HospitalInspections.org

Based on observation, staff interview and the Bio Electronics (a company that provides medical equipment management, preventive maintenance and repair). Equipment File List failed to ensure that 2 randomly observed pieces of patient care equipment received routine preventive maintenance:
- An Esprit Ventilator (the name of a ventilator - an appliance providing artificial respirations) manufactured by Phillips Respironics Corporation (a company that specializes in products that improve respiratory functions, and assists with preventive maintenance and repair).
- A Phillips Bipap (the name of a portable ventilator manufactured by Respironics Corporation).
The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the Respiratory Department and equipment storage area on 7/23/13 from 10:15 AM to 11:20 AM with the Respiratory Therapist revealed 2 machines:
- The Esprit Ventilator with the Bio Electronics sticker 0001017 and a Respironics sticker dated 10/5/10;
- The Phillips Bipap machine with a Respironics sticker dated 10/5/10 and no Bio Electronics sticker.

B. Interview with the Respiratory Therapist on 7/23/13 at 10:30 AM revealed, "We use the Esprit Ventilator with the Phillips Bipap Machine as the back up ventilator on an average of 3 times a year." "I will have Maintenance pull up the forms with the dates they were serviced."

C. Interview with the Maintenance Worker (MW)-A on 7/23/13 at 3:40 PM revealed, "The numbers on the Esprit Ventilator 0001017 isn't on the list. The Phillips Bipap isn't on the list either. Maybe Respironics is checking these 2 machines, I will check into it."

D. Interview with the Quality Assurance Manager (QA)-M on 7/24/13 at 11:39 AM revealed, "We checked into the Esprit Ventilator and somehow the number got dropped off the Bio Electronics list. Therefore, it hasn't been calibrated for preventative maintenance since 10/5/10. We are contacting the appropriate people for calibration maintenance. I would assume the Phillips Bipap is the same situation."

E. Interview with the QA-M on 7/24/13 at 12:15 PM revealed, "We have taken those 2 machines out of service and the Bio Electronics people will be here sometime today to service it."

Interview with the QA-M on 7/25/13 at 9:10 AM revealed, "No, neither Bio Electronics or Respironics came yesterday. They were notified and Bio Electronics will be here next week."

Interview with the Chief Nursing Officer (CNO) on 7/25/13 at 9:30 AM revealed, "We have a plan that Anesthesia will come in and use the anesthesia machine if we need to have someone on a ventilator until the preventative maintenance is completed. We will leave those out of service."

Review of the Bio Electronics Equipment File List dated 6/5/13 showed that neither the Esprit Ventilator or the Phillips Bipap Machine were on the current preventative maintenance list.

Based on review of policies and procedures, review of the Annual Evaluation and staff interview, the CAH (Critical Access Hospital) failed to include 1 of 3 required members in the group of professionals responsible for the development of patient care policies (midlevel practitioner/physician assistant). The CAH had 5 physician assistants that worked in the Emergency Department. Census on the first day of survey was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview on 7/24/13 from 8:00 AM to 8:10 AM with the Compliance Coordinator, individual identified as chairman for the Policies and Procedures Committee, revealed the membership of this committee lacked a physician, midlevel practitioner/physician assistant and a member not on staff at the CAH.

Review of the last meeting minutes that were available for the policy and procedures committee dated 5/30/13 confirmed a physician, midlevel practitioner/physician assistant and a person not on staff at the CAH were not listed as members present. The Stated Goal for this committee was:
"To produce online a comprehensive set of policies and procedures which are not department specific and are more function based thus lessening the chance of redundant policies and procedures occurring. There needs to be a prescribed format, method for archiving, and a sophisticated search function"

B. Review of the policy and procedure titled Adoption & Revision (last reviewed 6/11) revealed the following policy:
"Department Leaders shall be responsible to determine necessity of new or revised policies and procedures while maintaining no noticeable redundancy or repetition; and obtaining approval from the CEO [Chief Executive Officer]". The only mention of a physician, midlevel practitioner/physician assistant and/or person not on staff at the CAH was under Procedure 5 which stated "Documentation of a revision/review may also include a signature face sheet showing approval and/or revision date with CEO, Department Leader and/or Medical Director signature shall be maintained in the department Policy Manual."

C. Interview with the Quality Leader on 7/25/13 from 1:30 PM to 1:35 PM revealed that policies and procedures are reviewed annually during the meeting for the Annual Evaluation and also provided a copy of the last Annual Evaluation dated 3/16/13; but, indicated that they failed to have a physician assistant present. Review of the Annual Evaluation dated 3/16/13 revealed the members in attendance lacked a physician assistant.

D. Interview with Physician Assistant-Z on 7/23/13 from 11:00 AM to 11:15 AM revealed some policies and procedures were reviewed during Medical Staff meetings which physician assistant attend but have no voting privileges. This method for policy and procedure development and review lacks assurance that a physician assistant will be involved in the development of new patient care policies and procedures.

Based on review of policies and procedures, review of the Annual Evaluation and staff interview, the Critical Access Hospital (CAH) failed to include 1 of 3 required members in the group of professionals responsible for the annual review of the patient care policies (midlevel practitioner/physician assistant). The CAH had 5 physician assistants that worked in the Emergency Department. Census on the first day of survey was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview on 7/24/13 from 8:00 AM to 8:10 AM with the Compliance Coordinator, individual identified as chairman for the Policies and Procedures Committee, revealed the membership of this committee lacked a physician, midlevel practitioner/physician assistant and a member not on staff at the CAH.

Review of the last meeting minutes that were available for the policy and procedures committee dated 5/30/13 confirmed a physician, midlevel practitioner/physician assistant and a person not on staff at the CAH were not listed as members present. The Stated Goal for this committee was:
"To produce online a comprehensive set of policies and procedures which are not department specific and are more function based thus lessening the chance of redundant policies and procedures occurring. There needs to be a prescribed format, method for archiving, and a sophisticated search function"

B. Review of the policy and procedure titled Adoption & Revision (last reviewed 6/11) revealed the following policy:
"Department Leaders shall be responsible to determine necessity of new or revised policies and procedures while maintaining no noticeable redundancy or repetition; and obtaining approval from the CEO [Chief Executive Officer]". The only mention of a physician, midlevel practitioner/physician assistant and/or person not on staff at the CAH was under Procedure 5 which stated "Documentation of a revision/review may also include a signature face sheet showing approval and/or revision date with CEO, Department Leader and/or Medical Director signature shall be maintained in the department Policy Manual."

C. Interview with the Quality Leader on 7/25/13 from 1:30 PM to 1:35 PM revealed that policies and procedures are reviewed annually during the meeting for the Annual Evaluation and also provided a copy of the last Annual Evaluation dated 3/16/13; but, indicated that they failed to have a physician assistant present. Review of the Annual Evaluation dated 3/16/13 revealed the members in attendance lacked a physician assistant.

Based on observation, record review of Quality Assurance reports, and staff interview, the Critical Access Hospital (CAH) failed to ensure that Bio Electronics, a contracted Bio Medical Maintenance Service, provided quality reports to ensure the safety of critical patient care equipment could be evaluated. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. On 7/23/13 tour of Respiratory Therapy from 10:15 AM to 11:20 AM revealed the hospital had 2 machines to support respiration for critically ill inpatients. One was an Esprit Ventilator and the other a Phillips Bipap machine. Both machines had stickers dated 10/05/10. The Respiratory Therapist on 7/23/13 at 10:30 AM confirmed the machines are used on average 3 times per year.

B. Interview with the Quality Assurance Manager (QA)-M on 7/24/13 at 11:39 AM confirmed neither machine had been calibrated for preventive maintenance since 10/5/10. Further interview with QA-M on 7/25/13 at 10:45 AM revealed that the facility does not receive any quality data from the Bio Electronics contracted provider to ensure critical hospital equipment maintenance checks are done. The manager stated "we will be using this as an example to ensure all equipment is checked." Record review of other contracted services on 7/25/13 at 10:15 AM found evidence of Quality Assurance reporting/monitoring activity.

Based on record review, staff and patient interview, the Critical Access Hospital (CAH) failed to provide each patient with a notice of the 13 Swing Bed Resident Rights. The Resident Rights provided to the patients lacked 6 of the 13 Rights including:
- The right to be informed in writing at the time of admission of the charges covered under Medicaid or Medicare.
- The right to choose a physician.
- The right to work.
- The right to send and receive mail unopened.
- The right to retain and use personal property.
- The right to share a room with their spouse when married and live in the same facility.
The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have a separate Admission Packet for our Swing Bed Patients. We just use our Acute Care Admission Packet for both types of patients. So, no, I guess we don't have one that spells out all of the Swing Bed Rights."

B. Review of the Admission Packet provided on 7/24/13 at 12:45 PM revealed an undated copy of "Patient's Rights and Responsibilities". Within these "Patient's Rights and Responsibilities" 7 of the 13 Swing Bed Rights were covered.

C. Interview with Patient 39 on 7/25/13 at 9:20 AM, "No, I didn't get a list with the rights that I remember when I came to swing bed."

D. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a list of the Swing Bed Resident Rights. We just use the Acute Care Patient Rights."

Based on record review, staff and resident interview, 8 of 8 (5 current and 3 closed records) Swing Bed records failed to have evidence of written resident notification of expected benefits under Medicaid/Medicare and what items the resident may be responsible for either at admission or during their stay (Residents 35, 36, 37, 38, 39, 45, 46 and 47). The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of Swing Bed records lacked a signed Swing Bed agreement type form outlining the expected benefits and expected costs for items not covered during their Swing Bed stay for:
- Resident 35 admitted date 7/16/13 and current resident.
- Resident 36 admitted date 7/18/13 and current resident.
- Resident 37 admitted date 7/20/13 and current resident.
- Resident 38 admitted date 7/20/13 and current resident.
- Resident 39 admitted date 7/19/13 and current resident.
- Resident 45 admitted date 6/10/13 and discharged 6/14/13.
- Resident 46 admitted date 4/23/13 and discharged 5/23/13.
- Resident 35 admitted date 6/20/13 and discharged 7/22/13.

B. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have a charge sheet for services that I know of."

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, the Swing Bed residents are not notified of any financial benefits or costs expected that are not covered during their stay.

D. Interview with Patient 39 on 7/25/13 at 9:20 AM revealed "I wasn't given any information about payment for stay here." The resident wasn't aware if or what items are covered or not covered.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients due to their level of care or difficulty with their care. This has the potential to affect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

B. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components to protect Swing Bed patients' rights.

C. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have all that transfer and discharge information in a policy or procedure for our Swing Bed Patients. We use our hospital transfer sheets if we have to send someone to another facility, like another hospital to provide a higher level of care or a nursing home or assisted living. We provide discharge instructions for those that we dismiss. But that isn't the same as what you are talking about."

D. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients without cause. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the components related to a facility-initiated discharge or transfer unless:
- The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.
- The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.
- The safety/health of individuals in the facility would be endangered.
- The resident has failed, after reasonable and appropriate notice to pay for a stay at the facility.
- The facility ceases to operate.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH)failed to have a Policy and Procedure in place to ensure the physician completes the required documentation of a facility-initiated transfer and discharge. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components outlining the documention requirements for a facility-initiated transfer or discharge including:
- The Physician's documentation in the patient's record related to the necessity of transfer and discharge.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No we don't currently have a specific Policy and Procedure for Swing Bed patients transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure proper procedures for notification of tranfers. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components related to notification of facility-initiated transfers and discharges including:
- The resident, a family member or legal representative was provided a notice of the transfer or discharge and with the reasons for the move in writing in a language they understand.
- They record the reasons in the resident clinical record.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the resident is given timely notice of the facility-initiated discharge or transfer. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the components related to the timeliness of the written notice including:
- A notice at least 30 days before the planned date of transfer or discharge.
- The notice must be made as soon as practicable if the notice is due to the health and safety of the resident or individuals in the facility.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patients transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility-initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the written notice includes all the necessary components for the facility-initiated transfer or discharge of the resident. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of components included in a written notice, including:
- The reason for transfer or discharge.
- The effective date of transfer or discharge.
- The location to which the resident is transferred or discharged.
- A statement that the resident has the right to appeal the action to the State.
- The name, address and telephone number of the State long term care ombudsman.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility-initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to develop policies and procedures prohibiting the mistreatment, neglect and abuse of residents and prohibiting the misappropriation of resident property. The facility census was 9 acute patients and 9 swing bed patients. This has the potential to effect all Swing Bed Admissions.

Findings are:

A. Review of the two policies the facility provided regarding abuse revealed that they included:
- Procedures for Domestic Violence; contact with a victim of suspected abuse.
- Protocol for proper notification regarding cases of suspected abuse and/or neglect in minor children.
Neither addressed staff treatment of residents.

B. Interview with the Chief Nursing Officer on 7/25/13 at 3:20 PM verified the facility lacked a written Policy and Procedure that prohibits staff treatment of residents related to abuse, neglect and misappropriation of resident property.

Based on review of policies and procedures, review of personnel files, review of requested documentation and staff interview, the Critical Access Hospital (CAH) could not ensure that allegations of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the CAH and to the State survey agency and that those allegations are investigated with a report to the administrator and State survey agency within 5 days of the incident, as the CAH lacked:
- A policy and procedure addressing these requirements; and
- Failed to orient 12 of 12 sample employees hired since 5/19/11 to these abuse/neglect requirements at the time of hire.
Census on the first day of survey was 9 swing bed patients out of a total census of 18. This failed practice had the potential to affect all patients of the CAH.

Findings are:

A. Review of the 2 policies the facility provided regarding abuse revealed that they included:
- Procedures for Domestic Violence; contact with a victim of suspected abuse.
- Protocol for proper notification regarding cases of suspected abuse and/or neglect in minor children.
Neither addressed staff treatment of residents.

B. Interview with the Chief Nursing Officer on 7/25/13 at 3:20 PM verified the facility lacked a
written Policy and Procedure that prohibits staff treatment of residents related to abuse, neglect and misappropriation of resident property.



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C. Review of personnel files for Employee-A hired 5/14/12, Employee-B hired 3/29/12, Employee-C hired 10/8/12, Employee-D hired 9/18/12, Employee-E hired 9/24/12, Employee-F hired 5/13/13, Employee-G hired 6/19/11, Employee-H hired 9/6/12, Employee-I hired 5/27/11, Employee-J hired 11/5/12, Employee-K hired 10/2/12 and Employee-L hired 1/15/13 revealed no documentation of orientation to staff treatment of patients that prohibits abuse, neglect and misappropriation of resident property and the reporting requirements. Interview with the Human Resource Leader on 7/25/13 from 8:50 AM to 9:30 AM revealed that during general orientation talk about patient rights it just says that the patient has the right to be free from abuse. Review of a typed document by the Human Resource Leader dated 7/25/13 and provided at 1:15 PM regarding documentation of orientation on abuse and neglected by individual departments revealed the following:
" I have contacted Department, Leaders in Nursing, Radiology, Housekeeping, Food and Nutrition Services, Pharmacy and Laboratory. All have stated that they cover this in general with policy review, but do not have specific documentation to provide for orientation."

Since the CAH lacked a policy regarding mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property and the reporting requirements, the CAH could not ensure that allegation of abuse, neglect and misappropriation of resident property would be reported and investigated.

Based on staff interviews, record reviews, and review of policies and procedures; the Critical Access Hospital (CAH) failed to fully complete initial and periodic comprehensive assessments for 8 of 8 Swing Bed patients (Patients 35, 36, 37, 38, 39, 45, 46 and 47) as per regulation. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the Swing Bed Records for Patients 35, 36, 37, 38, 39, 45, 46 and 47 revealed a lack of a Comprehensive Assessment completed including all of the following components:
- Identification and demographic information.
- Customary routines.
- Cognitive patterns.
- Communication.
- Vision.
- Mood and behavior patterns.
- Psychosocial well-being.
- Physical functioning and structural problems.
- Continence.
- Disease diagnoses and health conditions.
- Dental and nutritional status.
- Skin condition.
- Activity pursuit.
- Medications.
- Special treatments and procedures.
- Discharge potential.
- Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.
- Documentation of participation in assessment.

B. Interview with the Case Manager on 7/24/13 at 12:15 PM when shown the components of the Comprehensive Assessment revealed, "No we don't do a Comprehensive Assessment with all of that. We have parts of those things interspersed in the patient's records, but no specific form or documentation that pulls all of those pieces into one place. I also meet with the patients nearly daily for updates on their status."

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No we don't have a specific policy or procedure that outlines the Comprehensive Assessments. We just do our regular assessments on our swing bed residents and the Case Manager works on the Discharge plans starting when they are admitted."

Based on staff interview and record review of 2 of 2 closed Swing Bed residents (Patients 46 and 47) who had been in the facility for 14 days or more failed to have a comprehensive, accurate, standardized, reproducible assessment completed. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Record review revealed Swing Bed Resident 46 was admitted on 4/23/13 status post hospitalization for recurrent left pneumothorax (collapsed lung), multiple sclerosis (a neurological disease), chronic obstructive pulmonary disease (a disease that affects breathing), anxiety and depression per the 6/14/13 Physician Discharge Summary. The patient was discharged home on 5/23/13.

B. Record review revealed Swing Bed Resident 47 was admitted on 6/20/13 status post hospitalization for Alzheimers disease (a progressive disease of the brain that leads to impaired intellectual functioning), chronic renal failure (kidney disease), metastatic carcinoma of the bladder (cancer of the bladder that spreads to other body tissues), diabetes, chronic obstructive pulmonary disease (a disease that affects breathing), hypertension (high blood pressure) per the 7/21/13 Physician Discharge Summary. The patient was transferred to a nursing home on 7/22/13.

C. Review of the entire paper and electronic medical record (EMR) on 7/25/13 failed to find a standardized comprehensive assessment performed. Staff interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N confirmed this finding.

D. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't have a Comprehensive Assessment form. We just use our regular assessments on our swing bed residents."

E. Interview with the Case Manager (CM) on 7/24/13 at 12:15 PM when shown the components of the Comprehensive Assessment revealed, "No, we don't do a Comprehensive Assessment with all of that on our Swing Bed patients."

Based on staff interviews and record reviews, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan for 8 of 8 Swing Bed patients (Patients 35, 36, 37, 38, 39, 45, 46 and 47) which would include medical, nursing, mental and psychosocial needs identified in the initial and periodic comprehensive assessments. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patient 35, 36, 37, 38, 39, 45, 46 and 47 on 7/24/13 and 7/25/13 was completed. The Care Plans (CP) for the 8 patients included the following problems:
- Resident 35's CP addressed Adult Standard of Care, Adult Swing Bed Care, Occupational and Physical Therapy CP and COPD (chronic obstructive pulmonary disease).
- Resident 36's CP addressed Adult Standard of Care, General Oncology (general cancer cares), Physical Therapy CP and high blood pressure.
- Resident 37's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP and Total Joint Replacement.
- Resident 38's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP and Total Joint Replacement.
- Resident 39's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP.
- Resident 45's CP addressed Adult Standard of Care, Congestive Heart Failure (disease of the heart), Occupational and Physical Therapy CP.
- Resident 46's CP addressed Adult Standard of Care, Chronic Obstructive Pulmonary Disease, Pneumothorax (collapsed lung), Impaired Immobility, Occupational and Physical Therapy CP.

B. Interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N verified that there is not a comprehensive care plan that includes all the areas on the comprehensive assessment. RN-N indicated that the care plans are more of a medical base.

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified the facility does not have a Comprehensive Care Plan that includes all of the areas on the Comprehensive Assessment form.

Based on staff interviews and record reviews, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan for 2 of 2 Swing Bed patients (Patients 46 and 47) prepared by an interdisciplinary team. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patients 46 and 47 on 7/24/13 and 7/25/13 was completed. The records lacked a Comprehensive Resident Assessment; therefore, the records lacked a Comprehensive Resident Care Plan prepared by an interdisciplinary team.

B. Interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N verified that there is not a comprehensive care plan that includes all the area on the comprehensive assessment. RN-N indicated that the care plans are more of a medical base.

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified the facility does not have a Comprehensive Care Plan that includes all of the areas on the Comprehensive Assessment form.

Based on record review and staff interview, the Critical Access Hospital (CAH) facility failed to ensure 3 of 3 discharged Swing Bed patients (Patients 45, 46 and 47) had a discharge summary that included a recapitulation of the patients' stay. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Record review revealed Swing Bed Resident 45 was admitted on 6/10/13 status post hospitalization for a fractured right ankle (broken right ankle), abrasion (scrapes) to the right elbow/forearm, hypertension (high blood pressure]) and atrial fibrillation (irregular heart beat)on anticoagulation (blood thinners) per the 6/14/13 Physician Discharge Summary. The patient was discharged to a nursing home on 6/14/13.

B. Record review revealed Swing Bed Resident 46 was admitted on 4/23/13 status post hospitalization for recurrent left pneumothorax (collapsed lung), multiple sclerosis (a neurological disease), chronic obstructive pulmonary disease (disease that affects breathing), anxiety and depression per the 6/14/13 Physician Discharge Summary. The patient was discharged home on 5/23/13.

C. Record review revealed Swing Bed Resident 47 was admitted on 6/20/13 status post hospitalization for Alzheimers disease (a progressive disease of the brain that leads to impaired intellectual functioning), chronic renal failure (kidney disease), metastatic carcinoma of the bladder (cancer of the bladder that spreads to other body tissues), diabetes, chronic obstructive pulmonary disease (a disease that affects breathing), hypertension (high blood pressure) per the 7/21/13 Physician Discharge Summary. The patient was transferred to a nursing home on 7/22/13.

D. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patient 45, 46 and 47 revealed a lack of a discharge summary by staff to recapitulate (summarize) the patients' stay as required.

E. Interview with RN (Registered Nurse)-N on 7/25/13 at 11:10 AM verified that there are no Discharge Summary/Recapitulation (brief summary) on the medical records for Swing Bed Patients 45, 46 or 47.

F. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a Policy and Procedure for the Discharge Summary/Recapitulation for the Swing Bed patients that have been discharged. "

Based on observation, staff interview and the Bio Electronics (a company that provides medical equipment management, preventive maintenance and repair). Equipment File List failed to ensure that 2 randomly observed pieces of patient care equipment received routine preventive maintenance:
- An Esprit Ventilator (the name of a ventilator - an appliance providing artificial respirations) manufactured by Phillips Respironics Corporation (a company that specializes in products that improve respiratory functions, and assists with preventive maintenance and repair).
- A Phillips Bipap (the name of a portable ventilator manufactured by Respironics Corporation).
The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the Respiratory Department and equipment storage area on 7/23/13 from 10:15 AM to 11:20 AM with the Respiratory Therapist revealed 2 machines:
- The Esprit Ventilator with the Bio Electronics sticker 0001017 and a Respironics sticker dated 10/5/10;
- The Phillips Bipap machine with a Respironics sticker dated 10/5/10 and no Bio Electronics sticker.

B. Interview with the Respiratory Therapist on 7/23/13 at 10:30 AM revealed, "We use the Esprit Ventilator with the Phillips Bipap Machine as the back up ventilator on an average of 3 times a year." "I will have Maintenance pull up the forms with the dates they were serviced."

C. Interview with the Maintenance Worker (MW)-A on 7/23/13 at 3:40 PM revealed, "The numbers on the Esprit Ventilator 0001017 isn't on the list. The Phillips Bipap isn't on the list either. Maybe Respironics is checking these 2 machines, I will check into it."

D. Interview with the Quality Assurance Manager (QA)-M on 7/24/13 at 11:39 AM revealed, "We checked into the Esprit Ventilator and somehow the number got dropped off the Bio Electronics list. Therefore, it hasn't been calibrated for preventative maintenance since 10/5/10. We are contacting the appropriate people for calibration maintenance. I would assume the Phillips Bipap is the same situation."

E. Interview with the QA-M on 7/24/13 at 12:15 PM revealed, "We have taken those 2 machines out of service and the Bio Electronics people will be here sometime today to service it."

Interview with the QA-M on 7/25/13 at 9:10 AM revealed, "No, neither Bio Electronics or Respironics came yesterday. They were notified and Bio Electronics will be here next week."

Interview with the Chief Nursing Officer (CNO) on 7/25/13 at 9:30 AM revealed, "We have a plan that Anesthesia will come in and use the anesthesia machine if we need to have someone on a ventilator until the preventative maintenance is completed. We will leave those out of service."

Review of the Bio Electronics Equipment File List dated 6/5/13 showed that neither the Esprit Ventilator or the Phillips Bipap Machine were on the current preventative maintenance list.

Based on review of policies and procedures, review of the Annual Evaluation and staff interview, the CAH (Critical Access Hospital) failed to include 1 of 3 required members in the group of professionals responsible for the development of patient care policies (midlevel practitioner/physician assistant). The CAH had 5 physician assistants that worked in the Emergency Department. Census on the first day of survey was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview on 7/24/13 from 8:00 AM to 8:10 AM with the Compliance Coordinator, individual identified as chairman for the Policies and Procedures Committee, revealed the membership of this committee lacked a physician, midlevel practitioner/physician assistant and a member not on staff at the CAH.

Review of the last meeting minutes that were available for the policy and procedures committee dated 5/30/13 confirmed a physician, midlevel practitioner/physician assistant and a person not on staff at the CAH were not listed as members present. The Stated Goal for this committee was:
"To produce online a comprehensive set of policies and procedures which are not department specific and are more function based thus lessening the chance of redundant policies and procedures occurring. There needs to be a prescribed format, method for archiving, and a sophisticated search function"

B. Review of the policy and procedure titled Adoption & Revision (last reviewed 6/11) revealed the following policy:
"Department Leaders shall be responsible to determine necessity of new or revised policies and procedures while maintaining no noticeable redundancy or repetition; and obtaining approval from the CEO [Chief Executive Officer]". The only mention of a physician, midlevel practitioner/physician assistant and/or person not on staff at the CAH was under Procedure 5 which stated "Documentation of a revision/review may also include a signature face sheet showing approval and/or revision date with CEO, Department Leader and/or Medical Director signature shall be maintained in the department Policy Manual."

C. Interview with the Quality Leader on 7/25/13 from 1:30 PM to 1:35 PM revealed that policies and procedures are reviewed annually during the meeting for the Annual Evaluation and also provided a copy of the last Annual Evaluation dated 3/16/13; but, indicated that they failed to have a physician assistant present. Review of the Annual Evaluation dated 3/16/13 revealed the members in attendance lacked a physician assistant.

D. Interview with Physician Assistant-Z on 7/23/13 from 11:00 AM to 11:15 AM revealed some policies and procedures were reviewed during Medical Staff meetings which physician assistant attend but have no voting privileges. This method for policy and procedure development and review lacks assurance that a physician assistant will be involved in the development of new patient care policies and procedures.

Based on review of policies and procedures, review of the Annual Evaluation and staff interview, the Critical Access Hospital (CAH) failed to include 1 of 3 required members in the group of professionals responsible for the annual review of the patient care policies (midlevel practitioner/physician assistant). The CAH had 5 physician assistants that worked in the Emergency Department. Census on the first day of survey was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview on 7/24/13 from 8:00 AM to 8:10 AM with the Compliance Coordinator, individual identified as chairman for the Policies and Procedures Committee, revealed the membership of this committee lacked a physician, midlevel practitioner/physician assistant and a member not on staff at the CAH.

Review of the last meeting minutes that were available for the policy and procedures committee dated 5/30/13 confirmed a physician, midlevel practitioner/physician assistant and a person not on staff at the CAH were not listed as members present. The Stated Goal for this committee was:
"To produce online a comprehensive set of policies and procedures which are not department specific and are more function based thus lessening the chance of redundant policies and procedures occurring. There needs to be a prescribed format, method for archiving, and a sophisticated search function"

B. Review of the policy and procedure titled Adoption & Revision (last reviewed 6/11) revealed the following policy:
"Department Leaders shall be responsible to determine necessity of new or revised policies and procedures while maintaining no noticeable redundancy or repetition; and obtaining approval from the CEO [Chief Executive Officer]". The only mention of a physician, midlevel practitioner/physician assistant and/or person not on staff at the CAH was under Procedure 5 which stated "Documentation of a revision/review may also include a signature face sheet showing approval and/or revision date with CEO, Department Leader and/or Medical Director signature shall be maintained in the department Policy Manual."

C. Interview with the Quality Leader on 7/25/13 from 1:30 PM to 1:35 PM revealed that policies and procedures are reviewed annually during the meeting for the Annual Evaluation and also provided a copy of the last Annual Evaluation dated 3/16/13; but, indicated that they failed to have a physician assistant present. Review of the Annual Evaluation dated 3/16/13 revealed the members in attendance lacked a physician assistant.

Based on observation, record review of Quality Assurance reports, and staff interview, the Critical Access Hospital (CAH) failed to ensure that Bio Electronics, a contracted Bio Medical Maintenance Service, provided quality reports to ensure the safety of critical patient care equipment could be evaluated. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. On 7/23/13 tour of Respiratory Therapy from 10:15 AM to 11:20 AM revealed the hospital had 2 machines to support respiration for critically ill inpatients. One was an Esprit Ventilator and the other a Phillips Bipap machine. Both machines had stickers dated 10/05/10. The Respiratory Therapist on 7/23/13 at 10:30 AM confirmed the machines are used on average 3 times per year.

B. Interview with the Quality Assurance Manager (QA)-M on 7/24/13 at 11:39 AM confirmed neither machine had been calibrated for preventive maintenance since 10/5/10. Further interview with QA-M on 7/25/13 at 10:45 AM revealed that the facility does not receive any quality data from the Bio Electronics contracted provider to ensure critical hospital equipment maintenance checks are done. The manager stated "we will be using this as an example to ensure all equipment is checked." Record review of other contracted services on 7/25/13 at 10:15 AM found evidence of Quality Assurance reporting/monitoring activity.

Based on record review, staff and patient interview, the Critical Access Hospital (CAH) failed to provide each patient with a notice of the 13 Swing Bed Resident Rights. The Resident Rights provided to the patients lacked 6 of the 13 Rights including:
- The right to be informed in writing at the time of admission of the charges covered under Medicaid or Medicare.
- The right to choose a physician.
- The right to work.
- The right to send and receive mail unopened.
- The right to retain and use personal property.
- The right to share a room with their spouse when married and live in the same facility.
The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have a separate Admission Packet for our Swing Bed Patients. We just use our Acute Care Admission Packet for both types of patients. So, no, I guess we don't have one that spells out all of the Swing Bed Rights."

B. Review of the Admission Packet provided on 7/24/13 at 12:45 PM revealed an undated copy of "Patient's Rights and Responsibilities". Within these "Patient's Rights and Responsibilities" 7 of the 13 Swing Bed Rights were covered.

C. Interview with Patient 39 on 7/25/13 at 9:20 AM, "No, I didn't get a list with the rights that I remember when I came to swing bed."

D. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a list of the Swing Bed Resident Rights. We just use the Acute Care Patient Rights."

Based on record review, staff and resident interview, 8 of 8 (5 current and 3 closed records) Swing Bed records failed to have evidence of written resident notification of expected benefits under Medicaid/Medicare and what items the resident may be responsible for either at admission or during their stay (Residents 35, 36, 37, 38, 39, 45, 46 and 47). The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of Swing Bed records lacked a signed Swing Bed agreement type form outlining the expected benefits and expected costs for items not covered during their Swing Bed stay for:
- Resident 35 admitted date 7/16/13 and current resident.
- Resident 36 admitted date 7/18/13 and current resident.
- Resident 37 admitted date 7/20/13 and current resident.
- Resident 38 admitted date 7/20/13 and current resident.
- Resident 39 admitted date 7/19/13 and current resident.
- Resident 45 admitted date 6/10/13 and discharged 6/14/13.
- Resident 46 admitted date 4/23/13 and discharged 5/23/13.
- Resident 35 admitted date 6/20/13 and discharged 7/22/13.

B. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have a charge sheet for services that I know of."

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, the Swing Bed residents are not notified of any financial benefits or costs expected that are not covered during their stay.

D. Interview with Patient 39 on 7/25/13 at 9:20 AM revealed "I wasn't given any information about payment for stay here." The resident wasn't aware if or what items are covered or not covered.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients due to their level of care or difficulty with their care. This has the potential to affect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

B. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components to protect Swing Bed patients' rights.

C. Interview with the Case Manager on 7/24/13 at 12:15 PM revealed, "We don't have all that transfer and discharge information in a policy or procedure for our Swing Bed Patients. We use our hospital transfer sheets if we have to send someone to another facility, like another hospital to provide a higher level of care or a nursing home or assisted living. We provide discharge instructions for those that we dismiss. But that isn't the same as what you are talking about."

D. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the facility does not initiate a discharge or transfer of the Swing Bed patients without cause. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the components related to a facility-initiated discharge or transfer unless:
- The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.
- The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.
- The safety/health of individuals in the facility would be endangered.
- The resident has failed, after reasonable and appropriate notice to pay for a stay at the facility.
- The facility ceases to operate.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH)failed to have a Policy and Procedure in place to ensure the physician completes the required documentation of a facility-initiated transfer and discharge. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components outlining the documention requirements for a facility-initiated transfer or discharge including:
- The Physician's documentation in the patient's record related to the necessity of transfer and discharge.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No we don't currently have a specific Policy and Procedure for Swing Bed patients transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure proper procedures for notification of tranfers. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the necessary components related to notification of facility-initiated transfers and discharges including:
- The resident, a family member or legal representative was provided a notice of the transfer or discharge and with the reasons for the move in writing in a language they understand.
- They record the reasons in the resident clinical record.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the resident is given timely notice of the facility-initiated discharge or transfer. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of the components related to the timeliness of the written notice including:
- A notice at least 30 days before the planned date of transfer or discharge.
- The notice must be made as soon as practicable if the notice is due to the health and safety of the resident or individuals in the facility.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patients transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility-initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure the written notice includes all the necessary components for the facility-initiated transfer or discharge of the resident. This has the potential to effect all Swing Bed Residents. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the old Swing Bed: Transfer/Policy and Procedure dated 11/10 revealed the lack of components included in a written notice, including:
- The reason for transfer or discharge.
- The effective date of transfer or discharge.
- The location to which the resident is transferred or discharged.
- A statement that the resident has the right to appeal the action to the State.
- The name, address and telephone number of the State long term care ombudsman.

B. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a specific Policy and Procedure for Swing Bed patient transfers or discharge. We had a policy that talks a little about it but it doesn't have all the components. We stopped using these Swing Bed Policy & Procedures about a year ago. [Pulled up a file on the computer with various policies and procedures.] We had some staff changes and possibly that is when the specific Swing Bed Policies & Procedures fell through the cracks."

C. Since the facility lacked a policy and procedure regarding facility-initiated transfers or discharges for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive all the appropriate components for a transfer or discharge against their will.

Based on review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to develop policies and procedures prohibiting the mistreatment, neglect and abuse of residents and prohibiting the misappropriation of resident property. The facility census was 9 acute patients and 9 swing bed patients. This has the potential to effect all Swing Bed Admissions.

Findings are:

A. Review of the two policies the facility provided regarding abuse revealed that they included:
- Procedures for Domestic Violence; contact with a victim of suspected abuse.
- Protocol for proper notification regarding cases of suspected abuse and/or neglect in minor children.
Neither addressed staff treatment of residents.

B. Interview with the Chief Nursing Officer on 7/25/13 at 3:20 PM verified the facility lacked a written Policy and Procedure that prohibits staff treatment of residents related to abuse, neglect and misappropriation of resident property.

Based on review of policies and procedures, review of personnel files, review of requested documentation and staff interview, the Critical Access Hospital (CAH) could not ensure that allegations of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the CAH and to the State survey agency and that those allegations are investigated with a report to the administrator and State survey agency within 5 days of the incident, as the CAH lacked:
- A policy and procedure addressing these requirements; and
- Failed to orient 12 of 12 sample employees hired since 5/19/11 to these abuse/neglect requirements at the time of hire.
Census on the first day of survey was 9 swing bed patients out of a total census of 18. This failed practice had the potential to affect all patients of the CAH.

Findings are:

A. Review of the 2 policies the facility provided regarding abuse revealed that they included:
- Procedures for Domestic Violence; contact with a victim of suspected abuse.
- Protocol for proper notification regarding cases of suspected abuse and/or neglect in minor children.
Neither addressed staff treatment of residents.

B. Interview with the Chief Nursing Officer on 7/25/13 at 3:20 PM verified the facility lacked a
written Policy and Procedure that prohibits staff treatment of residents related to abuse, neglect and misappropriation of resident property.



04557


C. Review of personnel files for Employee-A hired 5/14/12, Employee-B hired 3/29/12, Employee-C hired 10/8/12, Employee-D hired 9/18/12, Employee-E hired 9/24/12, Employee-F hired 5/13/13, Employee-G hired 6/19/11, Employee-H hired 9/6/12, Employee-I hired 5/27/11, Employee-J hired 11/5/12, Employee-K hired 10/2/12 and Employee-L hired 1/15/13 revealed no documentation of orientation to staff treatment of patients that prohibits abuse, neglect and misappropriation of resident property and the reporting requirements. Interview with the Human Resource Leader on 7/25/13 from 8:50 AM to 9:30 AM revealed that during general orientation talk about patient rights it just says that the patient has the right to be free from abuse. Review of a typed document by the Human Resource Leader dated 7/25/13 and provided at 1:15 PM regarding documentation of orientation on abuse and neglected by individual departments revealed the following:
" I have contacted Department, Leaders in Nursing, Radiology, Housekeeping, Food and Nutrition Services, Pharmacy and Laboratory. All have stated that they cover this in general with policy review, but do not have specific documentation to provide for orientation."

Since the CAH lacked a policy regarding mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property and the reporting requirements, the CAH could not ensure that allegation of abuse, neglect and misappropriation of resident property would be reported and investigated.

Based on staff interviews, record reviews, and review of policies and procedures; the Critical Access Hospital (CAH) failed to fully complete initial and periodic comprehensive assessments for 8 of 8 Swing Bed patients (Patients 35, 36, 37, 38, 39, 45, 46 and 47) as per regulation. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the Swing Bed Records for Patients 35, 36, 37, 38, 39, 45, 46 and 47 revealed a lack of a Comprehensive Assessment completed including all of the following components:
- Identification and demographic information.
- Customary routines.
- Cognitive patterns.
- Communication.
- Vision.
- Mood and behavior patterns.
- Psychosocial well-being.
- Physical functioning and structural problems.
- Continence.
- Disease diagnoses and health conditions.
- Dental and nutritional status.
- Skin condition.
- Activity pursuit.
- Medications.
- Special treatments and procedures.
- Discharge potential.
- Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.
- Documentation of participation in assessment.

B. Interview with the Case Manager on 7/24/13 at 12:15 PM when shown the components of the Comprehensive Assessment revealed, "No we don't do a Comprehensive Assessment with all of that. We have parts of those things interspersed in the patient's records, but no specific form or documentation that pulls all of those pieces into one place. I also meet with the patients nearly daily for updates on their status."

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No we don't have a specific policy or procedure that outlines the Comprehensive Assessments. We just do our regular assessments on our swing bed residents and the Case Manager works on the Discharge plans starting when they are admitted."

Based on staff interview and record review of 2 of 2 closed Swing Bed residents (Patients 46 and 47) who had been in the facility for 14 days or more failed to have a comprehensive, accurate, standardized, reproducible assessment completed. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Record review revealed Swing Bed Resident 46 was admitted on 4/23/13 status post hospitalization for recurrent left pneumothorax (collapsed lung), multiple sclerosis (a neurological disease), chronic obstructive pulmonary disease (a disease that affects breathing), anxiety and depression per the 6/14/13 Physician Discharge Summary. The patient was discharged home on 5/23/13.

B. Record review revealed Swing Bed Resident 47 was admitted on 6/20/13 status post hospitalization for Alzheimers disease (a progressive disease of the brain that leads to impaired intellectual functioning), chronic renal failure (kidney disease), metastatic carcinoma of the bladder (cancer of the bladder that spreads to other body tissues), diabetes, chronic obstructive pulmonary disease (a disease that affects breathing), hypertension (high blood pressure) per the 7/21/13 Physician Discharge Summary. The patient was transferred to a nursing home on 7/22/13.

C. Review of the entire paper and electronic medical record (EMR) on 7/25/13 failed to find a standardized comprehensive assessment performed. Staff interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N confirmed this finding.

D. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't have a Comprehensive Assessment form. We just use our regular assessments on our swing bed residents."

E. Interview with the Case Manager (CM) on 7/24/13 at 12:15 PM when shown the components of the Comprehensive Assessment revealed, "No, we don't do a Comprehensive Assessment with all of that on our Swing Bed patients."

Based on staff interviews and record reviews, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan for 8 of 8 Swing Bed patients (Patients 35, 36, 37, 38, 39, 45, 46 and 47) which would include medical, nursing, mental and psychosocial needs identified in the initial and periodic comprehensive assessments. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patient 35, 36, 37, 38, 39, 45, 46 and 47 on 7/24/13 and 7/25/13 was completed. The Care Plans (CP) for the 8 patients included the following problems:
- Resident 35's CP addressed Adult Standard of Care, Adult Swing Bed Care, Occupational and Physical Therapy CP and COPD (chronic obstructive pulmonary disease).
- Resident 36's CP addressed Adult Standard of Care, General Oncology (general cancer cares), Physical Therapy CP and high blood pressure.
- Resident 37's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP and Total Joint Replacement.
- Resident 38's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP and Total Joint Replacement.
- Resident 39's CP addressed Adult Standard of Care, Occupational and Physical Therapy CP.
- Resident 45's CP addressed Adult Standard of Care, Congestive Heart Failure (disease of the heart), Occupational and Physical Therapy CP.
- Resident 46's CP addressed Adult Standard of Care, Chronic Obstructive Pulmonary Disease, Pneumothorax (collapsed lung), Impaired Immobility, Occupational and Physical Therapy CP.

B. Interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N verified that there is not a comprehensive care plan that includes all the areas on the comprehensive assessment. RN-N indicated that the care plans are more of a medical base.

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified the facility does not have a Comprehensive Care Plan that includes all of the areas on the Comprehensive Assessment form.

Based on staff interviews and record reviews, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan for 2 of 2 Swing Bed patients (Patients 46 and 47) prepared by an interdisciplinary team. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patients 46 and 47 on 7/24/13 and 7/25/13 was completed. The records lacked a Comprehensive Resident Assessment; therefore, the records lacked a Comprehensive Resident Care Plan prepared by an interdisciplinary team.

B. Interview on 7/25/13 at 11:10 AM with RN (Registered Nurse)-N verified that there is not a comprehensive care plan that includes all the area on the comprehensive assessment. RN-N indicated that the care plans are more of a medical base.

C. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified the facility does not have a Comprehensive Care Plan that includes all of the areas on the Comprehensive Assessment form.

Based on record review and staff interview, the Critical Access Hospital (CAH) facility failed to ensure 3 of 3 discharged Swing Bed patients (Patients 45, 46 and 47) had a discharge summary that included a recapitulation of the patients' stay. The facility census was 9 acute patients and 9 swing bed patients.

Findings are:

A. Record review revealed Swing Bed Resident 45 was admitted on 6/10/13 status post hospitalization for a fractured right ankle (broken right ankle), abrasion (scrapes) to the right elbow/forearm, hypertension (high blood pressure]) and atrial fibrillation (irregular heart beat)on anticoagulation (blood thinners) per the 6/14/13 Physician Discharge Summary. The patient was discharged to a nursing home on 6/14/13.

B. Record review revealed Swing Bed Resident 46 was admitted on 4/23/13 status post hospitalization for recurrent left pneumothorax (collapsed lung), multiple sclerosis (a neurological disease), chronic obstructive pulmonary disease (disease that affects breathing), anxiety and depression per the 6/14/13 Physician Discharge Summary. The patient was discharged home on 5/23/13.

C. Record review revealed Swing Bed Resident 47 was admitted on 6/20/13 status post hospitalization for Alzheimers disease (a progressive disease of the brain that leads to impaired intellectual functioning), chronic renal failure (kidney disease), metastatic carcinoma of the bladder (cancer of the bladder that spreads to other body tissues), diabetes, chronic obstructive pulmonary disease (a disease that affects breathing), hypertension (high blood pressure) per the 7/21/13 Physician Discharge Summary. The patient was transferred to a nursing home on 7/22/13.

D. Review of the entire paper and electronic medical record (EMR) for Swing Bed Patient 45, 46 and 47 revealed a lack of a discharge summary by staff to recapitulate (summarize) the patients' stay as required.

E. Interview with RN (Registered Nurse)-N on 7/25/13 at 11:10 AM verified that there are no Discharge Summary/Recapitulation (brief summary) on the medical records for Swing Bed Patients 45, 46 or 47.

F. Interview with the Chief Nursing Officer 7/25/13 at 3:20 PM verified, "No, we don't currently have a Policy and Procedure for the Discharge Summary/Recapitulation for the Swing Bed patients that have been discharged. "