII.

Based on record review and interview, staff at this facility failed to ensure that the post-anesthesia evaluation records the patient's cardiopulmonary status and identifies any follow-up care and/or observations needed in 1 of 1 surgical medical record requiring a post-anesthesia evaluation out of a total of 20 medical records reviewed (Patient #23).

Findings include:

A medical record review was conducted on Patient #23's closed surgical medical record on 2/24/2016 at 8:56 AM accompanied by Surgery Manager J who, per interview, confirmed the following finding: Patient #23's post-anesthesia evaluation identifies #23's cardiovascular status and respiratory status as "acceptable." The term "acceptable" does not describe how these body systems are functioning. This does not constitute a complete post-anesthesia evaulation that includes: Cardiopulmonary status, level of consciousness and follow up care or complications. Surgery Manager J acknowledged this finding.

The facility's policy titled, "Anesthesia Procedure and Clinical Documentation," #ANES [Anesthesia] 2.3, dated 1/16, was reviewed on 2/25/2016 after it was received electronically from Surgery Manager J at 6:16 AM. The policy states in part, "A post-anesthesia evaluation of each post-operative patient will be documented by an Anesthesiologist prior to discharge from the PACU [post anesthesia care unit] and will be verified by their electronic signature. This will include a review of: a. respiratory function...c. cardiovascular function..."

The policy does not identify that follow up care and/or observations needed are being addressed at the time of the post-anesthesia evaluation as per the regulation.

Based on interview the facility failed to ensure there is a record of trained requestors and course provided to the requestors for approaching patients/families on organ donation in 1 of 1 interview (G). This deficieny has the potential to affect all families of patients who die at the facility.

Findings include:

Per interview with Director of Nursing G on 2/23/16 at 1:05 PM, the physicians are the requestors that approach the family for organ/tissue/eye donations. A list of requestors and their education was requested during the interview. On 2/24/16 at 7:35 AM, Director G stated there is no record of who the designated requestors are nor the training received or when.

Based on record review and interview, staff at this facility failed to inform Swing Bed patients of their rights under the Swing Bed program in 1 of 1 Swing Bed program reviewed. These deficiency potentially affects all swing bed patients treated at the facility.


Findings include:

A review of the Patient Rights and Responsibilities booklet was completed on 2/23/2016 at 7:10 AM. The booklet does not contain the following rights for Swing Bed patients:
1. The right to work, or refuse to work.
2. The right to send and receive mail and be given access to writing implements and stamps.
3. The right to bring in personal property and wear personal clothing.
4. The right for married couples to room together if applicable.

In an interview with Nurse Case Manager I and Social Worker H on 2/23/2016 at 8:03 AM regarding the Swing Bed program and patient rights, Nurse Case Manager I stated that Swing Bed patients receive the Patient Rights and Responsibilities booklet upon admission to Swing Bed and there are no other documents that contain any other patient rights that are given to the patients.

Based on record review and interview, staff at this facility failed to ensure that Swing Bed patients received a notice of transfer/discharge that explained the reason for their transfer/discharge, the effective date, where they would be discharged to, their right to appeal the discharge, and contact information for advocates of their care in 2 of 3 Swing Bed Patient medical records (Patient #19 and 22) out of a total of 20 medical records reviewed.

Findings include:

In an interview with Nurse Case Manager I and Social Worker H on 2/23/2016 at 8:03 AM regarding the Swing Bed program and transfer/discharge notice for Swing Bed patients, Nurse Case Manager I stated that the facility does not have a notice of transfer/discharge that explains the reason for patients transfer/discharge, the effective date, where they would be discharged to, their right to appeal the discharge, and contact information for advocates of their care (long term care ombudsman, mental health advocate, and developmental disability advocate).

A review of Patient #19's newly closed Swing Bed medical record (discharged on 2/23/2016) and Patient #22's closed Swing Bed medical record from 12/3/2015 confirmed that there was no transfer/discharge notice given in advance of the discharges. Nurse Case Manager I confirmed these findings during the medical record reviews on 2/23/2016 between 12:45 PM and 3:00 PM.

Based on record review and interview, staff at this facility failed to develop measurable, individualized goals and interventions with a defined timeframe for achievement for nursing care in the interdisciplinary care plan for Swing Bed patients in 3 of 3 Swing Bed medical records reviewed (Patient #19, 20 and 22) out of a total of 20 medical records reviewed.

Findings include:

A review of the facility's admission pack for Swing Bed patients was completed on 2/23/2016 at 7:20 AM. The folder contained a form titled, "Swing Bed Interdisciplinary Care Plan Population Goals," revision date 02/13. The form lists the following pre-printed information on page 1: 13 standardized goals, inclusion criteria for Swing Bed, Exclusion Criteria for Swing Bed, and 8 standardized discharge outcomes.

Per interview with Nurse Case Manager I and Social Worker H on 2/23/2016 at 8:03 AM regarding care plans for Swing Bed patients, Nurse Case Manager I stated the "Care plans are completed on admission. Nursing completes a paper document and each discipline develops their own care plan for the patient. The care conference pulls them all together." Nurse Case Manager I identified the form titled, "Swing Bed Interdisciplinary Care Plan Population Goals," as document nursing uses to develop their care plan.

The facility's policy titled, "Swing Bed Services," #CAH [Critical Access Hospital] 023, dated 2/15, was reviewed on 2/23/2016 at 11:25 AM. The policy states in part, "The patient's plan of care will contain measurable goals that are objectively and periodically reviewed to determine patient's progress."

A medical record review was conducted on Patient #19's closed Swing Bed record on 2/23/2016 at 12:45 PM accompanied by Nurse Case Manager I who confirmed the following finding: Patient #19, a 26 year old admitted to Swing Bed on 2/15/2016 for therapy for a fractured hip, had the standardized form, "Swing Bed Interdisciplinary Care Plan Population Goals," as #19's nursing care plan. On page 1 of the form there was no individualization to any of the pre-printed goals modifying them to the needs of Patient #19. The goals were not modified to make them measurable. The outcomes were not modified to identify when Patient #19 should reach the goals. In an interview with Nurse Case Manager I during the record review regarding the individualization of the care plan from nursing, Case Manager I stated, "No, they are not individualized."

A medical record review was conducted on Patient #20's open Swing Bed record on 2/23/2016 at 1:40 PM accompanied by Nurse Case Manager I who confirmed the following finding: Patient #20, a 73 year old admitted to Swing Bed on 2/20/2016 following back surgery, had the form "Swing Bed Interdisciplinary Care Plan Population Goals," as #20's nursing care plan. Page 1 of the form was identical to Patient #19's and lacked any modification to individualize the care plan to the needs of Patient #20.

A medical record review was conducted on Patient #22's closed Swing Bed record on 2/23/2016 at 2:55 PM accompanied by Nurse Case Manager I who confirmed the following finding: Patient #22, a 74 year old admitted to Swing Bed on 11/20/2015 following knee surgery, had the form "Swing Bed Interdisciplinary Care Plan Population Goals," as #22's nursing care plan. Page 1 of the form was identical to Patient #19 and 20's and lacked any modification to individualize the care plan to the needs of Patient #22.