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Based on record review and interview the facility failed to ensure the emergency crash cart, located in the Radiology department, was readily available when it did not perform daily checks.

Findings Include:

Review of the facility provided policy Crash Carts (dated March 2009) reflected:
"Purpose: To ensure...crash carts are managed effectively... Crash cart will be checked daily. The individual assigned to check the crash cart will sign the log located on the crash cart...."

During a tour of the facility's Radiology department on 4/18/16 at 12:00 p.m. the crash cart located in the Computed Tomography (CT) room revealed:
On 4/5/16, 4/8/16, 4/9/16, 4/10/16, 4/15/16, 4/16/16, and 4/17/16 the cart check list log was blank.

During an interview on 4/18/16 in the CT room, staff #5, the Chief Nursing Officer confirmed the finding.

Based on record review and interview the facility failed to follow the manufacturer-recommended maintenance activities and schedule; and failed to maintain documentation of the maintenance activity for the Table- Top Autoclave (Sterilizer).

Findings include:

Review of the facility provided Table-Top Autoclave manufacturer's MAINTENANCE INSTRUCTIONS Manual reflected: " ...9.1 Preventative Scheduled Maintenance ...Daily Clean door gasket with a mild detergent, water and soft cloth ...ONCE PER WEEK, clean the air jet ....clean the water sensor in the rear of the chamber with a damp cloth or sponge ....Once per week clean and descale the chamber, copper tubes and the reservoir ...Clean the tray holder and trays with detergent ...Periodically ...Once every six months clean the fan grid with compressed air from the inside outward ..."

Review of the facility provided CLEANING OF TABLE-TOP STEAM STERILIZER (undated) Policy did not include when the cleaning was to be performed. The instructions did not include the cleaning of the gasket, air jet, water sensor, descaling, tray holder, and the fan grid.

Review of the Portable Steam Autoclave Sterilizer Log reflected usage on:
1/8/16, 1/23/16, 2/3/16, 2/11/16, 2/24/16, 3/19/16, 3/22/16, 4/17/16, 4/18/16

Review, on 4/18/16, of the facility provided Table-Top Steam Autoclave Cleaning log reflected cleaning was performed on 1/22/16, 2/2/16, and 3/2/16.

During an interview on 4/18/16 at 1:20 p.m. Staff #17, Sterilization Technician stated, "I wipe it down with a wet cloth. I check to see if there is anything in it." "I don't clean the sterilizer, Staff #18 cleans it." "I use it to clean equipment for the clinic."

During an interview on 4/18/16 at 4:25 p.m. Staff #5, the Chief Nursing Officer, confirmed the finding.

Based on review of hospital documents and staff interview it was determined that the facility failed to assure the safety of patients in non-medical emergencies by not training staff annually in handling emergencies.

Findings were:

The facility did not have documentation that an annual training program was conducted for instructions of all personnel in the location and use of fire-fighting equipment, for reporting of fires, extinguishing of fires, and on handling non-medical emergencies.

In an interview with the facility Administrator (staff # 19) on the afternoon of 04-18-2016 the above information was confirmed.

Based on record review and interview the facility failed to provide Activities for (5) five out of (5) five patients admitted to the facility's Swing Bed unit. (Patients #3, #4, #5, #6, and #7)

Findings Include:

Review of Patient #3's medical records reflected an 81 year old male admitted to the facility's Swing Bed unit on 1/8/16 and discharged on 2/5/16. Patient #3's records did not include any documented attendance or the offering of activities.

Review of Patient #4's medical records reflected an 88 year old male admitted to the facility's Swing Bed unit on 2/29/16 and discharged on 3/15/16. Patient #4's records did not include any documented attendance or the offering of activities.

Review of Patient #5's medical records reflected an 82 year old male admitted to the facility's Swing Bed unit on 3/22/16 and discharged on 3/25/16. Patient #5's records did not include any documented attendance or the offering of activities.

Review of Patient #6's medical records reflected an 82 year old male admitted to the facility's Swing Bed unit on 4/8/16 and discharged on 4/12/16. Patient #6's records did not include any documented attendance or the offering of activities.

Review of Patient #7's medical records reflected an 89 year old male admitted to the facility's Swing Bed unit on 11/30/15 and discharged on 12/15/15. Patient #7's records did not include any documented attendance or the offering of activities.

Review of the facility provided Swing Bed Resident Rights (undated) Policy reflected: "...The resident has a right to a dignified existence...A facility must protect and promote the rights of each resident....You have a right to... Participate in activities..."

During an interview on 4/18/16, in the afternoon, in the conference room, the Staff #5, Chief Nursing Officer confirmed the findings.

Based on record review and interview the facility failed to provide a comprehensive care plan for (3) three out of (5) five patients admitted to the Swing Bed unit; Activities were not included in the Patient Care Plans. (Patients #3, #4, and #7)

Findings Include:

Review of Patient #3's medical records reflected an 81 year old male admitted to the facility's Swing Bed unit on 1/8/16 and discharged on 2/5/16. Patient #3's care plan did not include Activities.

Review of Patient #4's medical records reflected an 88 year old male admitted to the facility's Swing Bed unit on 2/29/16 and discharged on 3/15/16. Patient #4's care plan did not include Activities.

Review of Patient #7's medical records reflected an 89 year old male admitted to the facility's Swing Bed unit on 11/30/15 and discharged on 12/15/15. Patient #7's care plan did not include Activities.

Review of the facility provided Swing Bed Resident Rights (undated) Policy reflected: "...The resident has a right to a dignified existence...A facility must protect and promote the rights of each resident....You have a right to... Participate in activities..."

Review of the facility provided Care Plan Policy (undated) reflected: "...The Plan of Care will be review by the Interdisciplinary team and updated on a weekly basis....
Activities are recommended based upon the individual patient's activity assessment and interests...."

During an interview on 4/18/16, in the afternoon, in the conference room, the Staff #5, Chief Nursing Officer confirmed the findings.