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Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the staff removed outdated medication and supplies from the Emergency Room emergency crash cart and Obstetric (OB) emergency crash. Failure to remove outdated medications and supplies from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The CAH administrative staff identified a census of 1 inpatient on the day of the survey.

Findings included:

1. Review of the CAHs policies did not reveal a policy that discusses the procedure in the removal of outdated supplies. Administrative Assistant F acknowledged the CAH lacked a policy to address the procedure of the removal of outdated supplies.

2. During a tour on 5/8/23 with Registered Nurse (RN) E at approximately 1:35 PM of the Emergency Department (ED) and inspection of the ED crash cart, revealed the following:

One of one GreenLine D Fiber Optic Laryngoscope expired on 4/2023.

One of one Sensicare Synthetic Polyisophrene size 6 ½ Surgical Gloves expired on 2/2023.

One of one Sensicare with Aloe Vera size 6 ½ Sterile GlovesBD expired on 2/2023.

Four of four 18 gauge (GA) x 1 ¼ Protected IV Catheter expired on 3/10/2023.

Two of three 20 GA x 1" Protected IV Catheter expired on 2/21/2023.

One of three 20 GA x 1" Protected IV Catheter expired on 2/10/2023.

One of one Intranasal Mucosal Atomization Device expired on 6/9/2022.

3. During a tour on 5/8/23 with RN E at approximately 1:35 PM of the Emergency Department and inspection of the Obstetric crash cart, revealed the following:

Two of two Kiwi Cup with PalmPump expired on 4/23/2023.

3. During an interview on 5/2/23 at approximately 1:45 AM with the RN E revealed these crash carts are to be checked monthly for outdated supplies or medication. RN E acknowledged that these supplies were outdated.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to monitor and track the temperature of the blanket warmer or perform routine preventative maintenance, located on the medical surgical floor, radiology and in the equipment storage room. Failure to monitor and track the temperature of this devise could potentially result in ineffective therapeutical treatment and physical harm to patients. The CAH's administrative staff identified a current census of 1 patients on entrance.

Findings include:

1. During a tour of the medical surgical floor, radiology and equipment storage room on 5/8/23 at approximately 3:20 PM revealed, a blanket warmer with no log of temperature tracking or a preventative maintenance tag. Blanket warmer is used to warm linens and blankets for increasing body temperature due to illness or following surgery.

2. Review of the CAH policy, "Medical Equipment Management Plan" approved 5/2021, revealed in part, " ...equipment will be included in a preventative maintenance risk assessment program. Equipment will be inspected by the last day of the scheduled month of inspection."

3. During an interview on 5/10/2023 at approximately 1:15 PM with Maintenance L verified, there had been no record of a temperature log nor maintenance for this blanket warmers on the medical surgical floor, radiology or equipment storage room. Maintenance L acknowledged there was not documentation that these blanket warmer were on a preventative maintenance list and the temperatures were not being and it was a patient safety concern.

II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to place the 18 of 18 Styker hospital beds; 1 of 1 crib; 1of 1 Smart Lift, and 1 of 1 Smart Stand on a preventative maintenance program. Failure to perform preventative maintenance (PM) or log equipment malfunctions could potentially result in physical harm to patients. The CAH's administrative staff identified a current census of 1 patients on entrance.
Findings include:

1. During a tour of the hospital on 5/8/23 at approximately 3:20 PM revealed, all the Stryker hospital beds, 1 crib, 1 Smart Lift, and 1 Smart Stand did not have preventative maintenance sticker placed on this equipment. The location of the equipment are as follows:

Beds:
a. Emergency Department (ED) treatment room
b. ED Trauma room
c. Pre-Post Surgery room 1
d. Pre-Post Surgery room 2
e. Pre-Post Surgery room 3
f. ED spare family room
g. Surgery spare - clean utility room
h. Patient Room 1
i. Patient Room 2
j. Patient Room 3
k. Patient Room 4
l. Patient Room 5
m. Patient room 6 (two beds)
n. Patient Room 7 (two beds)
o. Patient Room 8 (two beds)
p. Baby Crib (storage room)
q. Smart Lift (storage 1434)
r. Smart Stand (storage 1435)

2. Review of the CAH policy, "Medical Equipment Management Plan" approved 5/2021, revealed in part, " ...equipment will be included in a preventative maintenance risk assessment program. Equipment will be inspected by the last day of the scheduled month of inspection."

3. During an interview on 5/10/2023 at approximately 1:15 PM with Maintenance L verified, there had been no record of a the Stryker beds and crib being placed on a preventative maintenance list, nor was there a contract for preventative maintenance with Stryker. Maintenance L verified with the Stryker representative that there had been no documentation of maintenance being performed. The Smart Lift and Smart Stand were also missed for being placed on the PM list as well. Maintenance L acknowledged there was not documentation that these blanket warmer were on a preventative maintenance list and it is a patient safety concern.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 applicable active physicians (Family Medicine Physician A and Orthopedic Surgeon B) and 2 of 2 teleradiologists (Teleradiologist C and Teleradiologist D) selected for review, received outside entity peer review by the Network Hospital, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review prior to reappointment, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the physicians provided care to patients in the past 12 months as follows:

Family Medicine Physician A - 606 patient encounters
Orthopedic Surgeon B - 85 patients encounters
Teleradiologist C- 176 diagnostic imaging encounters
Teleradiologist D - 114 diagnostic imaging encounters

Findings include:

1. Review of a document titled "System Peer Review Services Agreement", effective 11/1/19, revealed in part "... Upon written request of [CAH], [Network Hospital] shall make available one or more physicians to serve as system peer reviewers ... to provide Services to [CAH] ... [Network Hospital] shall designate for each Services request a Physician Reviewer(s) consistent with a profile delineated by [CAH], who is board certified and has no conflicts of interest with any physician pertaining to the case(s) under review...".

2. Review of the credential file for Family Medicine Physician A revealed the medical staff approved the reappointment to the Medical Staff on 2/14/2023. The Board of Trustees approved Family Medicine Physician A for reappointment to the Medical Staff on 2/27/2023. Family Medicine Physician A did not have any external peer review completed by Network Hospital prior to reappointment to the medical staff.

3. Review of the credential file for Orthopedic Surgeon B revealed the medical staff approved the reappointment to the Medical Staff on 8/16/2022. The Board of Trustees approved Orthopedic Surgeon B for reappointment to the Medical Staff on 8/29/2022. Orthopedic Surgeon B did not have any external peer review completed by Network Hospital prior to reappointment to the medical staff.

4. Review of the credential file for Teleradiologist C revealed the medical staff approved the reappointment to the Medical Staff on 9/13/2022. The Board of Trustees approved Teleradiologist C for reappointment to the Medical Staff on 9/26/2022. Teleradiologist C did not have any external peer review completed by Network Hospital prior to reappointment to the medical staff.

5. Review of the credential file for Teleradiologist D revealed the medical staff approved the reappointment to the Medical Staff on 12/14/2021. The Board of Trustees approved Teleradiologist D for reappointment to the Medical Staff on 1/31/2022. Teleradiologist D did not have any external peer review completed by Network Hospital prior to reappointment to the medical staff.

6. During an interview on 5/10/2021, at 10:10 AM, the Administrative Assistant acknowledged the CAH has not been conducting external peer review on any of it's physicians. She reported the CAH has policy drafts to address external peer review but they have not been approved.

7. During an interview on 5/10/23, at 11:00 AM, the Hospital Administrator reported the CAH has an agreement with their Network Hospital for external peer review but does not have a process in place and is currently working on developing a process.

The Hospital Administrator confirmed the CAH failed to ensure all Medical Staff members had external peer review results prior to reappointment, in order to assist in the evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to inform each patient of their visitation rights, including any clinical restriction or limitation on such rights, and the reasons for the clinical restriction or limitation for Emergency Department (ED) patients and 8 of 8 outpatient services. The inpatients (including swing bed) and outpatient's medical records also lacked documentation that the required notice was provided to each patient in advance of care whenever possible. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The CAH's administrative staff identified 98 ED patients and the following outpatient/inpatient services volumes in Fiscal Year 2022 (July 1, 2022 - March 31, 2023) as follows:

Lab - 51 patients
Therapy - 24- patients
Radiology - 88 patients
Same Day Surgery - 14 patients
Diabetic Education - 3 patients
Infusion - 44 patients
Emergency Room - 98 patients
Wound - 1 patient
Inpatient/Swing bed - 19 patients

Findings include:

1. Review of the policy, "Visitation Hours", last revised 2/2019, revealed in part, "the visitation rights disclosure shall be made in advance of furnishing patient care whenever possible."

2. Observations during a tour of the ED on 5/8/2023 at 1:35 PM revealed the CAH staff failed to post or otherwise make the patient's visitation rights information available to patients of the Emergency Department.

3. Observations on 5/10/2023 at 9:35 AM at the Main Entrance of the CAHs Patient Registration and Admitting desk revealed the CAH staff failed to post or otherwise make available the patient's visitation rights information available to the CAH's patients.

4. During an interview on 5/10/23 at approximately 9:35 AM with Clinic Director verified outpatient and present to the registration desk prior to receiving outpatient hospital services. The Clinic Director reported registration staff do not give patients or visitors these pamphlet they should be visible and available at the desk. Clinic Director acknowledged there were no visitation pamphlets available to outpatients that come to the CAH for services.

5. During an interview on 5/9/23 at approximately 2:40 PM with Director of Patient Care Services revealed the swing bed packet that is presented to the patients when they are admitted to swing bed did not include the patient visitation rights nor does staff discuss patient visitation rights with the patient at the time of admission.

6. During an interview on 5/10/23 at 11:20 AM, with the Chief Executive Officer (CEO) of the CAH revealed he was unaware that the Patient's Visitation Rights information was not posted, disclosed, or otherwise made available to ER ,Outpatients, Swing Bed and that all of the CAH's patients medical records lacked documentation that the required notice was provided to the patient or, as appropriate, the patient's support person.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital ' s (CAH) administrative staff failed to ensure the CAH staff kept patient medical information secure from unauthorized access in the CAH's Radiology Department. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified an average monthly census of 88 radiology patients from July 2022 to March 2023.

Findings include:

1. Review of the CAH policy "Security and Safeguarding Medical Records," approved 4/2022, revealed in part, " ...All paper and microfilmed medical records stored ...away from main Health Information Department are stored in locked or access proximity areas and medical records shall be restricted to authorized personnel only."

2. Observation on 5/8/23 at approximately 3:44 PM, during a tour of the Radiology Department with the Radiology Manager, revealed a wall of folders adjacent to the radiology technician's station that had future orders for radiology tests. Each folder had patient information (patient, name, date of birth, and test) that was unsecured. The folders housed 12 patient future test to be performed. The following are the type of test found in the folders:

a. Computerized tomography (CT) scan (a test that combines a series of X-ray images taken from different angles around your body) tests - 3 patient orders for 5/9/23, 6/6/23, and 10/16/23.

b. 14-Day Holter Monitor (is a type of portable electrocardiogram (ECG). It records the electrical activity of the heart continuously) tests - 6 patient orders.

c. Nuclear Medicine (is a method of producing images by detecting radiation from different parts of the body after a radioactive tracer is place) test- 3 patients orders.

3. During an interview on 5/8/23, at the time of the tour, the Radiology Manager, it was revealed she utilized this wall of folders for easy accessibility to the future orders for staff. These folders contained future test orders with the patient's name, date of birth, and type of test to be performed. Environmental Staff have badge access to the department after hours and on weekends when staff is not available. The Radiology Manager acknowledged this was against the CAH's policies to have protected health information unsecured for easily accessible by unauthorized persons.

II. Based on observation, document review, and staff interviews, the Critical Access Hospital ' s (CAH) administrative staff failed to ensure the CAH staff kept patient medical information secure from unauthorized access in the CAH's Laboratory Department. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified an average monthly census of 51 laboratory patients from July 2022 to March 2023.

Findings include:

2. Observation on 5/8/23 at approximately 4:30 PM, during a tour of the Laboratory Department with the Medical Laboratory Scientist (MLS) K, revealed multiple binders on open shelving throughout the Laboratory Department. Each binder contained multiple test performed from the years 2021 until 2023. These binders included information on the test performed, test results, patient's names, date of birth and the date the test was performed and resulted. The following is a list of binders and the information enclosed:

Blood Gas Result Binders (to evaluate respiratory diseases and conditions that affect the lungs, and it is used to determine the effectiveness of oxygen therapy):

a. 2021 binder - 24 patient names, date of birth, test results.
b. 2022 binder - 26 patient names, date of birth, test results.
c. 2023 binder - 9 patient names, date of birth, test results.

Drug Screen Binder (Urine drug tests are most commonly used to detect alcohol, amphetamines, benzodiazepines, opiates/opioids, cocaine and marijuana (THC):

a. 2021 binder - 70 patient names, date of birth, test results.
b. 2022 binder - 79 patient names, date of birth, test results.
c. 2023 binder - 19 patient names, date of birth, test results.

Human chorionic gonadotropin test (hCG- detects pregnancy), Mononucleosis test (mono- detects mono), Immunological Fecal Occult Blood test (I-FOB- A test that checks for hidden blood in the stool), Helicobacter Pylori test (H. Pylori - detects an infection of the digestive tract caused by the bacteria to help diagnose the cause of symptoms and/or ulcers.) Tests Binder:

a. 2021 binder - 108 HCG; 20 Mono; 1 I-FOB; 35 H. Pylori
b. 2022 binder - 80 HCG; 12 Mono; 4 I-FOB; 16 H. Pylori
c. 2023 binder - 21 HCG; 11 Mono; 7 H. Pylori
(patient names, date of birth, test results.)

Coagulation (Coag- test analyzes how quickly small blood vessels in your skin close up and stop bleeding); Prothrombin time (PT- test measures how long it takes for a clot to form in a blood sample) International Normalized Ratio (INR is a type of calculation based on PT test results. Prothrombin is a protein made by the liver) Binder:

a. 2021 binder - 221 Coag. PT/INR - patient names, date of birth, test results.
b. 2022 binder - 224 Coag. PT/INR - patient names, date of birth, test results.
c. 2023 binder - 74 Coag. PT/INR - patient names, date of birth, test results.

Drug Screen Binder (Urine drug tests are most commonly used to detect alcohol, amphetamines, benzodiazepines, opiates/opioids, cocaine and marijuana (THC) for the Department of Transportation:

a. 2021 binder - 28 patient names, date of birth, test results.
b. 2022 binder - 31 patient names, date of birth, test results.
c. 2023 binder - 17 patient names, date of birth, test results.

3. During an interview on 5/8/23, at the time of the tour, MLS K, it was revealed they were unaware that these binders could not be unsecured in the Lab. The Laboratory Manager was out on maternity leave. Staff is present until approximately 7:30 AM- 5:00 PM Monday through Friday. MLS K verified that during the times the staff is not present the Laboratory is cleaned by Environmental Services Staff, allowing unauthorized personnel to have access to the patient information within those binders.

Based on review of policies/procedures, medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure examination of the patient by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure in 5 of 5 closed medical records (Patients #5, Patient #6, Patient #7, Patient #8, and Patient #9) reviewed. Failure of a physician to examine a patient immediately before surgery could result in surgery performed on an unstable patient. The hospital's administrative staff identified the surgical services staff performed an average of 14 surgeries in the past fiscal year, 7/1/2022 - 3/30/2023.

Findings include:

1. Review of the Medical Staff Rules and Regulations, revealed, "If a complete history and physical examination has been recorded within thirty (30) days of admission for the same or related problem, an interval history and physical examination reflecting any subsequent changes shall be recorded ..."

1. Review of closed surgical records revealed the following:

a. On 4/25/23 at approximately 8:05 AM, Surgeon G performed a colonoscopy (is an examination of the inside of your large intestine, which includes your colon, rectum and anus) on Patient #5. Patient #5's medical record lacked documentation that Surgeon G examined Patient #5 immediately before surgery to evaluate the risk of the procedure to be performed.

b. On 3/21/23 at approximately 7:02 AM, Surgeon H performed a right inguinal hernia repair (surgery to push the bulge back into place and strengthen the weakness in the abdominal wall) on Patient #6. Patient #6's medical record lacked documentation that Surgeon H examined Patient #6 immediately before surgery to evaluate the risk of the procedure to be performed.

c. On 2/27/23 at approximately 8:26 AM, Surgeon I performed a left knee arthroscopy with partial lateral meniscectomy (a surgery to remove a portion of the meniscus, a crescent-shaped piece of cartilage in the knee) on Patient #7. Patient #7's medical record lacked documentation that Surgeon I examined Patient #7 immediately before surgery to evaluate the risk of the procedure to be performed.

d. On 1/3/23 at approximately 8:26 AM, Surgeon H performed a pilonidal cyst excision (a surgery that removes a cyst at the top of the crease of your rear end) on Patient #8. Patient #8's medical record lacked documentation that Surgeon H examined Patient #8 immediately before surgery to evaluate the risk of the procedure to be performed.

e. On 1/24/23 at approximately 10:56 AM, Surgeon J performed an Esophagogastroduodenoscopy (EGD) (is a test procedure to examine the lining of the esophagus, stomach, and first part of the small intestine. The procedure uses an endoscope. This is a flexible tube with a light and camera at the end. A biopsy can be taken through the endoscope of any suspicious areas that are seen) on Patient #9. Patient #9's medical record lacked documentation that Surgeon J examined Patient #9 immediately before surgery to evaluate the risk of the procedure to be performed.

2. During an interview on 5/9/23 at approximately 8:10 AM, with the Surgery Supervisor acknowledged the closed medical records for Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9 lacked documentation of an examination by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure. The Surgery Supervisor reported she was unaware there was a required examination by the surgeon immediately before surgery to evaluate the risks of the procedure to be performed.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the Environmental Service staff perform at complete terminal clean of patient rooms to prevent and control Healthcare Associated Infections (HAIs), through the maintenance of a clean and sanitary environment reducing the risk of transmission of infection, and any identified infection control issues. Failure to maintain a clean and sanitary environment to prevent the transmission of HAIs may result in the CAH staff failing to address potential infection outbreaks in the CAH, which could potentially result in the CAH patients developing a life-threatening infection or death. The CAH administrative staff identified an inpatient census of 1 patients upon entrance.

Findings include:

1. Review of the CAH's policy, "Infection Prevention Program and Surveillance," effective 11/2022, revealed in part ... "Hospital uses the CDC definitions of what constitutes a Healthcare Associated Infection in the Acute Care setting."

2. Review of the CDC's guidelines for "Options for Evaluating Environmental Cleaning," printed 12/2010, revealed in part, " ...transmission of many healthcare acquired pathogens (HAPs) is related to contamination of near-patient surfaces and equipment, all hospitals are encouraged to develop programs ...of high touch surfaces cleaning as part of the terminal room cleaning at the time of discharge or transfer of patients ...monitoring of the cleaning process of certain high touch surfaces e.g., the curtains that separates patient beds."

3. Review of the Infection and Quality Meeting Notes from 3/22/23 revealed during a surveillance of departments with the leaders reported a walk-through of the housekeeping department in January revealed staff were unsure of how to clean the privacy curtains in the patient's rooms.

4. During an observation on 5/10/23 at approximately 10:50 AM with Housekeeper M of a terminal clean of a patient room after patient has been discharged revealed, the cloth privacy curtains were not removed to be laundered.

5. During an interview on 5/10/23 at approximately 11:20 AM with the Facilities Manager, revealed the CAH utilizes an outside laundering company. The Facility Manager and Housekeeper M reported these cloth curtains could not be laundered by this company because the curtains would fall apart. The Facility Manager acknowledged this was a concern and was brought up in the March 2023 Infection and Quality meeting but there was no follow up after the meeting to discuss next steps.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the QAPI program included all departments of the CAH and contracted services at the CAH for 8 of 31 departments and services offered at the CAH (speech therapy, occupational therapy, CT scan, echocardiogram, tele-radiology, DEXA scan, wound clinic, and plant/maintenance). Failure to include all departments and services offered at the CAH could potentially result in the CAH staff failing to identify areas where the CAH staff could improve the delivery of patient care. The CAH administrative staff identified an inpatient census of 1 patients upon entrance.

Findings include:

1. Review of the CAH's "Quality Plan July 1, 2022-June 30, 2023," revealed in part, "The facility uses a ...systematic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement."

2. Review of the CAH's quality improvement committee "Infection and Quality" meeting minutes, from 5/25/22 to 4/26/23, revealed the CAH staff failed to include the following departments/services in the CAH's Quality Improvement program: speech therapy, occupational therapy, CT scan, echocardiogram, tele-radiology, DEXA scan, wound clinic, and plant/maintenance.

3. During an interview on 5/10/23 at 1:04 PM, the Director of Patient Care Services verified they failed to include the speech therapy, occupational therapy, CT scan, echocardiogram, tele-radiology, DEXA scan, wound clinic, and plant/maintenance in the CAH's quality improvement program, despite being informed of the requirement.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure that the medical staff document who was in attendance for the multidisciplinary care conference to evaluate/re-evaluate plan of cares in accordance with the CAH's policy for 4 of 5 reviewed medical records (Patient #1, Patient #2, Patient #3, and Patient #4). Failure to document who was in attendance of the multidisciplinary care conference could result in the staff failing to identify risk factor possibly causing incomplete patient care or harm. The CAH administrative staff identified a census of 1 at the beginning of the survey.

Findings include:

1. Review of the CAH policy "Skilled Care," dated 03/2023, revealed in part, "...Purpose of Care Conference: To inform patient and family of medical condition ...Plan and review nursing care, dietary needs, activities patient is or can participate in, and social service needs of patient. Discuss dismissal plans ...Document care conference in patient's medical record." "This plan of care is initiated by the physician (MD or DO) and developed on the nursing care plan by all team disciplines."

2. Review of medical records revealed the following:

a. Patient #1, admitted to skilled care on 9/23/22 for IV antibiotic and physical and occupational therapies due to right knee grafting site infection and discharged 10/24/22, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 9/26/22, 10/3/22, 10/10/22, and 10/17/22.

b. Patient #2, admitted to skilled care 10/19/22 for physical and occupational therapies due to prosthetic joint infection and discharged 11/21/22, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 10/24/22, 10/31/22, 11/7/22 and 11/14/22.

c. Patient #3, admitted to skilled care 12/2/22 for physical and occupational therapies due to status post left hip fracture and discharged 12/16/22, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 12/5/22 and 12/12/22.

d. Patient #4, admitted to skilled care on 4/27/23 for physical and occupational therapies due to status post bypass, stents and sepsis and discharged 5/5/23, revealed the medical record lacked documentation of who attended the multidisciplinary care conference on 5/1/23.

3. During an interview on 5/10/23 at 12:37 PM, the Director of Patient Care Services verified the medical records for Patient #1, Patient #2, Patient #3 and Patient #4, lacked documentation of who was (medical staff or family/caregiver) in attendance for the multidisciplinary care conferences during the evaluation/reevaluation of the plan of cares. The Director of Patient Care Service acknowledged this was not being performed per CAH policy.