HospitalInspections.org

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Based on contract review and interview, the provider failed to ensure two of two telemedicine contracts/agreements fully outlined:
*The credentialing responsibilities of the hospital's governing body receiving telemedicine services for two of two patient care services (e-ICU and radiology).
*The distant-site governing body's credentialing responsibilities for the provision of telemedicine services for two of two patient care services (e-ICU and radiology).
Findings include:

1. Review of the written e-ICU Service Agreement dated October 17, 2006; Exhibit 1 Facility Project Cost - 1 Bed, Exhibit 2 Facility Contracted Terms; and Amendment to e-ICU Service Agreement dated September 6, 2012 for e-ICU services, revealed the hospital's governing body had not established a contract that addressed the distant-site governing body's responsibilities for credentialing medical staff members. Review of the contract revealed no information:
*Regarding which categories of practitioners were eligible candidates for appointment to the medical staff.
*Medical staff members were appointed after considering recommendations of the existing members of the medical staff.
*That ensured the medical staff had current bylaws.
*That ensured the medical staff was accountable to the governing body for the quality of care provided to patients.
*The medical staff bylaws described the credentialing process to grant appointments and medical staff privileges.
*That appointments for professional privileges were not dependent on certification, fellowship, or membership in specialty organizations.
*That telemedicine services were furnished in a manner that allowed the hospital to comply with all applicable conditions of participation for contracted services.

Review of the written agreement for e-ICU services revealed the hospital's governing body failed to ensure the contract included but was not limited to addressing:
*Contracted practitioners were credentialed prior to providing services to hospital patients.
*The hospital was not required to rely on the distant-site credentialing process for granting privileges.
*The distant-site physicians must be licensed in South Dakota.
*The distant-site hospital quality assurance process for reviewing distant-site physician's or practitioner's performance and providing the receiving hospital that information.
*The receiving hospital's process for providing the distant-site hospital adverse information regarding adverse events and complaints on the distant-site physicians and practitioner.

2. Review of the Brookings Hospital, SD Credentialing and Privileging Acknowledgment Performed by Nighthawk Radiology Services LLC dated September 14, 2004, Exhibit A JCAHO Comprehensive Accreditation Manual for Hospitals Standard LD.3.50, Exhibit B Delineation of Medical Staff Privileges; and the Physician Credentialing and Privileging Agreement signed June 6, 2011 revealed there was no information relating to distant-site provider responsibility to:
*Ensure there were current and approved medical staff bylaws.
*Ensure the medical staff was accountable to the governing body for the quality of care provided to patients.

3. Interview and review on 6/7/17 at 5:00 p.m. with staff member C of the e-ICU and the radiology telemedicine contracts revealed the responsibilities for the hospital and the distant-site hospital were not fully outlined in those service contracts.

Based on observation, interview, and policy review, the provider failed to ensure:
*The security of a medication tackle box in one of one computed axial tomography (CT) room.
*The security of two of two observed crash carts (emergency department and patient floor).
*The security of five of five physician's prescription pads in one of one operating room (OR) physician dictation desk.
Findings include:

1. Observation and interview on 6/6/17 at 10:15 a.m. of the CT room with director of imaging G revealed:
*A medication tackle box containing Benadryl, epinephrine, methylprednisone, Atropine, and saline.
*A red numbered tab kept the medication tackle box securely shut but could have been easily removed.
*The medication tackle box could have been easily removed from the CT room.
*No log documenting the red numbered tab was available.
*Housekeeping and other unauthorized personnel had access to the room.
*He agreed the medication tackle box could have been easily removed from the area.

2. Interview on 6/6/17 at 2:20 p.m. and on 6/7/17 at 12:35 p.m. with pharmacist F, pharmacy technician N, and pharmacist technician O revealed:
*The blue tabs on the crash carts were used to secure medication and was monitored by the pharmacy.
*The red tabs on the crash carts were used to secure the crash cart's medical supplies and were monitored by the nursing staff.
*The red tabs were not tracked with a log.
*The process for the monitoring of the red tabs by the nursing staff occurred in February 2017.
*The crash carts were checked monthly by the pharmacy.
*They agreed the red tabs not being logged could lead to potential tampering of the crash cart medication.





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3. Observation and interview on 6/5/17 at 1:30 p.m. of the intensive care crash carts with RN S revealed:
*The intensive care crash was secured with a red numbered tag. The tab number was not recorded as part of the daily check of the crash cart.
*The red numbered tags were stored in an unlocked drawer at the nurses station and the locked medication room.
*There was a potential for the red tag to be removed and replaced without staff awareness creating an opportunity for drug diversion.

Observation and interview on 6/5/17 at 2:10 p.m. with RN C of the emergency room crash cart revealed:
*The cart had been secured with an unnumbered red tag.
*The unnumbered red tags were stored in an unlocked cabinet and accessible to unauthorized and authorized staff members.
*There was a potential for the red tag to be removed and replaced without staff awareness creating an opportunity for drug diversion.



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4. Observation on 6/6/17 at 1:25 p.m. at the physician's dictation desk in the OR area revealed:
*An unidentified physician came over to the dictation desk and pulled a prescription pad out the drawer.
*The unsecured desk drawer had four prescription pads from [hospital name] and one perscription pad from [eye clinic name].
*Housekeeping and maintenance had access to that area.

Interview on 6/6/17 at 1:43 p.m. with OR director E regarding the above observation revealed the prescription pads should have been secured and not available to unauthorized personnel.

5. Review of the provider's April 2013 Medication Storage, Handling, Safety, Administration, and Documentation policy revealed:
*All medications would have been stored in secured areas to prevent access by patients, residents, visitors, and unauthorized individuals.
*Prescription pad security was not addressed in the policy.
*The numbered security tabs were not addressed in the policy.

Based on interview and policy review, the provider failed to ensure the utilization review (UR) committee reviewed the duration of stay for one of one sampled patient (17) that had an extended stay of approximately fifty-one days. Findings include:

1. Interview and review on 6/7/17 at 5:05 p.m. with case manager B of the hospital's Utilization Review policy and the utilization review process for patient 17 revealed:
*He was admitted on 3/15/17 and was discharged on 5/27/17.
*His treatment was complicated, and his diagnosis was postprocedure retroperitoneal abscess.
*She confirmed the patient had a long duration of stay, and it was an expensive hospital stay.
*The case managers reviewed his case daily with the physician responsible for providing his care and had determined his stay was necessary with each review. They had not considered it to be an outlier and required review.
*The patient's medical record was never reviewed by the physician's on the UR committee or discussed with those physicians.
*The General Medicine Committee Meeting met twice a year, and UR was discussed at that time.
*The last meeting was held on 3/7/17, and had discussed one midnight stay. The patients' case was not reviewed or discussed at that meeting.
*At the General Medicine Committee Meetings there were no reviews of patient charts. The UR section in that meeting was primarily used to report data and obtain recommendations if appropriate.
*The UR plan had not addressed what was considered an extended stay for hospital patients.

Review of the provider's 5/17/12 UR policy revealed:
*"The Utilization Review Plan provided for both concurrent and retrospective review of the services provided by the hospital and members of the Medical Staff. The plan included review of admissions, extended stays, and professional services for appropriateness and medical necessity. Utilization review is intended to promote appropriate use of hospital resources in an effort to provide quality care in a cost-effective manner."
*Concurrent and retrospective utilization reviews for medical necessity of hospital admission, duration of hospital stay, and professional services by case management staff.
*"Outlier cases and extended stay cases that exceed the outlier threshold will be identified by Medical Health Information staff, then reviewed by the Case Management Director and referred to the Utilization Review Committee within 7 days of identification."

A. Based on observation, interview, review of manufacturer's instructions for use, and policy review, in the Main Avera Medical Group Clinic the provider failed to:
*Follow the manufacturer's instructions for dating and tracking expiration dates for one of one opened bottle of Cidex OPA test strips.
*Document the strength and temperature of Cidex OPA used for high level disinfection for one of one ear, nose, and throat endoscope (ENT scope).
*High level disinfect one of one trans-vaginal probes between patient use.
*Follow the manufacturer's expiration date for two of two containers of Oxivir Five 16 Concentrate one-step disinfectant cleaner.
*Identify the shelf life for the in-use dilution of Oxivir Five 16 mixed into one of one spray bottle for one of two x-ray rooms.
*Follow the manufacturer's instructions for mixing Oxivir Five 16 Concentrate into one of one spray bottle for one of two x-ray rooms.
Findings include:

1. Observation and interview on 6/6/17 at 8:40 a.m. with registered nurse (RN) Q in the Main Avera Medical Group Clinic where the ENT scope was high level disinfected revealed:
*They were using Cidex OPA for high level disinfection.
*The Cidex OPA test strip bottle was not dated when opened.
-According to the label those strips were only good for ninety days after the bottle was opened.
*The in-use solution strength of Cidex OPA was tested every time it was used but, they did not record the results of the test.
*The ENT scope could have been used and disinfected multiple times during the day.
*She was not aware:
-The Cidex OPA test strip bottle was to have been dated when opened.
-The test strips expired ninety days after the bottle had been opened.

Review of the provider's September 2015 Manual Endoscope Cleaning and Disinfection policy revealed it did not address the use of Cidex OPA, Cidex OPA test strips, or documentation of the test results.

2. Interview on 6/6/17 at 9:00 a.m. with RN R in the Main Avera Medical Group Clinic where the ultrasound machine was stored revealed:
*She was responsible for cleaning the trans-vaginal probe between patients.
*She had not high level disinfected the trans-vaginal probe between patient use but had wiped the probe down with a disinfectant wipe.

Interview on 6/7/17 at 2:00 p.m. with RN R revealed:
*She had just started working with a new physician approximately two months ago.
*She had no experience with the cleaning and disinfecting of the trans-vaginal probe prior to working with the new physician.
*She had read the general cleaning instructions for the trans-vaginal probe but had no formal training in regards to cleaning and disinfecting the probe.
*She was not aware the trans-vaginal probe should have been high level disinfected between patient use.

Review of the provider's January 2013 Pelvic Ultrasound TA-TV policy revealed: "After the procedure, the sheath should be disposed of and the probe rinsed with water and soaked in an antimicrobial solution (Cidex) according to manufacturer's instructions."




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3. Observation and interview on 6/6/17 at 8:36 a.m. of the Main Avera Medical Group Clinic radiology room 2 with radiological technologist H revealed:
*A spray bottle of Oxivir Five 16 disinfectant with no label or expiration date on it.
*An Oxivir Five 16 concentrate bottle with an expiration date of September 2016 on it.
*The spray bottle was used to clean the x-ray table and other equipment between patient use.
*She stated she never labeled the bottles with an expiration date.
*She was unsure how long the product would have been good for after mixing the Oxivir Five 16 concentrate with water.
*She verified the Oxivir Five 16 concentrate had expired.

Surveyor 25107:
4. Observation and interview on 6/6/17 at 9:20 a.m. with radiological technologist H in the Main Avera Medical Group Clinic utility room where Oxivir Five 16 was stored and mixed revealed:
*Both dispensers were set to the setting with a red bucket that had three drops in it.
*Each dispenser had four settings for dispensing the disinfectant solution.
-Green bucket with one drop.
-Red bucket with three drops.
-Green spray bottle with one drop.
-Red spray bottle with three drops.
*The bucket with the three drops setting was the one they had always used to fill spray bottles.
*She was not aware there was a setting for spray bottles with three drops.
*She had been instructed by a former employee to fill the spray bottles using the setting with the bucket that had three drops in it.
*She had no formal training in the operation of the Oxivir Five 16 dispensing equipment.

Review of the Oxivir Five 16 Concentrate label revealed:
*When diluted to 1:16 [1 to 16] dilution in 200 parts per million (ppm) hard water the product was a disinfectant.
*The product would have remained effective for ninety days.
*The setting of the red spray bottle with three drops in it would dispense a dilution of 1:16 which was a one-step hospital grade disinfectant cleaner in five minutes.
*The setting of the red bucket with threes drop in it would dispense 1:128 dilutions which was a non-food contact sanitizer in three minutes.

B. Based on observation, interview, review of manufacturer's instructions for use, and policy review, the provider failed to:
*Protect the supply of clean linen from contamination in one of one utility room in the imaging suite.
*Ensure one of one nasopharyngeal endoscope was not stored in the manufacturer's shipping case in one of one emergency department.
*Ensure hand hygiene during the medication administration pass for one of one sampled patient (27) was performed after contact with the contaminated hand washing sink.
*Ensure the clipboard used for one of one sampled patient (27) in isolation was made of cleanable material.
Findings include:

1. Observation and interview on 6/6/17 at 4:20 p.m. with director of imaging G in the utility room of the imaging suite in the hospital revealed:
*Clean linens were stored in the same room where trans-vaginal probes were high level disinfected.
*The clean linen had covers to protect it, but the covers had been left opened exposing the linen.
*He agreed the process of high level disinfection of trans-vaginal probes was considered a dirty process and should not have been performed where clean linens were stored.
*The hospital was new. The containers used for high level disinfection of the trans-vaginal probes were originally supposed to have been installed in the procedure rooms where the ultrasounds were performed.
-Do to lack of space they had to find an alternate place to install the equipment for high level disinfection.
-They had chosen the utility room but had not considered the storage of clean linens in the same room.




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2. Observation and interview on 6/5/17 at 2:00 p.m. with the emergency room director revealed:
*A flexible nasopharyngeal endoscope was stored in a case on the ears, eyes, and nose supply cart.
*The endoscope had been disinfected by the hospital staff after the last use.
*It had been quite some time since the endoscope had been used on a patient.
*It would not have been disinfected by reprocessing prior to the next use.
*She was not aware the endoscope should not have been stored in the manufacturer's shipping case.

Review of the Association of periOperative Registered Nurses, Guidelines for Preoperative Practice, 2016 Ed., pages 723 and 724, revealed:
*Page 723, "Flexible endoscopes should be stored in a drying cabinet. The collective evidence shows that optimal storage of flexible endoscopes facilitates drying, decreases the potential for contamination, and provides protection from environmental contaminates."
*Page 724, "Flexible endoscopes should not be stored in the original shipment cases. The cases are difficult to clean, may be contaminated, and are designed for shipment only."

3. Observation on 6/6/17 at 9:15 a.m. of patient 27's medication pass revealed:
*The patient was on contact isolation precautions.
*Registered nurse trainee J while wearing clean gloves turned on the faucet, filled a medication cup with water, turned off the faucet, and squirted medication from a syringe into the medication cup.
*She then assisted the patient to take his medication and documented in the computer the medication had been administered.
*Prior to registered nurse trainee J exiting the room she removed her gloves and performed hand hygiene.
*During the medication pass a clipboard holding transfer certification paperwork was passed into the room. The clipboard was passed to the patient for signature.

Observation and interview with RN M immediately after exiting the room revealed she used a disinfectant wipe to clean the clipboard. RN M confirmed the clipboard was not made of paperlike noncleanable material.

Interview on 6/7/17 at 10:21 a.m. with RN M regarding hand washing revealed:
*The handwashing sink in the room was considered contaminated.
*Registered nurse trainee J should not have turned the faucet on and off with her gloved hands, mixed the patient's medication in the water, and then administered the patient his medication using contaminated gloves.

Review of the provider's October 2013 BHS Infection Control Program policy revealed "Hand hygiene during patient care is necessary to remove transient microbial contamination from recent contact with infected, colonized, or past-colonized patients or environmental sources."




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C. Based on observation, interview, and policy review, the provider failed to ensure:
*Clear plastic bubble tubing used for patient suction in three of three operating rooms (OR) and one of five post anesthesia recovery units was changed after each patient's use.
*One of one Yankauer suction was not opened prior to use in OR suite two during terminal cleaning.
*One of ten same day surgery rooms (9) had a blood spill immediately cleaned up from the floor to prevent staff and visitors from walking in the blood spill.
*One of one surgeon (I) used appropriate hand hygiene during one of one bilateral inguinal hernia robotic surgery on one of one patient (34).
*Appropriate disinfection of the surgical bed and pads during cleaning between OR cases in one of three OR suites (two).
Findings include:

1. Observation and interview on 6/5/17 from 1:30 p.m. to 2:30 p.m. in the OR suites revealed:
*There were three OR suites and each of those suites had a clear hard plastic bubble tubing hanging from the suction machines.
*Interview with OR director (E) regarding those clear hard plastic tubing hanging from the suction machines revealed:
-The bubble tubing came in a large container and was cut as needed for use in the OR.
-The bubble tubing was not sterile.
-The tubing did not touch the surgical patients.

Observation on 6/5/17 at 3:00 p.m. of the bubble tubing box revealed there was no indication of how to care for the tubing or if it was a one-time patient use item.

Observation on 6/7/17 at 10:25 a.m. in the post anesthesia recovery unit bays one through five revealed:
*There was clear bubble tubing hanging from all the suction canisters.
*The tubing was wrapped around the suction machine or just hanging loosely from the suction control device on the wall.

2. Observation on 6/5/17 at 3:25 p.m. in room nine of the same day surgery unit revealed:
*On the right side of the gurney there was a small blood spill on the floor.
*There was no patient in the room.
*The blood spill was almost stepped in by the surveyor, and could have been easily stepped in by staff and tracked throughout the unit.

3. Observation on 6/5/17 at 4:15 p.m. in OR suite two during the terminal cleaning revealed an opened package of an unused Yankauer suction tip placed on the anesthesia cart. The Yankauer was opened during terminal cleaning of the OR suite.

Interview on 6/5/17 at 4:30 p.m. with OR director E regarding the above observation revealed the blood spill should have been cleaned up immediately per hospital protocol.

Review of the provider's May 2012 Hazardous Waste Management policy revealed "All spills of infectious waste are to be cleaned up immediately and the surface areas disinfected with a hospital-approved disinfectant."

4. Observation on 6/6/17 at 1:43 p.m. in OR suite two during the cleaning of the room in between surgical cases revealed:
*The surgical team was cleaning the room prior to the next surgical case.
*The OR table pads were disinfected and cleaned on the sides and the top of the pads.
-However the pads were not removed from the operating table for appropriate cleaning and disinfecting underneath the pads.
- The OR table underneath the pads was not cleaned and disinfected.

5. Observation on 6/6/17 at 3:20 p.m. during the surgical case for patient 34 with surgeon I revealed:
*The surgeon started the case by making the incisions for the use of the robotic equipment.
*After he had completed those incisions and placed the equipment in the abdominal area he removed his gown and gloves. He went directly over to the robotic area without washing or sanitizing his hands.

6. Interview on 6/6/17 at 4:45 p.m. with OR director E regarding the above observations on 6/6/17 revealed:
*The surgical team should have cleaned and disinfected the entire surgical table including the area underneath the pads as well as the table underneath the OR pads.
*The surgeon should have washed his hands after removing his soiled gloves and prior to touching the robotic control area.

Interview on 6/7/17 at 3:40 p.m. with infection control coordinator D regarding the above observations revealed:
*Surgeon I should have washed his hands after removing his gloves after the incisions had been made and prior to operating the robotics equipment.
*The bubble tubing was used in the OR but should have had a white valve tip on the end of the tubing to prevent any contamination inside the tubing.
*One time use items should not have been opened prior to use and not placed in the opened package prior to patient use.

Review of the provider's October 2013 Hand Hygiene policy revealed:
*Hand hygiene was the single most important method of preventing the spread of infection. The use of gloves was not a substitute for hand hygiene.
*Caregivers must perform hand hygiene at the following times:
-Before and after contact with the patient or environment.
*After contact with a source of microorganisms likely to be contaminated including:
-Body fluids/substances.
-Non-intact skin.
*After removing gloves, masks, or other protective gear.

Review of the provider's July 2012 Environmental Cleaning in Perioperative Setting policy revealed:
*The purpose was to have provided a clean and safe perioperative environment.
*Provide guidance and disinfection in the surgical practice setting.
*Application should result in a clean environment for the patients and staff and minimize expose risk to potentially infectious microorganisms.
*All surgical procedures should have been considered potentially infectious.
"c. Clean mattresses, carts, cuffs, and notify Supervisor of any damages or worn coverings. All receptacles, work surfaces, and tables are cleaned and disinfected. "

A policy on single-use items was requested from quality director P and ER/medical/surgical director C on 6/7/17 at 3:35 p.m. The policy was not provided prior to the completion of the survey.

Based on record review, interview, and policy review, an individualized planned activities program was not provided for five of six sampled discharged swing bed patients (7, 8, 10, 11, and 12). Findings include:

1. Review of patient 7's medical record revealed:*He had been admitted to a swing bed on 2/9/17 and was discharged to a skilled nursing facility on 2/24/17.
*His diagnoses included: weakness, hypotension, and mild mental retardation.
*He had lived in a group home prior to his admission.

Review of patient 7's 2/14/17 activities assessment revealed:
*It was completed by a case management nurse five days after his admission.
*His only activity preference was conversation.
*He had only occasional visitors.
*Barriers to his activities were fatigue, dyspnea, and weakness.

Review of patient 7's activity involvement documentation from his admission through his discharge revealed:
*On 2/10/17 he was unable to participate in activities.
*On 2/11/17 and 2/14/17 he had visitors, and no activities were completed by staff.
*On 2/12/17 and 2/13/17 he had no type of activity specified, but "tolerated well" was documented as the response.
*On 2/15/17 and 2/16/17 his only activity was TV.
*On 2/17/17, 2/20/17, 2/21/17, and 2/23/17 visitors and TV were listed.
*On 2/18/17 and 2/19/17 there was no type of activity specified.
*On 2/21/17 conversation, TV, and visitors were listed.
*On 2/22/17 conversation and TV were listed.
*His preferred activity of conversation was completed by the staff only two days of his fifteen day stay.

2. Review of patient 8's medical record revealed:*She had been admitted to a swing bed on 2/20/17 and was discharged to a skilled nursing facility on 3/7/17.
*Her diagnoses included osteomyelitis to her right great toe.

Review of patient 8's 2/21/17 activities assessment revealed:
*It was completed by the case management nurse.
*Her preferred activities included reading, watching TV, and conversation.
*She had occasional visitors.
*Her only barrier to activities was fatigue.

Review of patient 8's activity involvement documentation from her admission through discharge revealed:*On 2/21/17 and 2/22/17 she had conversation, TV, and visitors listed.
*On 2/23/17 she had conversation only.
*On 2/24/17 and 3/4/17 there was no type of activity specified.
*On 2/25/17 and 2/26/17 she had the newspaper and TV.
*On 2/27/17, 3/3/17, and 3/5/17 she had conservation, TV, and phone calls.
*On 2/28/17 and 3/1/17 music, visitors, and phone calls were listed.
*There was no documentation for 3/2/17.
*On 3/6/17 and 3/7/17 TV and visitors were listed.
*Her preferred activity of reading was completed only two days of her fifteen day swing bed stay.

3. Review of patient 10's medical record revealed:*She had been admitted to a swing bed on 3/30/17 and was discharged to a different hospital on 5/10/17.
*Her diagnoses included sepsis related to methicillin resistant staphylococcus aureus in her lumbar spine.

Review of patient 10's 3/31/17 activities assessment revealed:
*It was completed by the case management nurse.
*Her preferred activities included reading, cards, games, puzzles, watching TV, and conversation.
*There were no barriers to her activities documented.

Review of patient 10's activity involvement documentation from her admission through discharge revealed:
*On 4/15/17, 4/25/17, 4/29/17, and 5/8/17 there was no type of activity specified.
*On 4/3/17, 4/6/17, 4/19/17, 4/28/17, 5/1/17 only TV was listed.
*The other days activities included: conversation, newspaper, TV, walking, magazines, phone calls, visitors, mail, religious visits, reminiscing, IPAD, and books.
*Nine days of her forty-one day swing bed stay had either no activities specified or TV only completed by staff.

4. Review of patient 11's medical record revealed:*She had been admitted to a swing bed on 10/11/16 and was discharged to a different hospital on 11/14/16.
*Her diagnoses included osteomyelitis of her left foot.

Review of patient 11's 10/12/16 activities assessment revealed:*It was completed by the case management nurse.
*Her preferred activities included only watching TV and conversation.
*There were no barriers to her activities documented.

Review of patient 11's activity involvement documentation from her admission through her discharge revealed:*On 10/31/16 and 11/5/16 there was no type of activity specified.
*Her activities included conversation, TV, visitors, phone calls, books,walking, newspaper, magazines, reminiscing, crossword puzzles, personal handiwork, and word finds.
*Only TV and conversation had been mentioned in her activity assessment.

5. Review of patient 12's medical record revealed:*She had been admitted to a swing bed on 10/11/16 and was discharged to home on 12/19/16.
*Her diagnoses included an infection requiring intravenous antibiotics.

Review of patient 12's 11/11/16 activities assessment revealed:*It was completed by the case management nurse.
*Her preferred activities included watching TV, conversation, and her spouse would bring in her beading supplies.
*The only barrier to her activities was immobility.

Review of patient 12's activity involvement documentation from her admission through her discharge revealed:*On 11/27/16, 12/3/16, and 12/17/16 there was no type of activity specified.
*Her activities included: conversation, crafts, TV, visitors, phone calls, movies, personal handiwork, religious visits, magazine, audio books, newspaper, and crossword puzzles.
*Only TV, conversation, and beading supplies were mentioned in her activity assessment.

6. Interview on 6/6/17 at 2:50 p.m. with case management director B regarding swing bed activities revealed:*She oversaw the case management nurses and the swing bed services.
*Patient activities assessments were done by the case management nurses after admission.
-Those assessments were meant to identify the patients' preferred activities.
*There was no formal documentation or process to make sure other staff were aware of the patients' preferred activities from their assessments.
*The case management nurse verbally communicated the residents' preferred activities to the nursing assistants.
*The nursing assistants were responsible for providing swing bed patient activities and the documentation of them.
*The nursing assistants got to the know the patients better, and she felt they could choose whatever activities they wanted to do with the patient.
*Activities supplies were available to the patients to use.
*There was no planned activity calendar or group activities.
*All activities were completed in the patients' room.
*Patient activities were not listed as part of the patient's care plan.
*She confirmed patients' activities should have been individualized for them.

Further interview on 6/6/17 at 3:40 p.m. with case management nurse director B and case management nurse K regarding swing bed activities revealed:*The nurse completed the activities assessment for each patient after admission to find out their preferred activities.
*From those assessments the nursing assistants should have been following through and providing those preferred activities.
*They reported the only way the nursing assistants found out about those preferred activities was a verbal report from the case management nurse.
*There was no specific documentation of that report, and preferred activities were not a part of the patient's care plan.
*Occupational therapy assistant L helped oversee the activities of the swing bed patients.
-She helped ensure supplies were available for patients to use.

Interview on 6/7/17 at 9:45 a.m. with occupational therapy assistant L regarding swing bed activities revealed:*She had done some training with the nursing assistants regarding patient activities in the past.
*She had made supplies available for activities.
*Patient's activities should have been individualized for them and carried out by the nursing assistants.
*There should have been a process implemented for the resident's preferred activities to be known and carried out by the nursing assistants.
*There was no formal group activities or planned activity calendar, because activities were primarily completed in the patient's room.
*Activities were an important part of maintaining a patient's psychosocial well being.

Review of provider's May 2013 Swing Bed policy revealed:
*"Brookings Health System will provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each patient. This will be directed by a qualified occupational therapist or occupational therapy assistant."
*"Each Skilled Swing Bed patient will have care planning performed by the nursing staff and Case Management staff, which will include twice weekly Interdisciplinary Care Conferences attended by all clinical staff involved..."

Review of the provider's reviewed September 2015 Interdisciplinary Patient Care Planning Process revealed:*"A patient's condition may be multidimensional and complex. A collaborated, interdisciplinary approach helps evaluate care and planning to meet patient care goals and achieve optimal outcomes. The mix of disciplines involved and the intensity of the collaboration will vary with each patient..."
*"1. An RN and the Case Manager construct an appropriate plan of care into the EMR which includes the problems, outcomes, and nursing interventions."