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Based on policy review, and staff interview, the facility failed to ensure patient care policies were reviewed annually by the required individuals. In addition, policies and procedures related to nutrition/dietary had not been developed to direct patient care. The findings were:

1. Review of random patient care policies showed they had not been reviewed annually. Interview with the director of administration on 12/12/18 at 9:26 AM revealed the system for reviewing the policies and procedures annually needed to be revised. She confirmed there was no annual review completed by the required individuals since 2015.

2. Interview with the dietary manager on 12/12/18 at 9:47 AM revealed she was unaware of the process for when a nutrition assessment or screening was to be completed by the registered dietitian (RD) for a patient. She further stated there was no menu for special/therapeutic diets. She stated the menu and expectations for how to deliver specific therapeutic diet orders was in need of development by the RD.

3. Review of the nutrition/dietary department policies and procedures showed essential procedures for nutrition assessment and diet delivery were not developed. These included the areas of: nutritional assessments/screening procedures, special/therapeutic diets and menus.

4. Interview with the director of nursing on 12/12/18 at 2 PM verified there were no written policies or procedures related to these areas.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure staff followed acceptable standards of infection prevention practices during pre-procedure anesthesia care. This failure was observed during observations of 1 of 2 patients (#24) receiving pre-procedure anesthesia care. The findings were:

1. On 12/11/18 at 8:06 AM registered nurse (RN) #1 was observed assisting certified registered nurse anesthetist (CRNA) #1 with intubation (process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway) for patient #24. Continuous observation revealed RN #1 did not wear gloves or perform hand hygiene during the following tasks: The RN opened packages, and handed instruments and supplies to the CRNA, who wore gloves. The CRNA completed the intubation procedure and gave the used items to the RN. The RN placed the used reusable instruments in the bin for items to be sterilized, and discarded the single use items. Interview with infection control practitioners #1 and #2 on 12/12/18 at 10:15 AM revealed RN #1 did not follow the facility standards of practice and policies and procedures when she failed to wear gloves while assisting the CRNA.

2. Review of the policy and procedure, titled "Surgical Precautions for Invasive Procedures", revised 2018, showed, ..."All surgical team members who participate in invasive procedures must routinely use appropriate barrier precautions to prevent skin and mucous membrane contact with blood and other body fluids of all patients."..."Gloves and surgical masks must be worn for all invasive procedures."

Based on medical record review, staff interview, and policy review, the facility failed to ensure that discharge summaries were completed within 15 days of discharge for 2 of 17 sample patients (#8, #12). The findings were:

1. Review of the medical record showed patient #12 was admitted on 6/22/18 and discharged on 6/24/18. Further review showed a discharge summary was lacking. Interview with the director of nursing (DON) on 12/12/18 at 10:40 AM confirmed the discharge summary was not available.

2. Review of the medical record showed patient #8 was admitted on 8/21/18 and discharged on 8/22/18. Review of the discharge summary showed it was completed and signed on 9/18/18 (26 days after discharge).

3. Review of facility policy titled "SUBJECT: INCOMPLETE MEDICAL RECORDS" Reference #5029, page 1 of 1, last approved and dated 10/2018 showed: "All hospital records must be completed and signed by the responsible physician within fifteen days following discharge."

Based on medical record review, staff interview and policy review, the facility failed to ensure the family of each potential donor, in collaboration with the designated Organ Procurement Organization (OPO), was informed of its option to either donate or not donate organs, tissues, or eyes for 1 of 3 sample patients reviewed (#23). The findings were:

Review of the medical record showed patient #23 had been admitted on 11/07/2018 and deceased on 11/09/18. The OPO was properly notified and determined the patient eligible for bone/tissue donation. However, the form was not completed to show if the hospital's designated requestor contacted the family/patient representative or if a decision was made by the family/patient representative. Interview with the director of nursing (DON) on 12/12/18 at 10:40 AM revealed the form was incomplete, and contact with the family/patient representative could not be confirmed. Review of hospital policy titled "POLICY ON DEATH" Reference procedure #1600-31, last reviewed 13/2000 showed #3 "nurse charting responsibilities" were to call the facility OPO and follow the form.

Based on review of patient admission information, and staff interview, the facility failed to ensure swing bed patients were fully informed of all required rights. The swing bed census was 5. The findings were:

Review of the patient admission information showed written rights information was provided to each resident. Review of these rights showed work, mail access, and rights related to married couples were not included. Interview with the director of administration on 12/12/18 at 2:07 PM revealed the list needed to be revised to include these areas of rights for those admitted to swing bed status.