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Based on observation, interview and record review the facility failed to ensure that expired or opened supplies were unavailable for patient use in the Emergency Department (ED), Operating Room (OR), the inpatient supply area, and the Outpatient Specialty Clinic. These failures indicated that the facility did not have an effective process to ensure that safe, current supplies were available for patient use and had the potential to affect all patients resulting in adverse or delayed treatment. The facility census was four.

Findings included:

1. Although requested the facility failed to provide a policy regarding checking of outdated supplies.

2. Record review of the facility document titled, "Daily Duties Checklist," dated 03/07/17 showed a list of eight duties that were to be completed on both day and night shift. Item five stated that staff was to check all things for expired dates (crash cart supplies, needles, IV's, etc.) on the 25th of the month for January, March, May, July, September and November. The day shift was responsible for January, March, May, July, September and November and the night shift was responsible for the remaining months. The Charge Nurse was to delegate these duties and was to sign at the end of the section.

3. Observation on 03/06/17 at 2:40 PM in the Emergency Department trauma room showed four infant urinary catheter (a tube that drains urine from the bladder to a bag outside the body) kits that were expired as of 02/2017 and one endotracheal tube (a tube is placed in the windpipe (trachea) to help a person to breath) which was expired as of 02/2017.

During a concurrent interview, Staff E, Nurse Manager, stated that staff checked all supplies on the 25th of each month for expirations but did not pull supplies out of service that would expire at the end of the month.

4. Observation with concurrent interview in the Operating Room (OR) on 03/07/17 at 11:15 AM showed two bottles of Isopropyl Alcohol 70% (rubbing alcohol, a colorless liquid that is used to clean wounds and skin), 16 ounce (oz.) bottle, and expired 01/2017. One bottle was open with approximately one third left in the bottle. The other bottle was unopened. Staff K, OR Coordinator, confirmed the finding.

During an interview on 03/08/17 at 11:51 AM, Staff K stated that expiration dates on supplies were checked monthly, but staff did not document to a list of supplies with the expiration dates documented

5. Observation on 03/06/17 at 2:45 PM in the supply area located directly behind the inpatient nursing station showed:
- Eleven Vacutainers (a sterile glass or plastic tube that is used for blood collection) with an expiration date of 11/2015, one of these had an open package;
- One vacutainer with a manufacturers' expiration date of 04/2013;
- One 200 milliliter (unit of liquid volume) latex free urine meter (measuring chamber that accurately measures urine output) with a manufacturers' expiration date of 02/2017;
- Three infant catheter kits with a manufacturers' expiration date of 02/2017.

During an interview on 03/06/17 at 10:20 AM, Staff G, Registered Nurse (RN), Charge Nurse, stated that supplies were checked for outdates on the 25th of each month. She stated that the day and night shift each had specific months that the staff checked for expired supplies. She referred to the daily duties checklist and stated that the charge nurse signed off for each duty listed.

During an interview on 03/06/17 at 4:00 PM, Staff F, Licensed Practical Nurse (LPN) stated that nursing staff were to check for outdates at the request of the charge nurse.

6. Observation on 03/08/17 at 2:45 PM in the Outpatient Specialty Clinic treatment rooms showed:
- Three suture (stitch) removal kits with scissors with a manufacturers' expiration date of 02/01/17 and one general purpose suture removal kits with a manufacturers' expiration date of 08/01/16 in treatment room four;
- One suture removal kit with scissors with a manufacturers' expiration date of 08/01/16 in treatment room five;
- One catheter stabilizer device with a manufacturers' expiration date of 08/2016 in treatment room six;
- One general purpose suture removal kit with a manufactures' expiration date of 10/01/16 and one silver antimicrobial (additives to dressings that help in the healing of a wound) dressing with a manufactures' expiration date of 03/2016 in the medication/supply room.

During an interview on 03/08/17 at 2:30 PM Staff AA, RN stated that the supplies were checked for outdates monthly. She stated they just picked a day when there wasn't a doctor there and just went through the cabinets.

During an interview on 03/09/17 at 12:30 PM Staff E, RN, Nurse Manager, stated that she expected all supplies to be checked on a regular basis to avoid expired supplies being used for patient care.




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29117

Based on interview and record review the Governing Body (GB) failed to ensure:
- Preventative maintenance (PM, maintenance that is regularly performed on a piece of equipment to lessen the likelihood of it failing), was completed in a timely manner for nine of 10 devices in the Operating Room; three of three vital sign monitors (a device that takes an automatic blood pressure, pulse, and shows the patient's heart rhythm) in the Pre/post anesthesia area, and approximately 23 other devices;
- The completion of an annual Periodic Evaluation of the Critical Access Hospital (CAH) total program; and
- An outside entity review of the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services. The facility census was four.

Findings included:

1. Record review of the facility's document titled, "Constitution and Bylaws of the Hospitals Board of Directors," showed:
- The president of the board was the Chief Executive Officer (CEO).
- At the end of each fiscal year, the board shall meet for the purpose of reviewing its performance during the past year.
- The duties of the CEO included ensuring all physical properties are kept in good state of repair and operating condition and that the best possible care may be rendered to all patients.

During an interview on 03/09/17 at 9:30 AM, Staff GG, GB member, stated that:
- The GB was ultimately responsible for the all hospital activities.
- The GB relied on communications from the CEO and senior staff.
- They were not able to judge quality, but relied on the response of the community, surveyors, and trends.
- Currently, there was an increase in hospital usage and services used which showed the community was happy with the facility services.
- The GB was not aware that the hospital was behind in PM. That can be fixed.
- The GB reviewed annual reports, but not to the extent of a periodic evaluation.
- At one time the facility had a financial and management agreement with an outside facility, but the facility no longer had that.

2. Record review of the facility's document titled, "Critical Access Hospital Program Medicare Rural Hospital Flexibility Program Network Agreement," dated 06/12/12, showed an agreement with an outside facility to provide reasonably objective oversight and assistance to the CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by the CAH's physicians and to reasonably assist the CAH to implement its Quality Assurance (QA) Plan, to review findings under the CAH's QA Plan, and to propose improvement plans and/or recommend corrective action.

During an interview on 03/08/17 at 10:15 AM and 03/09/17 at 10:45 AM, Staff B, CEO, stated that he was not aware the biomedical company was behind on PM and felt equipment should not be used in patient services until inspections were completed. He was aware that the facility needed to complete an annual, periodic evaluation, but was not aware that the facility had not performed the periodic evaluation. He was not aware that an outside entity review of the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services was needed and had not been completed.

Based on observation, interview, record review and policy review the facility failed to ensure that infection control practices used by staff minimized the risk of cross contamination when:
- Surgical and endoscopic (instrument used to examine hollow organs of the body) instruments were not cleaned with the correct concentration of water to detergent ratio;
- Three (L, K, and M) of three Operating Room (OR) staff failed to perform hand hygiene after glove removal;
- Staff did not change gloves and perform hand hygiene when moving from a contaminated site to a clean site during wound care for one patient (#2) of one patient observed;
- One (JJ) of one dietary staff failed to change gloves and perform hand hygiene between glove changes;
- One (D) of one laboratory staff failed to change gloves and perform hand hygiene between glove changes; and
- Staff failed to consistently perform catheter (flexible tube that drains urine from the bladder) care for one patient (#1) of one patient.
These failed practices had the potential to increase the risk of infection for all patients, staff and visitors. The facility census was four.

Findings included:

1. Record review of the facility's undated policy titled, "Endo-Use and Care of Steris Unit," showed the directive for staff that general instruments and immersible endoscopic instruments must be cleaned following manufacture recommendations. Failure to clean thoroughly results in ineffective sterilization processes.

2. Record review of the Association of periOperative Registered Nurses (AORN) "Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment" dated 2014, showed cleaning agent manufacturers' written instructions should be followed during dilution.

3. Observation with concurrent interview on 03/08/17 at 12:11 PM, in the instrument cleaning area, showed a sink with no line for a water level and no measuring devices. Staff L, Scrub Technician, stated that she had to guess on how much water was in the sink for the correct amount of detergent to clean instruments. She filled the sink with water to what she thought was half full (approximately three gallons of water) and added six ounces of detergent. Staff L stated that if the detergent to water ratio was not per manufacture guidelines the instruments could become damaged or not cleaned appropriately.

4. Record review of the manufacture guidelines for the detergent used showed two ounces of detergent to one gallon of water.

During an interview on 03/08/17 at 1:02 PM, Staff L, OR Coordinator, stated that typically, the staff guessed at how much water was in the sink. To ensure the instruments were cleaned appropriately, the water must be measured to ensure the correct detergent to water ratio.

5. Record review of facility referenced material titled, "Perry & Potter Clinical Nursing Skills & Techniques," 8th Edition showed the following for hand washing:
- Wash with either plain soap and water or an antibacterial soap and water when hands are visibly dirty, soiled with blood or other body fluids, before eating, and after using the toilet.
- Before and after having direct contact with patients;
- After contact with body fluids or excretions, mucous membranes, and non-intact skin;
- After contact with wound dressings;
- When moving from a contaminated body site to a clean body site during patient care; and
- After removing gloves.

6. Record review of the nationally accepted standards of care for reducing the risks of infection and hand hygiene (hand washing) published by the Centers for Disease Control and Prevention (CDC), reviewed 05/01/14, showed "Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings)."

7. Record review of the facility policy titled, "Hand Decontamination," dated 03/26/2012 showed all staff will perform hand decontamination by hand-washing with soap and water or by use of an ethyl alcohol hand-rub preparation according to the manufacture's instruction at the following times:
- Before and after each patient contact.
- Before performing clean or aseptic procedures.
- After body fluid exposure risk.
- If moving from a contaminated body site to a clean body site during care.
- After touching any item in a patients surroundings.
- Before donning gloves.
- After removing gloves.
- Before and after any act of self-care including, but not limited to: toileting, smoking, eating, applying make-up or lip balm, or inserting contacts.
- Any time the hands are visibly soiled they will be decontaminated by hand-washing with soap and water.

8. Observation on 03/07/17 at 9:35 AM in the Operating Room (OR) showed:
- Staff L, Scrub Technician, removed gloves, put on new gloves, touched the patient and failed to perform hand hygiene after she removed her gloves;
- Staff L placed trash in the trash receptacle, removed gloves, and failed to perform hand hygiene;
- Staff K, OR Coordinator, removed her gloves, picked up a physician preference card and took it to the recovery area and failed to perform hand hygiene after she removed her gloves.

During an interview on 03/07/17 at 10:10 AM, Staff L stated that she should have used sanitizer after she removed her gloves, but there was none in the OR.

During an interview on 03/07/17 at 10:15 AM, Staff K stated that she should have performed hand hygiene after she removed her gloves and expected the other OR staff to perform hand hygiene after they removed their gloves.

9. Observation with concurrent interview on 03/07/17 at 12:06 PM in the OR showed Staff M, Registered Nurse (RN), applied an antiseptic agent on the patient's leg, removed her gloves, threw away trash, and moved a cart across the room. She failed to perform hand hygiene after she removed her gloves. Staff M stated that she should have placed on clean gloves on her hands after she removed her gloves.

During an interview on 03/08/17 at 12:05 PM, Staff K stated that typically, staff, left the OR to wash their hands if soiled. There was no hand sanitizer in the OR and there had not been since it opened approximately two years ago.

Although requested the facility was unable to provide a policy regarding clean dressing changes. The Perry & Potter Clinical Nursing Skills and Techniques was the facility's reference for dressing changes.

10. Observation on 03/07/17 at 1:45 PM, showed Staff F, Licensed Practical Nurse, (LPN), perform a dressing change to Patient #2's bilateral (both) lower leg wounds. Staff F removed the patients' leg braces and placed them on a chair next to a purse that belonged to a visitor. Staff F removed the dressing to the left lower leg and with the same gloves she sprayed a wound cleaner and cleaned the wound; applied Aquaphor (name brand of healing ointment) and then applied the new dressing. Staff F repeated this process to the right lower leg wound. Staff F did not remove and perform hand hygiene after she removed the old dressing prior to applying the healing ointment or applying the new dressings. Staff F replaced the leg braces to the patients' lower legs but did not clean off the chair where she had placed them.

During an interview on 03/07/17 at 2:20 PM, Staff F, LPN, stated that she wasn't aware of any policy regarding wound care dressing changes. She stated that she should have placed the leg braces somewhere other than the chair where the visitor had been seated and her purse remained. Staff F also stated that she should have changed her gloves and washed her hands after she removed the dirty dressings. She stated that she didn't think about it.

During an interview on 03/09/17 Staff E, RN, Nurse Manager stated that she expected the staff to change gloves and wash their hands after removing gloves and when they moved from a contaminated body site to a clean body site.

11. Observation on 03/08/17 at 11:40 AM showed Staff JJ, Cook, testing temperatures of food. She removed her gloves and reapplied gloves without performing hand hygiene. She then removed utensils from a drawer; placed the utensils in the food trays and removed her gloves and applied gloves without performing hand hygiene.

During an interview on 03/08/17 at 1:00 PM Staff JJ stated that she should have performed hand hygiene after removing her gloves but was nervous and forgot.

During an interview on 03/08/17 at 9:25 AM Staff W, RN, Infection Control, stated that he rarely goes into the kitchen area and only observed staff from outside the window.

12. Observation on 03/06/17 at 2:50 PM in the laboratory showed Staff D, Medical Laboratory Technician:
- She removed the gloves she was wearing, picked up a box and a specimen bag and threw them away in the trash and failed to perform hand hygiene.
- Wearing gloves, she obtained fluid from a specimen to place on a cartridge for an influenza (highly contagious viral infection of the respiratory passages) test. She removed the gloves, picked up paper records and then picked up the telephone. She failed to perform hand hygiene after she removed her gloves.
- Wearing gloves she obtained a specimen of blood in a tube to confirm the name on the specimen to the name on the lab results. She put the tube up and removed her gloves, but failed to perform hand hygiene.

During an interview on 03/06/17 at 2:55 PM, Staff D stated that if her hands were not visibly soiled between different tests she changed gloves and did not perform hand hygiene.

During a telephone interview on 03/07/17 at 11:45 AM Staff J, Lab Coordinator, and Staff N, Pathologist, stated that they expected Laboratory staff to perform hand hygiene after removal of gloves.

13. Record review of the facility's policy titled, "Care of Patient with Foley Catheter," dated 09/2011 showed that catheter care was to prevent infection in patients with Foley catheters (FC) in place and for staff to assist patient with bath giving special attention to the perineal (peri, area between the legs) washing well with soap, rinse and thoroughly dry the area around the catheter.

14. Observation and concurrent interview on 03/07/17 at 10:50 AM, showed Staff Q, Certified Nurse Aid (CNA), performed catheter care to Patient #1. During the care Patient #1 whispered to the surveyor that this was the first time this had been done. Staff Q stated that the CNA's usually did the catheter care but that she wasn't able to do it the day before because she was a patient sitter in the Emergency Department.

15. Record review of Patient #1's documentation for patient care of FC between 03/02/17 (date of admission) and 03/07/17 showed a bath was given on 03/05/17 at 9:21 AM, assisted with hygiene at 8:22 PM, and peri care given on 03/07/17 at 10:50 AM. This documentation showed that Patient #1 had assistance with hygiene three times out of seven days of her inpatient admission.

During an interview on 03/08/17 at 9:25 AM Staff W, RN, Infection Control, stated that he expected staff to perform hand hygiene after removing gloves and expected staff to change gloves and perform hand hygiene after removing a soiled dressing. He also stated that FC care should be performed daily to help decrease the chance for infection to the patient.




27727

Based on interview, record review, and policy review the facility failed to ensure Surgical Services were performed in a safe manner in accordance with applicable regulations and guidelines governing surgical services as well as standards and recommendations promoted by the Association of periOperative Registered Nurses (ARON). The facility failed to ensure preventative maintenance (PM, maintenance that is regularly performed on a piece of equipment to lessen the likelihood of it failing), was completed in a timely manner for nine of 10 devices in the Operating Room (OR); three of three vital sign monitors (a device that takes an automatic blood pressure, pulse, and shows the patient's heart rhythm) in the Pre/post anesthesia area, and approximately 23 other devices. The facility also failed to ensure that there was a tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) Kit for emergencies in the OR area.

The severity and cumulative effect of these deficient practices resulted in the facility's overall non-compliance with the requirement found at CFR 485.639 Condition of Participation: Surgical Services.

These deficient practices put all patients receiving surgical care at the facility at risk for care in an unsafe environment. The facility performs an average of 33 surgical cases per month. The facility census was four.

Findings included:

1. Record review of the facility's policy titled, "Medical Equipment Management Plan," dated 05/12/15, showed staff directives that electrically powered devices will be safety inspected annually and a sticker will be affixed.

2. Observation on 03/07/17 at 9:55 AM in the OR showed the following devices with orange PM biomedical stickers. The stickers were dated 01/2016 and showed PM was due 01/2017:
- A device for irrigation during surgeries for the ear, nose, or throat;
- A device for shaving cartilage (whitish, elastic flexible type of connective tissue) from the inside of the knee joint during arthroscopy (a procedure for diagnosing and treating joint problems);
- A device for irrigation of the inside of the knee during arthroscopy surgery;
- A cabinet called a tower that contained a camera, light source, computer, and a power box used for arthroscopy surgeries;
- A device that inflated the abdomen for Laparoscopic (a procedure in which a fiber optic instrument and other instruments are inserted through small incisions in the abdomen wall) surgeries; and
- Cautery instrument (an instrument using electrical current to cut or destroy tissue).

3. Observation 03/06/17 at 9:25 AM and at 10:30 AM in the pre-operative and post anesthesia care area showed three vital sign monitors with orange biomedical stickers from PM that were dated 01/2016 and due 01/2017.

During an interview on 03/06/17 at 9:25 AM and on 03/09/17 at 9:30 AM, Staff K, OR Coordinator, stated that the biomed equipment inspections were overdue because of a change in the biomed companies. The facility followed AORN recommendations for standards of care for surgical services.

4. Record review of the AORN "Recommended Practices for Electrosurgery", dated 2014, showed electrosurgical devices should be inspected periodically, and receive PM by a designated individual responsible for equipment maintenance (biomedical engineering services personnel). Periodic preventative maintenance ensures continued safe operation of electrosurgical devices

During an interview on 03/06/17 at 1:47 PM, Staff U, Maintenance Supervisor, stated that the previous biomed company completed all biomed inspections during January of each year. The new biomed company started 11/2016 and came monthly. Staff U was aware that the biomed inspections were behind and the biomed company was scheduled 03/20/17 for completion of biomed inspections in the OR area.

5. Record review of the facility's untitled and undated document showed the above documented devices were due for PM inspection along with approximately 23 other devices that the biomed company failed to inspect in January of 2017.

6. Observation with concurrent interview on 03/07/17 at approximately 10:15 AM in the OR area, showed no tracheostomy kit in the crash cart. Staff K confirmed the finding and stated there was no tracheostomy kit in the OR area for emergencies.

During an interview on 03/08/17 at 3:15 PM, Staff A, Chief Nursing Officer (CNO), stated that there were no policies related to emergency equipment needed in the OR area.

Based on interview and record review the facility failed to ensure a periodic evaluation to evaluate its services was completed annually, failed to maintain an effective facility-wide Quality Assessment and Performance Improvement (QAPI) Program that included all hospital departments and contracted services and failed to have an eligible outside entity review the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services.
The severity and cumulative effect of the deficient practices resulted in the facility being out of compliance with the requirements for the Condition of Participation: Periodic Evaluation and Quality Assurance Review. The facility census was four.

Please see C0331, C0337 and C0340

Based on interview, record review, and policy review the facility failed to ensure a periodic evaluation to evaluate its services was completed annually. This lack of review could prevent identification of problems with patient care and services and affect the quality of care for all patients. The facility census was four.

Findings included:

1. Record review of the facility's document titled, "Quality Assessment Performance Improvement (QAPI) Plan", dated 01/2016, showed no plan for a periodic evaluation to be completed annually.

2. Record review of the facility's policy titled, "Process Improvement", dated 01/2015, showed no plan for a periodic evaluation to be completed annually.

During an interview on 03/07/17 at 9:15 AM, Staff A, Chief Nursing Officer, stated that the facility did not complete a periodic evaluation for the year of 2016.

Based on interview, record review, and policy review the facility failed to ensure that three patient services (Pharmacy, Social Services, and Nursing Services) of nineteen direct patient care services and 48 of 48 contracted patient services were involved in the hospital wide Quality Assessment Performance Improvement (QAPI) program. This deficient practice had the potential to adversely affect quality patient care in each area not involved in the hospital wide QAPI program. The facility census was four.

Findings included:

1. Record review of the facility's policy titled, "Process Improvement," dated 01/2015, showed all services and departments within the hospital, which have a bearing on patient care, shall participate in the Process Improvement Program.

2. Record review of the facility's document titled, "QAPI Plan," dated 01/2016, showed involvement of all services and departments was required.

During an interview on 03/07/17 at 2:00 PM, Staff V, Pharmacy Manager, stated that the pharmacy failed to be involved in the hospital wide QAPI. She and the Chief Nursing Officer (CNO) had discussed that Pharmacy needed to be involved, but had not started any quality. The Pharmacy had not been involved in the QAPI program for two years.

3. Record review of Staff V's job description showed she should participate in performance improvement and continued quality improvement activities.

During an interview on 03/08/17 at 10:15 AM, Staff A, CNO, stated that the Pharmacy, Social Services, and Nursing Services were not involved in the hospital wide QAPI program.

During an interview on 03/09/17 at 10:05 AM, Staff R, Swing Bed Coordinator and Social Services, stated that she functioned in the Social Service role and was involved in discharge planning. She stated that the previous person in the Social Service role was not involved in the QAPI program and she was not aware she needed to be involved.

During an interview on 03/08/17 at 4:05 PM, Staff E, Nurse Manager for Medical-Surgical and Emergency Department, stated that the prior Nurse Manager left abruptly and when she started the position she was not made aware her departments needed to be involved in quality.

4. Record review of the Performance Improvement meeting minutes from May 2016 (first quarter 2016 reports), July 2016 (second quarter 2016 reports), and January 2017 (third and fourth quarter reports) showed no involvement of contracted services.

During an interview on 03/09/17 at 11:30 AM, Staff A, CNO, stated that there were no contract services involved in the hospital wide QAPI program.

5. Record review of the facility's undated document titled, "Contracts," showed there were 48 contracted patient services.

Based on interview, record review, and policy review the facility failed to have an eligible outside entity review the quality and appropriateness of the diagnosis, treatment or outcome of treatment provided by each physician who provided patient care services. The failure to have an outside review of the quality and appropriateness of treatment had the potential for inadequate patient care and unsatisfactory treatment outcomes. The facility census was four.

Findings included:

1. Record review of the facility's document titled, "Quality Assessment Performance Improvement (QAPl) Plan," dated 01/2016, showed no evidence that physician peer review was integrated into the facility-wide Quality Assessment (QA) Plan or Program.

2. Record review of three of three physicians' (N, HH, and II) Medical Staff credentialing (credentialing and privileging are processes of formal recognition and attestation that a physician is both qualified and competent) records showed no Quality Assessment evaluation of clinical practice for the physicians currently providing direct patient care.

3. Record review of the facility's undated directory titled, "Provider Names," showed two physicians with admitting privileges, 17 Consulting physicians and 11 Emergency Department physicians.

During an interview on 03/09/17 at 11:55 AM, Staff DD, Physician Credentialing, stated that the facility did not complete QA on the physicians and she did not know what QA was for physicians.

During an interview on 01/28/14 at 1:00 PM, Staff A, Chief Nursing Officer, stated that physicians did not receive outside peer reviews conducted by the network facility or by arrangement with an outside agency.

Based on interview, record review and policy review the facility failed to provide an initial activity assessment that would identify and/or provide daily activities of individualized interests for two discharged patients (#18 and #19) of six Swing Bed patients (a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) reviewed. This had the potential to deny all Swing Bed patients their actual interests in activities. The facility census was four. The Swing Bed census was one.

Findings included:

1. Record review of the facility's policy titled, "Swing Bed Program Activity Program," dated 08/30/16 showed:
- Activities were to be offered to each Swing Bed resident by the Certified Activity Person on a daily basis;
- The Certified Activities Director was responsible for Activities Program;
- The Swing Bed Coordinator or Certified Activities Director was to make certain each activities program was approved by the residents' attending physician and treatment team;
- The Certified Activities Person was to monitor resident response/participation to activities offered on a daily basis.

2. Record review of Patient #18's History and Physical (H&P) dated 02/07/17, showed the patient was admitted to the Swing Bed program on 02/06/17 with a diagnosis of Chronic Obstructive Pulmonary Disease (obstructive lung disease characterized by shortness of breath) and need for continued intravenous (IV, within the vein) antibiotic and steroid therapy.

Record review of Patient #18's Initial Activity Assessment showed a blank assessment.

3. Record review of Patient #19's H&P dated 12/05/16, showed the patient was admitted to the Swing Bed program on 12/05/16 with a diagnosis of urinary tract infection (bacterial infection in the urinary tract) and the need for continued IV antibiotic therapy.

Record review of Patient #19's Initial Activity Assessment showed a blank assessment.

During an interview on 03/07/17 at 1:35 PM, Staff Q, Certified Nurse Assistant, (CNA), stated the following:
- She was the Activities Director for the Swing Bed program;
- She offered patient movies or something to read;
- Friday's were always popcorn Fridays on the activity calendar;
- She was responsible for the patients' initial activity assessment.
- Nursing was to offer patients activities listed on the calendar in her absence; and

During an interview on 03/08/17 at 9:15 AM, Staff R, Swing Bed Coordinator, Licensed Occupational Therapist, stated that:
- She acted as the social worker for the facility as she had a Bachelor's degree in Psychology;
- She assessed the Swing Bed patients on their admission;
- She didn't do an initial assessment on Patient #19 because the patient was only going to be there for three days for IV antibiotics and the time frame for completion of the assessment was seven days. "If the patient was here longer than three days and reached the seventh day the assessment would have been done."

Based on interview, record review and policy review the facility failed to ensure that Social Services or designee developed an initial assessment for two discharged (#20 and #22) of six Swing Bed patients (a specific type of reimbursement for patients that need a skilled service [such as therapy] but don't need the level of care in a regular patient bed) reviewed. This failure had the potential to prevent residents from maintaining or improving their ability to manage their everyday physical and medical needs (psychosocial needs).
The facility census was four. The Swing Bed census was one.

Findings included:

1. Record review of the facility policy titled, "Swing Bed Admission Social Services," dated 09/22/16 showed the following direction:
- Social Services will be available to Swing Bed patients, their families and other health care staff since Social Services recognizes that there is a significant relationship between the patients' psychosocial condition and the patients' recovery;
- Each patient and/or family is interviewed at the time of admission to the Swing bed program within 48 hours by Social Services or designee and given the Swing Bed Packet and forms to be signed; and
- Social Services or designee develops an initial assessment for each Swing Bed patient in participation with the patient, family, provider and other interdisciplinary treatment team staff within 48 hours of admission.

2. Record review of Patient #20's History and Physical (H&P) dated 12/30/16 showed the patient was admitted to the Swing Bed program on 12/30/16 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, obstructive lung disease characterized by shortness of breath) and need for continued intravenous (IV, within the vein) steroids and Physical Therapy for weakness.

Record review showed no Social Service assessment for the length of the patients Swing Bed admission.

3. Record review of Patient #22's H&P dated 01/12/17 showed the patient was admitted to the Swing Bed program on 01/03/17 with a diagnosis of weakness status post cerebral vascular accident (stroke), influenza A and altered mental status with the need for therapy.

Record review showed no Social Service assessment.

During an interview on 03/08/17 Staff A, Chief Nursing Officer stated that Staff R, Social Services, was out on medical leave during the time of Patient #20's admission and obviously when she was out of the building for an extended period of time nobody was covering for her.