HospitalInspections.org

Based on review of credential files (CF), facility documents, and staff interview (EMP), it was determined the facility failed to ensure the Pediatric Advanced Life Support (PALS) Certification was current for one of seven credential files reviewed (CF4).

Findings include:

Review of facility's "Administration: Licensure and Certification-Verification and Control System" policy, last revised May 27, 2015, revealed "Policy: To ensure that licenses/certificates presented by personnel are valid and current. The Administration Department shall have full responsibility to verify and maintain valid proof of licensure/certification on all employees in positions that require such licensure/certification. Procedure: ... 3. Personnel must present their renewed license/certificate to the Administrative Secretary, who will verify dates, make a copy for the facility, file and return the original to the employee. 4. Personnel who do not renew licenses/certificates in a timely manner, may not work in the facility until renewed license/certificate is received by the Administrative Secretary... ."

Review on June 17, 2015, of CF4, revealed the PALS certification expired May 31, 2015.

Interview with EMP9 on June 17, 2015, at 9:30 AM, confirmed the PALS certification for CF4 expired May 31, 2015. EMP9 confirmed no time was scheduled for CF4 to take the PALS certification course. EMP9 confirmed CF4 was required to have PALS certification.

Interview with EMP6 on June 17, 2015, at 1:50 PM, confirmed the PALS certification for CF4 expired May 31, 2015. EMP9 confirmed no time was scheduled for CF4 to take the PALS certification course.

Interview with EMP2 on June 17, 2015, at 1:55 PM, confirmed the PALS certification for CF4 expired May 31, 2015, and no PALS certification was scheduled for CF4.

Interview with EMP2 on June 18, 2015, at approximately 2:15 PM, confirmed CF4 worked on June 2, 2015, June 3, 2015, June 11, 2015, June 12, 2015, June 13, 2015, June 14, 2015, June 17, 2015 and June 18, 2015. EMP2 confirmed CF4 was required to have PALS certification.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to follow its policy for restraints for one of one restraint record reviewed (MR22).

Findings include:

Review on June 16, 2015, of the facility's "Physical Restraint" policy, last reviewed May 2015, revealed "Policy: Bucktail Medical Center promotes an environment that is restraint free recognizing that all patients have the right to be free of physical restraints. Restraints will be only be [sic] utilized after all alternative measures have been attempted and exhausted, and a patient's medical symptoms warrant the use of restraints. Bucktail Medical Center prohibits the use of restraints for discipline or convenience. Physical Restraint: ... any manual method of physical or mechanical device, material, or equipment attached or adjacent to the patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. ... Procedure: 1. Alternative measures will be attempted and exhausted prior to utilizing restraints. The use of alternative measures and the outcome from the attempted use will be documented on the alternative measures form. 2. Restraints will be utilized only when necessary to treat a patient's medical symptoms. A restraint assessment will be completed prior to the use of restraints. ... 5. A physician's order will be obtained prior to restraint use. The order will include the type of restraint to be utilized and the reason for restraint use. ... 8. All patients utilizing restraints will have the restraint released every two hours for a period of at least 10 minutes during waking hours. This will be documented on the restraint release form. During the release time the patient will be provided with the opportunity to move and exercise. During sleeping hours patients with a restraint will be checked by the caregiver for safety every hour and will be provided with position changes at least every three hours or as determined by the resident's needs. ..."

Review of MR22 on June 17, 2015, revealed the patient was admitted to the facility's Emergency Department (ED) on May 31, 2015, with escalating behaviors. Nursing documentation noted facility staff forcibly restrained the patient due to continued escalating behaviors. Continued review of MR22 revealed no documentation the ED physician ordered a physical hold for facility staff to forcibly restrain the patient or what techniques the facility staff used to restrain MR22. There was no documentation of the facility staff who participated in forcibly restraining MR22 or the parts of MR22's body that were forcibly restrained. There was no documentation indicating the time facility staff started and stopped restraining MR22. There was no documentation that facility staff assessed MR22 for injury following the release of the physical hold.

Interview with EMP2 on June 17, 2015, at approximately 2:00 PM confirmed MR22 was admitted to the facility's ED with escalating behaviors and that facility staff forcibly restrained the patient due to continued escalating behaviors. Continued interview with EMP2 confirmed there was no documentation the ED physician ordered a physical hold or what techniques the facility staff used to restrain MR22. EMP2 confirmed there was no documentation of what facility staff participated in forcibly restraining MR22 or the parts of MR22's body that were forcibly restrained. EMP2 also confirmed there was no documentation indicating the time facility staff started and stopped restraining MR22 and that facility staff did not assess MR22 for injury following the release of the physical hold.

Based on review of facility documents and staff interview (EMP), it was determined the facility's contracted pharmacy failed to ensure drugs available for patient use in Acute Care and Swing Bed units were not expired.

Findings include;

Review on June 15, 2015, of the facility's [name of contracted pharmacy] agreement, revealed "Schedule 1-A Required Consultant Services 1. Consultant shall provide consultation regarding all material aspects of providing pharmaceutical services to Facility. A written report regarding the provision of pharmaceutical services will be provided to Facility quarterly (or more frequently if required by Applicable Law). ..."

Review on June 15, 2015, of the [name of contracted pharmacy] review for December 17, 2014, revealed documentation that 10 vials of Bacteriostatic Water expired on December 1, 2014, and were removed from use.

Review on June 15, 2015, of the [name of contracted pharmacy] review for June 25 to 30, 2014, revealed documentation that four Intravenous doses of Cardizem (no dose concentration documented) expired on June 1, 2014, and were removed from use.

Review on June 15, 2015, of the [name of contracted pharmacy] review for December 12, 2013, revealed documentation that one dose of Vitamin K 4 (no dose concentration documented) expired on October 1, 2013, and was removed from use.

Review on June 15, 2015, of the [name of contracted pharmacy] review for June 25, 2013, revealed documentation that Heplock 100 units/ml (millimeters) syringes (no number of syringes documented) expired on March 2013, and were removed from use.

Review on June 15, 2015, of the [name of contracted pharmacy] review for June 25, 2013, revealed documentation that Metronidazole (an antibiotic) 500 mg (milligrams) PO (orally) (no number of tablets documented) expired on May 31, 2013, and were removed from use.

Interview with EMP2 on June 15, 2015, approximately 2:00 PM confirmed these expired drugs were available for patient use in Acute Care and Swing Bed. Further interview with EMP2 revealed there were no pharmacy reviews completed by the contracted pharmacy for Acute Care and Swing Bed for January through June 2015. EMP2 confirmed there was no documentation the expired medications were removed from use prior to their expiration.

Cross reference:
485.641(b) Quality Assurance

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to maintain a sanitary environment in the facility's dietary department and physical therapy department.

Findings include:

1) Review on June 16, 2015, of the facility's "Hair Nets" policy, no revision date, revealed "Policy: It is the policy of Bucktail Medical Center that Dietary Personnel wear Hair Nets while working in the Dietary Department Procedure: All Dietary Personnel will wear a Hair Net while working in the department. Hair nets should be on before entering the department. Hair nets must cover ALL hair."

Observation of EMP10 and EMP11 on June 16, 2015, at approximately 12:00 PM revealed these employees in the food preparation area of the kitchen. Further observation revealed EMP10 and EMP11's hair was not all contained by the hair net.

Interview with EMP11 on June 16, 2015, at approximately 12:05 PM confirmed this employee and EMP10's hair was not all contained by the hair net. Further interview with EMP11 revealed the hair nets currently used are not large enough to contain dietary employees' hair.

2) Observation on June 16, 2015, at approximately 12:10 PM revealed EMP12 enter the dietary department to request the container of food brought in from home from the dietary refrigerator.

Interview with EMP11 on June 16, 2015, at approximately 12:10 PM confirmed EMP12's container of food was lunch brought in from home. Further interview revealed EMP12 routinely requests dietary to store lunch in the dietary refrigerator. Continued interview with EMP11 revealed it was not appropriate for facility staff to store food brought in from home in the dietary refrigerator. There was no facility policy/procedure to address this practice.

Interview with EMP2 and EMP11 on June 16, 2105, at approximately 2:45 PM revealed facility staff have a lounge with a refrigerator to store lunch brought in from home.

3) Observation on June 16, 2015, of the facility's dietary department revealed a soup kettle. Inside the soup kettle on the bottom, there was an accumulation of gray dust and dried food debris, measuring approximately a nickel in size when gathered together.

Interview with EMP11 on June 16, 2015, at approximately 12:15 PM confirmed the accumulation of gray dust and dried food debris on the bottom of the soup kettle measuring approximately a nickel in size when gathered together. Further interview revealed the soup kettle was not on a cleaning schedule.

4) Observation on June 16, 2015, of the facility's dietary department revealed a deep fryer containing dark brown oil. Further observation revealed an accumulation of dried food and oil measuring approximately 1" in height around the entire deep fryer just above the dark brown oil.

Interview with EMP11 on June 16, 2015, at approximately 12:20 PM confirmed the deep fryer containing dark brown oil and the accumulation of dried food and oil measuring approximately 1" in height around the entire deep fryer just above the dark brown oil. Further interview revealed the last time the deep fryer was cleaned was approximately one and one-half months ago, and the deep fryer was not on a cleaning schedule.

5) Review on June 15, 2015, of the facility's "Dietary Guidelines for Infection Control" policy, last revised February 2012, revealed "Policy: Prevention of infection in a food service department. Procedure: Introduction Prevention of infection in a food service department requires healthy personnel; properly maintained equipment, uncontaminated supplies, and an ongoing awareness or proper sanitation and hygiene. Maintenance of sanitation standards is of paramount importance in a health care facility. ..."

Observation of EMP10 on June 16, 2015, revealed this employee wearing blue gloves, approach the cash register, accept money for payment for lunch, return to the food preparation area, remove the blue gloves, touch the garbage can lid with the left hand, deposit the gloves in the garbage can then begin handling coffee filters and coffee without washing hands.

Interview with EMP10 on June 16, 2015, at approximately 12:25 PM confirmed this employee was wearing blue gloves, approached the cash register, accepted money for payment for lunch, returned to the food preparation area, removed the blue gloves, touched the garbage can lid with the left hand, deposited the gloves in the garbage can then begin handling coffee filters and coffee without washing hands.

6) A request was made of EMP13 for a rehabilitation policy addressing maintenance of the ice pack refrigerator and the storage of water bottles in the freezer in the physical therapy department. No policy was provided.

Observation on June 17, 2015, of the top opening freezer in the physical therapy department revealed ice buildup measuring approximately 1" thick on all four sides of the freezer, and approximately 1/2" of ice buildup on the ice packs. Further observation revealed two frozen plastic water bottles.

Interview with EMP13 on June 17, 2015, at approximately 9:45 AM confirmed the top opening freezer in the physical therapy department had ice buildup measuring approximately 1" thick on all four sides of the freezer and approximately 1/2" on the ice packs.

Interview with EMP13, EMP14 and EMP15 on June 17, 2015, at approximately 10:15 AM confirmed the two frozen plastic water bottles containing ice. Further interview with EMP14 and EMP15 revealed these frozen plastic water bottles were used to treat a foot condition. EMP13 revealed these plastic water bottles did not belong in the ice pack freezer.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure proper storage of food for 12 of 12 months reviewed (June 2014, July 2014, August 2014, September 2014, October 2014, November 2014, December 2014, January 2015, February 2015, March 2015, April 2015, and June 2015).

Findings include:

Review of the facility's "Refrigerator and Freezer Temperatures" policy, last reviewed May 29, 2015, revealed "Policy: It is the policy of the Bucktail Medical Center to ensure the proper storage of food by accurately monitoring the temperatures of all Refrigerators and Freezers utilized for patients and residents. Procedure: ... Nursing Staff 1. Acceptable temperatures for the safe and proper storage of food in a freezer unit is 0 degrees F or below. 2. Acceptable temperatures for the safe and proper storage of food in a refrigerator unit is 41 degrees or below... 5. Should temperatures be above normal, maintenance personnel are to be notified and a work requisition issued. ..."

Review of the facility's "Dietary Guidelines for Infection Control" policy, last reviewed May 29, 2015, revealed "Policy: Prevention of infection in a food service department. Procedure: Introduction Prevention of infection in a food service department requires healthy personnel, properly maintained equipment, uncontaminated supplies, and an ongoing awareness of proper sanitation and hygiene. Maintenance of sanitation standards is of paramount importance in a health care facility. ... Infection Control Practices ...F. Food Prepared or Stored Outside Dietary Department ... 2. Food stored on the nursing unit. a. ... 2. Temperatures of the refrigerators should be checked daily and record weekly by a member of the nursing staff. ..."

1) Review on June 16, 2015, of the nursing unit refrigerator and freezer temperatures, revealed no documentation the temperatures were monitored on June 5, 2015, June 13, 2015 and June 14, 2015.

Interview with EMP1 on June 16, 2015, at 10:15 AM, confirmed there was no documentation of the temperatures on June 5, 2015, June 13, 2015 and June 14, 2015.

2) Review on June 17, 2015, of the nursing unit refrigerator and freezer temperature logs for June 2014, July 2014, August 2014, September 2014, October 2014, November 2014, December 2014, January 2015, February 2015, March 2015, April 2015, and June 2015 revealed elevated temperatures as follows:

12 out of 30 days in June 2014
10 out of 31 days in July 2014
20 out of 31 days in August 2014
28 out of 30 days in September 2014
26 out of 31 day in October 2014
24 out of 30 days in November 2014
31 out of 31 days in December 2014
29 out of 31 days in January 2015
13 out of 28 days in February 2015
11 out of 31 days in March 2015
18 out of 30 days in April 2015

There was no documentation maintenance personnel were notified for these elevated refrigerator or freezer temperatures.

Interview with EMP2 on June 17, 2015, at approximately 2:00 PM, confirmed there was no documentation maintenance personnel were notified when refrigerator or freezer temperatures elevated for the days noted.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the informed consent forms contained the time the consent was obtained for eight out of nine Emergency Department (ED) medical records reviewed (MR2, MR3, MR4, MR5, MR12, MR13, MR14, and MR15).

Findings include:

Review on June 16, 2015, of the facility policy "Advance Directive/Consent for treatment," last reviewed May 29, 2015, revealed "Policy: All patients requiring services at Bucktail Medical center will have consent for treatment form signed. All in-patient's [sic] will have the Advance Directive section on the consent form completed. Procedure: 1. The Admitting shift/Registration staff will get all consents signed during the admission process. 2. All inpatients must have the advance directive section completed. 3. If a patient is not able to sign for their own consent and a family member/spouse has to sign a note should be made on the treatment for ie: 'unable to sign related to vomiting' or 'too ill to sign' or 'in too much pain'. Any patient that is mentally competent has to sign for their own consent, unless a reason is documented. ..."

Review of the facility "Consent Form" revealed an area for the patient to sign, date and time for their consent for treatment and for hospital witness to sign, date and time they witnessed the patient's signature for consent for treatment.

Review on June 15, 2015, of MR2 revealed the patient was seen in the ED on June 14, 2015. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 15, 2015, of MR3 revealed the patient was seen in the ED on June 13, 2015. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 15, 2015, of MR4 revealed the patient was seen in the ED on June 11, 2015. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 15, 2015, of MR5 revealed the patient was seen in the ED on June 10, 2015. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Interview with EMP5 at approximately 2:00 PM on June 15, 2015, confirmed the consent forms for MR2, MR3, MR4 and MR5 did not have documentation of the time permission for treatment was obtained.

Review on June 16, 2015, of MR12 revealed the patient was seen in the ED on July 29, 2014. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 16, 2015, of MR14 revealed the patient was seen in the ED on August 31, 2014. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 16, 2015, of MR15 revealed the patient was seen in the ED on August 26, 2014. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Review on June 16, 2015, of MR16 revealed the patient was seen in the ED on June 8, 2015. Further review revealed a Consent Form with no documentation of the time permission for treatment was obtained.

Interview with EMP5 at approximately 10:50 AM on June 16, 2015, confirmed the consent forms for MR12, MR14, MR14 and MR16 did not have documentation of the time permission for treatment was obtained. EMP5 confirmed the consent forms with no documentation of the time the consent was obtained was pattern.

Based on review of facility documents and staff interview (EMP), it was determined the facility's contracted pharmacy failed to fulfill the agreement to provide the facility with an Acute Care and Swing Bed Quality Improvement Report, and the facility failed to ensure Laboratory Services reported to the Quality Improvement Committee.

Findings include:

Review on June 15, 2015, of the facility's "Facility-Wide Quality Assurance Program" last revised January 18, 2012, revealed "Policy: The Bucktail Medical Center, Through the Board of Directors, Medical Staff and Administrator is dedicated to the provisions of quality of care to all its patients/residents. In order to ensure that quality of care is provided, an ongoing QA program includes and [sic] effective mechanism for monitoring patient/resident care and responding to problem areas in an appropriate and timely manner. Purpose: The Bucktail Medical Center QA plan is designed to fulfill the facility's responsibility to its patients, residents, community and staff in accordance with the Department of Health Code and policies and procedures of other regulatory agencies. The QA plan will coordinate and integrate all QA and Risk management activities throughout the facility thereby providing an effective mechanism for the identification of opportunities to improve care, within the limitation of the available resources to the facility. Goals: 1. To develop appropriate standards for the provisions of patient/resident care. 2. To develop appropriate standards for the performance of professional and support staff. 3. To monitor and evaluate systematically the quality and appropriateness of patient/resident care. 4. To identify trends and patterns of care through the use of department check list. 5. To ensure appropriate ongoing staff development for all disciplines. 6. To reduce actual and potential risk to the populations. 7. To reduce financial liability to the institution. Objectives: A. To ensure the provision of high-quality patient care through objective care evaluation and other QA activities. B. To ensure coordination and integration of all QA activities by establishing a QA committee as the focal point through which all QA information will be exchanged and monitored. C. To identify and correct patient/resident care problems by assessing their cause and scope and implementing actions to resolve them. D. To prioritize identified problems and that those directly affecting patent/resident care can be resolved in a timely manner. E. To ensure communication and reporting among the QA personnel, Administrator, Department Heads, Medical Staff and Board of Directors. ... 2. When action has been implemented but the problem has not been resolved, the QA Coordinator has the authority to implement additional action, after consultation with The Administrator and Board of Directors. 3. The QA Committee shall have the authority to make recommendations to the Medical Staff and other Committees as needed to conduct investigation regarding specific problems or issues identified by the QA monitoring."

1) Review on June 15, 2015, of the facility's "[name of contracted pharmacy] Pharmacy participation in Facility's Quality Assurance Meetings/Committees" policy, last revised September 1, 2012, revealed "Applicability: This Policy 1.2 sets forth procedures relating to Facility Quality Assurance (QA) Committee Meetings ('QA Meetings'). This meeting may also be referred to as the Quality Assurance meeting of the Pharmacy and Therapeutics Meeting. Procedure: 1. Pharmacy staff will participate in QA meetings to the extent provided in the Pharmacy Services Agreement. The Pharmacy representative may be the Consultant Pharmacist or other designated Pharmacy staff member, as permitted by Applicable Law. ... 3. The Consultant pharmacist or Pharmacy representative will present quality assurance reports to the Committee at least quarterly that include, but are not limited to; 3.1 Pharmacy Quarterly Quality Assurance Report; 3.2 Psychopharmacological Medication; 3.3 Drug Utilization Report; 3.4 An overview of pharmaceutical care and pharmacy services."

Review on June 15, 2015, of the [name of contracted pharmacy] Quality Improvement: Consultant Pharmacist Summary Bucktail Snf [Skilled Nursing Facility] for March 24, 2015, revealed no documentation the pharmacy provided a Quality Assurance quarterly report to the facility including the Pharmacy Quarterly Quality Assurance Report, Psychopharmacological Medication review, the Drug Utilization Report or an overview of pharmaceutical care and pharmacy services for Acute Care and Swing Bed for 2013, 2014 and 2015. Further review revealed this report only addressed concerns regarding the facility's skilled nursing unit.

Review on June 15, 2015, of the facility's Quality Assurance Committee meeting minutes for 2013, 2014 and 2015, revealed no documentation the facility's contracted pharmacy provided a Quality Assurance quarterly report to the facility addressing the Pharmacy Quarterly Quality Assurance Report, Psychopharmacological Medication review, the Drug Utilization Report or an overview of pharmaceutical care and pharmacy services for Acute Care and Swing Bed services for 2013, 2014 and 2015.

Interview with EMP2 on June 16, 2015, at approximately 10:30 AM confirmed there was no documentation the pharmacy provided a Quality Assurance quarterly report including the Pharmacy Quarterly Quality Assurance Report, Psychopharmacological Medication review, the Drug Utilization Report or an overview of pharmaceutical care and pharmacy services for Acute Care and Swing Bed services for 2013, 2014 and 2015. EMP2 confirmed this report only addressed concerns regarding the facility's skilled nursing unit.

Interview with EMP7 on June 16, 2015, at approximately 10:45 AM confirmed there was no documentation the facility's contracted pharmacy attended or provided a Quality Assurance quarterly report to the facility's Quality Assurance Committee addressing the Pharmacy Quarterly Quality Assurance Report, Psychopharmacological Medication review, the Drug Utilization Report or an overview of pharmaceutical care and pharmacy services for Acute Care and Swing Bed services for 2013, 2014 and 2015.

2) Review on June 16, 2015, of the facility's Quality Assurance (QA) committee meeting minutes for November 2014 to June 2015, revealed no documentation the facility's laboratory reported on the QA approved quality indicators for November 2014 through June 2015.

Interview with EMP8 on June 16, 2015, at approximately 2:00 PM revealed this employee worked in the laboratory as a manager from January 2015 to present. Further interview confirmed EMP8 did not monitor or submit the approved QA monitoring to the QA committee from January 2015 to June 2015.

Interview with EMP7 on June 16, 2015, at approximately 2:15 AM confirmed EMP8 worked in the laboratory as a manager from January 2015 to present and EMP8 did not reported on the QA approved quality indicators for November 2014 through June 2015.

Cross reference:
485.635(a)(3) Provision of Services

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide an ongoing activity program to meet the needs of two of nine swing bed medical records reviewed (MR24 and MR25).

Findings include:

Review on June 17, 2015, of the facility policy "Therapeutic Recreation Programming," no review date, revealed "Policy: Recreational Therapy group programs will be offered to all BMC SBU (Bucktail Medical Center swing bed unit) patients unless contraindicated in writing on the chart by the admitting physician. Procedure: A. All new admission to BMC SBU will be offered an initial leisure assessment with the TR director and be encouraged to attend scheduled recreational programs. B. Patients have the option to refuse the initial leisure assessment to focus on their rehabilitation services with proper documentation provided by the TR Director. ..."

Review of MR24 on June 17, 2015, revealed the facility admitted the patient to the Swing Bed Program on November 20, 2014, and discharged the patient on December 5, 2014. Further review of MR24 revealed no documentation the facility completed an activity assessment on MR24 when admitted to the Swing Bed Program or at any time during the patient's stay in the Swing Bed Program. Continued review revealed no documentation the facility offered MR24 activities or that the patient refused activities while in the Swing Bed program.

Review of MR25 on June 17, 2015, revealed the facility admitted the patient to the Swing Bed Program on November 16, 2014, and discharged the patient on February 26, 2015. Further review of MR25 revealed no documentation the facility completed an activity assessment on MR25 when admitted to the Swing Bed Program or at any time during the patient's stay in the Swing Bed Program. Continued review revealed no documentation the facility offered MR25 activities or that the patient refused activities while in the Swing Bed program.

Interview with EMP2 on June 17, 2015, at approximately 2:30 PM confirmed MR24 and MR25 were patients in the facility's Swing Bed Program. EMP2 confirmed the facility did not complete an activity assessment for MR24 or MR25 on admission or at any time during their stay in the Swing Bed Program. Continued interview with EMP2 confirmed there was no documentation the facility offered MR24 and MR25 activities or that the patients refused activities while in the Swing Bed program.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the physical therapy plan of care documentation was included in the medical record for two of two current swing bed patients (MR30 and MR31).

Findings include:

Review on June 17, 2015, of the physical therapy provider policy "Clinical Record Management/Retention/Destruction, effective January 2015, revealed "Purpose: To ensure necessary records/documents, including electronic documents, are adequately maintained, protected, and destroyed in accordance with all applicable laws and regulations. Clinical records must be completely and accurately documented, readily accessible and systematically organized to facilitate the retrieval and compilation of information. Maintenance: 1. All clinical records will be kept in the Rehabilitation office ensuring confidentiality and safeguarding against loss. ... 2. All documentation should be placed in the patient's medical record immediately after completion. ..."

Review on June 17, 2015, of the physical therapy provider policy "Progress Report," effective January 2015, revealed "Purpose: The Progress Report serves as a means to summarize and document the care provided, response to treatment, and measurable progress. The Progress Report also serves as team communication for ongoing care planning. ... Place a copy of the Progress Report in the chart on the nursing unit and maintain the original within the EMR system."

Review on June 17, 2015, of the facility policy "Completion of Medical Records," no review date, revealed "Policy: Bucktail Medical Center will ensure that patient records are completed in a timely manner. ..."

Review on June 17, 2015, of MR30 revealed a physician order for a physical therapy evaluation and treatment dated June 12, 2015. Further review of MR30 revealed no documentation of physical therapy evaluation or plan of care.

Review on June 17, 2015, of MR31 revealed a physician order for physical therapy evaluation and treatment dated June 1, 2015. Further review of MR31 revealed no documentation of physical therapy evaluation or plan of care.

Interview with EMP3 and EMP5 at approximately 2:15 PM on June 17, 2015, confirmed MR30 and MR31 did not have documentation of physical therapy evaluation or plan of care. EMP3 stated the physical therapy evaluations were in a bin in the Emergency Department for the physician to sign. EMP3 stated the physical therapy progress notes were kept in the Physical Therapy Department until the patient was discharged. After the patient was discharged the notes were scanned and placed into the patient's medical record.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure a discharge summary reflecting a recapitulation of the patient's stay, a final summary of the patient's status and a post-discharge plan of care was included in the medical record upon the patient's discharge for three of nine swing bed medical records reviewed (MR26, MR27 and MR28).

Findings include:

Review on June 17, 2015, of facility policy "Completion of Medical Records," no review date, revealed "Policy: Bucktail Medical Center will ensure that patient records are completed in a timely manner. Procedure: Medical Records of discharged patients shall be completed within thirty (30) days following discharge. ..."

Review on June 17, 2015, of MR26 revealed the patient was admitted into Swing Bed status on December 10, 2014 and discharged on December 14, 2014. Further review revealed no discharge summary reflecting a recapitulation of the MR26's stay, a final summary of their status and a post-discharge plan of care.

Review on June 17, 2015, of MR27 revealed the patient was admitted into Swing Bed status on February 12, 2015 and discharged on February 13, 2015. Further review revealed no discharge summary reflecting a recapitulation of the MR27's stay, a final summary of their status or a post-discharge plan of care.

Review on June 17, 2015, of MR28 revealed the patient was admitted into Swing Bed status on March 6, 2015 and discharged on March 12, 2015. Further review revealed no discharge summary reflecting a recapitulation of the MR28's stay, a final summary of their status and a post-discharge plan of care.

Interview with EMP3 and EMP5 at approximately 2:15 PM on June 17, 2015, confirmed MR26, MR27 and MR28 did not have a discharge summary reflecting a recapitulation of the patient's stay, a final summary of the patient's status and a post-discharge plan of care.