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Iowa Administrative Code: 481 - 51.20(3) Food and nutrition service staff.
a. A licensed dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or
consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis.
These services shall be of sufficient duration and frequency to provide continuing liaison with medical
and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff
of the food and nutrition service, approval of all menus, and participation in the development or revision
of departmental policies and procedures and in planning and conducting in-service education programs.

Based on observation and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure a licensed dietitian provides regular, on premises services scheduled at a sufficient frequency to provide guidance and education to the supervisor and staff of the food and nutrition services department and participate in the development and revision of department policies according to state law. The administrative staff identified a census of 8 patients at the time of the survey and an average census of 4 patients. The Supervisor of Food and Nutrition Services reported the department served an average of 16 meals daily. Failure to ensure a licensed dietitian provides regular, on premises services could potentially result in a lack of policies/procedures, menu development and meal services to meet the needs of the CAH patients.

Findings include:

1. During an interview on 8/5/2019, at 11:10 AM, the Supervisor of Food and Nutrition Services reported a contracted dietitian provided services remotely to conduct inpatient nutrition assessments and the contracted dietician did not conduct onsite services. The CAH employed Licensed Dietician G to occasionally provide outpatient education, but Licensed Dietician G did not provide any guidance, education, or assistance in policy/procedure development for the patient foodservice portion of the department.

2. During an interview on 8/5/2019, at 5:20 PM, and a follow-up interview on 8/7/19 at 10:20 AM, Licence Dietician G reported the CAH employed her on a casual basis to provide outpatient services at the CAH. Licence Dietician G did not play a role in patient menu approval, patient menu choices, consultation, or providing guidance to the patient foodservice operation. The on-site Supervisor of the Food and Nutrition Services at the CAH lacked involvement and support from an on-site licensed dietician in the foodservice department.

3. During an interview on 8/6/2019, at 12:30 PM, the Division Director of Food and Nutrition Services for Hospital A confirmed the dietician services provided to CAH patients occurred at the corporate/network level. The dietician services did not occur at the CAH. Instead, the menu development/planning and policy/procedure development occurred at an off-site location by a corporate dietician who did not go on-site to the CAH.

4. During an interview on 8/7/2019, at 1:30 PM, the Supervisor of Food and Nutrition Services confirmed a licensed dietician did not provide services to the patient foodservice portion of the CAH's dietary department by participating in the patient menu approval, the policy/procedure development, or staff guidance/education.

Based on observation and staff interviews, the Critical Access Hospital (CAH) failed to remove outdated supplies from the Emergency Department (ED), Cardiac and Pulmonary Rehab, and Specialty Clinics. Failure to remove outdated patient supplies from the CAH's ED, Cardiac and Pulmonary Rehab, and Specialty Clinic supplies, resulted in expired supplies remaining available for use in patient care, potentially resulted in staff using the expired items for patient care after the manufacturers' expiration date (the date after which the manufacturer will no longer guarantee the safety and quality of the supply). The CAH identified an average of approximately 300 patient visits per month in the ED, 420 patient visits in the Specialty Clinic, and 219 patient visits in Cardiac and Pulmonary Rehab.

Findings include:

1. Observations during a tour of the ED on 08/05/19 at 2:48 PM, revealed the following expired supplies:

Exam 1, Triage Room
a. 11 of 30 Cotton-tipped applicators, 10 expired 06/2019, 1 expired 04/2019
b. 1 of 1 bottles of Hydrogen Peroxide, 8 ounces, expired 03/2019
c. 17 of 17 Rapid Rhino Tampanades (used to help stop nosebleeds), expired 06/30/18
d. 4 of 8 Merocel Standard Nasal Dressing, expired 06/01/19
e. 2 of 10 Cobas PCR Urine Sample Packet, expired 12/2018
f. 1 of 1 Universal Viral Transport, expired 07/2019
g. 1 of 2 tongue blades, expired 02/28/19
h. 4 of 4 Mitypac pearl edge bell cups (used to assist during in deliveries), expired 06/2019
I. 4 of 4 Affirm VPIII (used during female exam to detect bacteria), expired 06/04/19

Exam Room 2
a. 11 of 11 Beckman Coulter Gastrocults (used to detect blood in the stomach), expired 05/2019
b. 8 of 8 24 gauge Intravenous (IV) catheters, expired 05/31/19

Exam Room 3
a. 2 of 9 18 gauge BD Insyte Autogaurd IV catheters, expired 04/30/19
b. 4 of 9 24 gauge BD Insyte Autogaurd IV catheters, expired 05/31/19
c. 6 of 16 25 gauge 1 inch needles, 5 expired 04/2019, 1 expired 05/2019

Exam Room 5
a. 5 of 5 21 gauge 1 ½ inch IV catheters, 4 expired 07/19 , 1 expired 06/2019
b. 1 of 2 cotton tip applicators, expired 06/2019
c. 5 of 5 Gastrocults, expired 05/2019

Pediatric Crash Cart
a. 1 of 3 pediatric colormetric CO2 detectors (used to ensure correct breathing tube placement), expired 07/02/19

Trauma Room
a. 12 of 12 Beckman Coulter Gastrocults, expired 05/2019
b. 2 of 9 BD Insyte Autoguard 18 gauge IV catheters, expired 01/2019
c. 1 of 1 Cotton-tipped applicators, expired 06/2019
d. 1 of 2 Foley Tray Systems, 16Fr (used to insert a catheter into the bladder to drain urine), expired 04/30/19
e. 1 of 2 adult colormetric CO2 detectors, expired 02/10/19

Storage Room
a. 1 of 2 Sterile central line dressing kits, expired 06/01/19

2. During an interview at the time of the tour, ED Supervisor revealed they expected the ED staff to check the supplies every month and remove any outdated supplies. The ED Supervisor acknowledged the ED staff failed to remove the expired supplies from the emergency department. The ED Supervisor then acknowledged, that since the ED staff failed to remove the expired supplies from the department, the ED staff could potentially use the expired supplies for patient care.

3. Observations during a tour of the Cardiac and Pulmonary Rehab in the Wellness Center Building on 08/05/19 at 11:29 AM revealed the following expired supplies in the emergency cart:

a. 4 of 6 18 gauge BD Insyte Autogaurd IV catheters, 3 expired 01/2019, 1 expired 04/30/19
b. 2 of 3, 22 gauge BD Insyte Autogaurd IV catheters, expired 11/2018
c. 4 of 6, 20 gauge BD Insyte Autogaurd IV catheters, expired 01/2019

4. During an interview at the time of the tour, RN A revealed they expected the rehab staff to check the supplies every month and remove any outdated supplies. RN A acknowledged the rehab staff failed to remove the expired supplies from the rehab department. RN A then acknowledged, that since the rehab staff failed to remove the expired supplies from the department, the rehab staff could potentially use the expired supplies for patient care.

5. Observations during a tour of the Specialty Clinic on 08/06/19 at 10:24 AM, revealed the following expired supplies in Room 306 supply cart:

a. 6 of 6 4-0 Vicryl suture, expired 07/2019

6. During an interview at the time of the tour, the Specialty Clinic Supervisor revealed they expected the clinic staff to check the supplies every month and remove any outdated supplies. The Specialty Clinic Supervisor acknowledged the clinic staff failed to remove the expired supplies from the speciality clinics. The Speciality Clinic Supervisor then acknowledged, that since the clinc staff failed to remove the expired supplies from the department, the clinic staff could potentially use the expired supplies for patient care.

Based on review of Medical Staff Bylaws, credentialing documentation, and staff interview, the Critical Access Hospital (CAH) governing body failed to ensure 2 of 3 Hospitalist providers (attending physician) had active staff privileges at another certified hospital in accordance with the Medical Staff Bylaws (Hospitalist L and Hospitalist M). Failure of the governing body ensured the Medical Staff members followed the Medical Staff Bylaws could potentially allow unqualified providers to care for patient at the CAH. Hospitalist L cared for 2 inpatients from October 2018 to July 2019. Hospitalist M cared for 13 inpatients from October 2018 to July 2019. The CAH administrative staff identified a census of 6 patients at the beginning of the survey.

Findings include:

1. Review of the Medical Staff Bylaws, approved 11/20/18, revealed in part, "Courtesy Staff: Qualifications: The Courtesy Staff shall consist of members who wish to participate in patient care occasionally while holding an Active Medical Staff appointment at another accredited and/or Medicare certified hospital."

2. Review of credentialing file documentation revealed the following:

a. The CAH's Medical Staff approved Hospitalist L's application to the CAH's Medical Staff with Courtesy Privileges on 5/1/19. The CAH's Governing Body appointed Hospitalist L to the CAH's Medical Staff on 5/10/19. Hospitalist L had Provisional privileges at another certified hospital from 1/1/2018 through 1/1/2020.

b. The CAH's Medical Staff approved Hospitalist M's application to the CAH's Medical Staff with Courtesy Privileges on 6/6/19. The CAH's Governing Body appointed Hospitalist M to the CAH's Medical Staff on 6/8/19. Hospitalist M had Consulting privileges at another certified hospital from 10/13/2017 through 10/13/2019.

3. During an interview on 8/8/19 at 11:00 AM, the Vice President Patient Care Services acknowledged Hospitalist L and Hospitalist M lacked active staff privileges at another certified hospital in accordance with the Medical Staff Bylaws.

Based on review of policies/procedures, meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually for 9 of 20 patient care departments (Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Specialty Clinic, Diabetic Education, Health Information Management, and Infusion). Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures. The CAH administrative staff identified a census of 6 patient at the beginning of the survey.

Findings include:

1. Review of the CAH's policies and procedures revealed the CAH lacked a requirement that the requited group of CAH staff (including a physician and mid-level provider) review all of the CAH's policies annually.

2. Review of the "Medical Staff Meeting Minutes," for January 3, 2018 through July 3, 2019, revealed the Medical Staff last approved the policies for Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy policies on 3/7/18.

The Medical Staff Meeting Minutes lacked documentation the Medical Staff approved all patient care policies for the Specialty Clinic, Diabetic Education, Health Information Management, Activities, and Infusion.

3. During an interview on 8/8/19 at 11:25 AM, the Administrative Coordinator for Projects verified the required group of professionals last approved the Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy policies on 3/7/18. The required group of professionals had not reviewed and approved the policies since 3/7/18.

The Administrative Coordinator for Projects acknowledged the required group of professionals failed to review and approve the policies for Specialty Clinic, Diabetic Education, Health Information Management, and Infusion.

4. During an interview on 8/8/19 at 8:30 AM, the Vice President Patient Care Services confirmed the only time a physician or mid-level provider would formally review and approve the CAH's policies was during a Medical Staff meeting.

I. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) staff failed to store 1 of 1 vial of Succinylcholine (medication used to relax muscles during surgery) in the anesthesia medication cart according to manufacturer's recommendations. Failure to ensure Succinylcholine is stored according to manufacturer's recommendations could potentially result in patients receiving a medication that does not work in the body as expected resulting in unintended consequences or side effects. The CAH's administrative staff identified the surgical services staff performed an average of 240 surgical procedures per year.

Findings include:

1. Observations on 8/7/19 at 9:50 AM in OR #1, revealed the anesthesia cart contained 1 of 1 unopened 200 milligram vial of succinylcholine, with a shortened expiration date of 9/6/19.

2. Review of the manufacturer's recommendations for the storage of Succinylcholine revealed, in part: "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

3. During an interview at the time of the observation, Certified Registered Nurse Anesthetist (CRNA) B revealed that CAH staff stored the Succinylcholine for up to 30 days outside the refrigerator. CRNA B confirmed they removed the Succinylcholine more than 14 days ago.

4. During an interview on 8/7/19 at at 10:50 AM, the Pharmacy Supervisor confirmed the CAH's staff normally stored the Succinylcholine for up to 30 days after they removed the Succinylcholine from the refrigerator. The Pharmacy Supervisor acknowledged the manufacturer recommended the CAH staff store the Succinylcholine for only 14 days after removing the Succinylcholine from the refrigerator.



II. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) surgical services staff failed to ensure the CAH staff monitored 2 of 2 observed medication refrigerators (Surgical Services and Pharmacy) to ensure the temperature in the medication refrigerators did not go outside the recommended range for medication storage. Failure to ensure the temperature in the medication refrigerators did not go outside the recommended ranges could potentially result in the medications unexpectedly lacking potency, and potentially not working in the patients' bodies as the CAH staff expected, potentially resulting in antibiotics failing to treat infections or the medications used in surgery failing to relax patients prior to surgery. The CAH's surgical services staff performed an average of 240 surgical procedures per year and 240 endoscopy procedures per year. The CAH's administrative staff identified an average census of 4 inpatients per day.

Findings include:

1. Observations on 8/7/19, at approximately 10:00 AM, during a tour of the operating suite, revealed a refrigerator in the clean hall that contained the following medications:

a. 2 vials of Bacitracin (prevents bacterial infections) 5,000 Units
b. 1 Proparacain HCL Opthalmic solution (numbs the eye for surgery) 0.5%
c. 1 vial Succinylcholine (medication used to relax muscles during surgery) 20 milligrams/10 milliliters
d. 10 vials Rocuronium (medication used to relax muscles during surgery) 100 milligrams/10 milliliters
e. 10 vials Cisatracurium (medication used to relax muscles during surgery) 10 milligrams/5 milliliters

Observations revealed the refrigerator lacked a device capable of monitoring the refrigerator's temperature which alerted the surgical services staff if the refrigerator temperature went outside the pre-determined range.

2. Review of the manufacturer's recommendations for the storage of Bacitracin revealed, in part: "Store the unreconstituted product a refrigerator 2 degrees to 8 degrees C [Celsius]..."

3. Review of the manufacturer's recommendations for the storage of Succinylcholine revealed, in part: "Store in refrigerator at 2 (degrees) to 8 (degrees) [Celsius]."

4. Review of the manufacturer's recommendations for the storage of Rocuronium revealed, in part, "Rocuronium ... should be stored in a refrigerator 2 degrees to 8 degrees [Celsius]..."

5. Review of the refrigerator temperature logs for July and August 2019, at the time of the tour, revealed CAH surgical services staff failed to document refrigerator temperatures 15 out of 38 days, including weekends and holidays, when the OR was not in use.

6. Review of the policy, "Medication Management: Storage and Disposal of Mediations," revised 10/2018, revealed, in part, "Medications requiring refrigeration will be stored in a refrigerator ... capable of maintaining the required temperature.... The temperature will be recorded daily or monitored by a temperature device. Temperatures will be maintained at: ... Refrigerator: 2 degrees [Celsius] to 8 degrees [Celsius]."

7. During an interview at the time of the tour, the Surgery Supervisor confirmed the surgical services staff did not monitor the refrigerators when the OR was closed, and the surgical services staff would not know if the refrigerator went outside the desired temperature range when the surgical services staff did not monitor the refrigerator.

8. During an interview on 8/7/19 at 10:50 AM, the Pharmacy Director verified the pharmacy staff did not monitor the refrigerator in the clean hall of the surgical suite. The Pharmacy Director acknowledged the refrigerator contained multiple medications which required refrigeration between 2 and 8 degrees Celsius.

9. Observations on 8/5/19 at approximately 11:38 AM, during a tour of the Pharmacy, revealed 1 of 1 pharmacy refrigerator. The pharmacy refrigerator contained multiple medications intended for patient use. The refrigerator contained a thermometer, but the device lacked the capability to alert the pharmacy staff if the refrigerator went outside the desired temperature range.

10. Review of the pharmacy refrigerator temperature log for July 2019, at the time of the tour, revealed CAH pharmacy staff failed to document refrigerator temperatures 9 out of 31 days in July 2019.

11. During an interview on 6/7/19 at 1:05 PM, the Pharmacy Director acknowledged the pharmacy refrigerator contained multiple medications intended for patient use. The Pharmacy Director verified the medications in the pharmacy refrigerator required refrigeration between 2 and 8 degrees Celsius.

The pharmacy staff did not monitor the pharmacy refrigerator's temperature on weekends or holidays, when the pharmacy staff was not present in the pharmacy. The pharmacy's refrigerator temperature monitoring device lacked the ability to alarm if the temperature went out of the desired range. If the pharmacy staff did not monitor the refrigerator's temperature and if the thermometer lacked the ability to notify staff the temperature went outside the desired range, the pharmacy staff would not know the refrigerator went outside the desired temperature range if the refrigerator returned to the desired temperature range by the next business day, when pharmacy staff returned to the pharmacy.


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Based on staff interview and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff notified the patients' physician following the discovery of a medication error for 2 of 10 medication errors reviewed (Patient #15 and Patient #17) and failed to document the date and time the nursing staff notified the physician for 7 of 10 medication errors reviewed (Patients #11, #12, #13, #14, #16, #18, and #19). Failure to notify the physician of medication errors could potentially result in the physician lacking knowledge of the medication error and failing to potentially modify the patient's treatment plan, potentially resulting in a life-threatening complication. The CAH administrative staff reported a census of 6 patients on entrance.

Findings include:

1. Review of the CAH policy "Medication Management-Administration and Verification," revised 7/2019, revealed in part, "...A medication event is defined as an error in prescribing, transcribing, dispensing, and administration... Document if physician notified...."

2. Review of medication errors on 8/8/19 revealed the following:

a. On 6/25/19 at 9:10 PM, the nursing staff discovered they failed to administer a dose of Cleocin (a medication to treat infection) to Patient #11. The medication error record lacked documentation of the date or time the nursing staff notified Patient #11's physician of the medication error.

b. On 4/1/19 at 1:33 AM, the nursing staff discovered they administered an incorrect dose of Vancomycin (a medication to treat infection) to Patient #12. The medication error record lacked documentation of the date or time the nursing staff notified Patient #12's physician of the medication error.

c. On 3/15/19 at 6:34 PM, the nursing staff discovered they administered the wrong Humalog insulin (a medication to treat diabetes) to Patient #13. The medication error record lacked documentation of the date or time the nursing staff notified Patient #13's physician of the medication error.

d. On 2/6/19 at 9:36 AM, the nursing staff discovered they failed to administer a dose of Aspirin (a medication to treat pain or heart disease) to Patient #14. The medication error record lacked documentation of the date or time the nursing staff notified Patient #14's physician of the medication error.

e. On 1/27/19 at 6:07 AM, the nursing staff discovered they failed to administer a dose of Unasyn (a medication to treat infection) to Patient #15. The medication error record lacked documentation the nursing staff notified Patient #15's physician of the medication error.

f. On 11/15/18 at 11:31 AM, the nursing staff discovered they administered the wrong dose of Zoloft (a medication to treat depression) to Patient #16. The medication error record lacked documentation of the date or time the nursing staff notified Patient #16's physician of the medication error.

g. On 12/13/18 at 11:22 AM, the nursing staff discovered they administered Patient #17 a dose of Levaquin (a medication to treat infection) prior to the ordered time. The medication error record lacked documentation the nursing staff notified Patient #17's physician of the medication error.

h. On 10/12/18 at 2:12 PM, the nursing staff discovered they administered the wrong dose of Baclofen (a medication to treat muscle spasms) to Patient #18. The medication error record lacked documentation of the date or time the nursing staff notified Patient #18's physician of the medication error.

i. On 10/19/18 at 11:19 AM, the nursing staff discovered they administered the wrong dose of Digoxin (a medication to treat heart disease) to Patient #19. The medication error record lacked documentation of the date or time the nursing staff notified Patient #19's physician of the medication error.

3. During an interview on 8/8/19 at 8:05 AM, the Case Manager verified the medical records lacked documentation the nursing staff notified the physician when they made a medication error for Patient #15 and Patient #17 and the medical records lacked documentation of the date or time the nursing staff notified the physician of the medication error for Patients #11, #12, #13, #14, #16, #18, and #19.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Food and Nutrition Departed failed to ensure 1 of 1 dish machine met the manufacturer's and food safety requirements to ensure the proper sanitation of patient dishware and food preparation equipment. The CAH administrative staff identified a census of 8 patients at the time of the survey and an average census of 4 patients. The Supervisor of Food and Nutrition Services reported the department served an average of 16 patient meals service daily. Failure to properly sanitize dishware and food preparation equipment prior to patient use could potentially result in surface contamination and inadequate removal of microorganisms leading to patient illness including foodborne illness.

Finding include:

I. Review of the policy "Dish Machine Temperatures," effective 8/2019, revealed in part "... Dish machine wash and rinse water will be maintained at temperatures not less than those established by the Food and Drug Administration ... Final rinse temperature of 180 degrees Fahrenheit ... Temperatures are monitored by TempTrak (a continuous temperature monitoring system ... three times per day ..." The policy lacked the identification of a procedure for the use of a T-stick.

2. Review of the document "[Entity A] Temperature Chart," posted on the wall near the dish machine, revealed a log utilized to record the dish machine temperature checks by documentation of the date, initials of employee verifying the check, and attachment of a T-stick 165 (a single-use cardboard thermometer designed to turn purple when the water temperature reaches 165 degrees Fahrenheit (F)).

The log showed the dietary staff completed the temperature checks between 11/4/18 to 4/2/19. Further review of the log revealed multiple days where the dietary staff failed to document they checked the dish machine's temperature. The dietary staff failed to document they checked the dish machine's temperatures from 4/2/19 to 7/30/19. The dietary staff failed to document any dish machine checks after 7/31/19.

3. Observation in the kitchen on 8/5/2019 at 10:55 AM of the dish machine revealed the manufacturer data label on the dish machine identified a minimum rinse temperature of 180 degrees Fahrenheit (F.).

4. During an interview at the time of the observations, the Supervisor of the Food and Nutrition Services Department reported the dietary staff should verify the dish machine rinse temperature with a T-stick 165. The Supervisor of the Food and Nutrition Services Department identified the water needed to reach 165 degrees F at the dish rack level of the dish machine (the manufacturer required the water to reach 180 degrees F, which was 15 degrees higher than the Supervisor of the Food and Nutrition Services Department incorrectly believed).

The Supervisor of the Food and Nutrition Services Department confirmed the posted logs revealed the staff failed to check the temperature in the dish machine since 4/2/19. Normally Cook I would check the temperature in the dish machine. When Cook I went on medical leave, the other dietary staff failed to check the temperature in the dish machine.

5. Observation in the kitchen on 8/6/2019 at 2:40 PM, revealed the staff did not document checking the dish machine temperature for the day.

6. During an interview on 8/6/2019 at 2:40 PM, Dietary Aide H reported she completed the dish machine temperature checks sometimes but usually does not check the dish machine temperature.

7. During an interview on 8/6/2019 at 2:43 PM, Cook E reported she never checked the dish machine temperature checks. Cook E reported that Cook I was the employee who normally checked the dish machine temperatures.

8. During an interview on 8/6/2019 at 2:40 PM, Cook I reported she was not formally assigned to perform the dish machine temperature checks. She took it upon herself to check the dish machine temperature on the days she worked. However, Cook I acknowledged she had not checked the dish machine temperature on 8/6/19.

9. During an interview on 8/7/2019 at 1:30 PM, the Supervisor of the Food and Nutrition Services Department confirmed he failed to assign a specific individual to check the temperature of the dish machine, which resulted in the staff failing to identify the dish machine reached the required temperature (180 degrees F). The Supervisor of the Food and Nutrition Services Department acknowledged the dietary staff failed to follow the CAH's policy on checking the dish machine's temperature.




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II. Based on observation, document review and staff interviews, Critical Access Hospital (CAH) surgical services staff failed to monitor and document the temperature and humidity in the surgical suite (1 of 1 decontamination room, 1 of 1 central sterilizer room, and 1 of 1 sterile supplies storage area). Failure to monitor the temperature and humidity in the surgical suite can potentially result in the buildup of humidity that contains bacteria, which can fall onto sterilized surfaces or operating tools potentially causing serious infections in patients. The CAH administrative staff reported the surgical services staff performed an average of 240 surgeries per year and 240 endoscopies per year.

Findings include:

1. Observations during a tour of the surgical suite on 8/7/19 at 10:00 AM revealed the surgical services staff lacked documentation for temperature and humidity in the decontamination room, central sterilizer room, and the sterile supplies storage area.

2. During an interview at the time of the tour, the Surgery Supervisor confirmed the surgery staff did not monitor the temperature or humidity in the decontamination area, central sterilizer room, or sterile supply storage area.

The Surgery Supervisor stated the CAH surgical staff based their surgical policies on the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines. The Surgery Supervisor was not aware of the AORN standards related to monitoring temperature and humidity in areas other than OR #1.

3. Review of the AORN Guidelines for Environment of Care, copyright 2018, revealed in part: "The health care organization should create and implement a systematic process for monitoring HVAC [Heating, Ventilation, Air Conditioning] performance parameters and a mechanism for resolving variances ... The HVAC system is intended to reduce the amount of environmental contaminates (eg, microbial laden skin squames, dust, lint) in the surgical suite."

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) Administrative staff failed to ensure a functional menu system which ensured 3 of 3 observed patients (Patient #4, Patient #5, and Patient #6) received therapeutic diets, in accordance with the practitioner's orders and the patients' nutritional needs. The CAH administrative staff identified a census of 8 patients and an average daily census of 4. The Supervisor of Food and Nutrition Services reported the Food and Nutrition Services Department served an average of 16 patient meals daily.

Meeting individual patient nutritional needs may include the use of therapeutic diets. Therapeutic diets refer to a diet ordered as part of the patient's treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet. Failure to ensure the dietary staff used a menu system could potentially result in the dietary staff serving therapeutic diets to patients which do not meet the patients' nutritional needs and/or national standards for the therapeutic diets ordered by the practitioners.

Findings include:

1. Observation on 8/5/2019, beginning at 11:50 AM, revealed Cook E, assigned to serve the lunch meal to patients.

2. During an interview at the time of the observations, Cook E reported she had 4 patient trays to serve and none of the patients had completed a self-select menu, so she picked one of the options identified on the patient self-select menu for the patients. She selected from the patient self-select menu for the patients to receive sliced roast beef, mashed potatoes, beef gravy, winter blend vegetables, fruit, cottage cheese, cookie and iced tea.

Patient #6's therapeutic diet order identified the need for gluten free food, so Patient #6 would not receive the cookie or mashed potatoes/gravy, and would get a baked potato, margarine and sour cream instead of the mashed potatoes/gravy. Cook E confirmed Patient #6 would not receive a cookie, as the dietary department lacked gluten free cookies.

Cook E confirmed the kitchen lacked a posted menu available which defined what foods a patient would receive if the patients failed to select their own food options from the menu in their room.

3. Observations confirmed Cook E substituted the baked potato, margarine and sour cream for the mashed potatoes/gravy for Patient #6 and the patient did not receive a substitute for the cookie.

4. Observation on 8/6/2019, beginning at 11:55 AM, revealed Cook E assigned to serve the lunch meal to patients.

5. During an interview at the time of the observations, Cook E reported she had 4 patient trays to serve. The patients received food from the employee cook-out, which included grilled hamburgers. Cook E identified the "grill/deli" portion of the patient self-selection menu, which included a hamburger, fresh fruit, bag of baked chips and iced tea. Cook E would follow this section of the patient menu, and substitute food as needed, based on the patients' diet orders.

6. Observations at the time of service showed Patient #4 received a grilled hamburger on bun with pickles, sliced tomato and onion, mixed fruit cup, potato chips, pudding, and a Sierra Mist. Patient #5 received an egg salad sandwich, applesauce, pudding and Sierra Mist. Patient #6 received a hamburger (no bun), mixed fruit cup, pudding, potato salad and pickles, sliced tomato and onion.

7. Cook E confirmed she lacked a written menu to identify what to to serve the patients on their various diets. Cook E had learned through experience what patients could have on each therapeutic diet and made her decisions accordingly.

8. Review of the CAH policy "Patient Menus," effective 12/2016, revealed in part "Director ... posts menu in the kitchen, where it is readily accessible for all those involved in the service of patients ..."

9. Review of the CAH policy "Menu Preparedness Process," effective 10/2016, revealed in part "Patients on all diets, except pureed and liquid diets, will be offered a selective menu ... Nutrition Assistant ... enter patient selections into Computrition (a computer system for menu management and tray ticket generation), print tray tickets ... ".

10. Review of the CAH policy "Menu Substitutions," effective 12/2016, revealed in part "Appropriate substitute foods are utilized when a menu change is necessary. Substitutions are of similar nutritional values ... Production Manager/Executive Chef obtains dietitian's approval for substitutions(s) to patient menu as needed ..."

11. Review of the CAH policy "Diet Orders," effective 5/2018, revealed in part "Food and nutrition products are provided for the patient, as appropriate ... Accurately assemble each tray in accordance with a neatly-printed tray ticket ..."

12. Review of the CAH policy "Nutritional Adequacy of Menus/Menu Approval," effective 10/2016, revealed in part "Meal selections are bundled to assure patients select a nutritionally balanced diet; nonselective rotations meet nutritional guidelines ... Modified diet menus offer foods consistent with requirements ... All master menus and modified diets are approved by a qualified dietitian using the 'Menu Approval' form ..."

13. Review of Patient #4's medical record identified a diet order of NDD3/Soft (National Dysphagia Diet Level 3 used for patients with mild problems with chewing and/or swallowing).

Review of Patient #5's medical record identified a diet order of NDD2 (National Dysphagia Diet Level 2 used for patients with mild to moderate problems with chewing and/or swallowing and used a transition from a pureed diet).

Review of Patients #6's medical record identified a diet order of House diet (general diet) with a gluten allergy identified.

14. During an interview on 8/5/19, at 2:00 PM, the Supervisor of Food and Nutrition Services reported patients have a self-select menu in their room to make their meal selections. If the patients are unable to make a dietary selection or do not care to make a dietary selection, the dietary staff use the patient self-select menu and select a feature item for the patients. The Supervisor of Food and Nutrition Services acknowledged the staff did not have access to menu spreadsheets (a menu that identifies the appropriate items/quantities/texture to serve on therapeutic diets) staff to use if a patient does not select from the menu.

15. During a telephone interview on 8/6/2019 at 12:30 PM, the Division Director of Food and Nutrition Services at Hospital A acknowledged the dieticians performed the majority of dietician services related to foodservice off-site at the corporate level. The corporate dieticians write the menus for all the facilities in the corporation and staff can access the menus in Computrition. The Supervisor of Food and Nutrition Services had access to Computrition.

The Division Director revealed the corporate dieticians wrote the patient selection menus to provide feature selections, which included a main entree, starch, vegetable, fruit, etc.. The dieticians designed the menus for nutritional balance and meet the patient's needs. The policies restrict automatic substitutions in order to protect the nutritional integrity of the menu.

The Division Director reported the menu system defines the "house diet" for all therapeutic diet types, so if a patient did not make their own selections, the computer system would generate a system meal ticket specific to their diet order and any allergies/preferences entered into the system, which the CAH staff should follow. The CAH staff should revise any policies and procedures, as needed, to reflect minor process adjustments specific to the CAH.

16. During an interview on 8/7/19 at 1:30 PM, the Supervisor of Food and Nutrition Services confirmed he lacked access to the Computrition system and therefore did not have the planned menus specific to the therapeutic diets, or the ability to enter patient selections and produce a tray ticket specific to the patient's diet.

The Supervisor of Food and Nutrition Services acknowledged the department did not follow the policies "Patient Menus," "Menu Preparedness Process," "Menu Substitutions," and "Nutritional Adequacy of Menus/Menu Approval." The Supervisor of Food and Nutrition Services verified the policies applied to the CAH. He lacked documented menu approval, as identified in the policy, since he lacked a dietitian working with foodservice at the CAH. He confirmed he failed to post the menus for the various therapeutic diets in the kitchen. The Supervisor of Food and Nutrition services acknowledged he failed to utilize the Computrition system to generate the planned menus or generation of patient tray tickets so foodservice staff had a clear guidelines of what to serve each patient.

17. During an interview on 8/8/2019, at 10:00 AM, the Supervisor of Food and Nutrition Services verified the CAH staff lacked documentation of the education and competencies for Cook E in regards to providing modified diets for patients and menu management.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) x-ray staff failed to ensure staff secured 1 of 1 radiation exposure cord to not allow staff access into the x-ray room during completion of radiologic tests of patients. The CAH x-ray staff reported completing an average of 318 x-rays per month. Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing an x-ray procedure and exposing staff to unnecessary radiation.

Findings include:

1. Observations during tour of the radiology department on 8/6/19 at 1:55 PM, with the Supervisor of Imaging, revealed 1 of 1 exposure cord in the general x-ray room the staff failed to secure, which allowed a staff member to enter approximately 8 feet into the x-ray room and still activate the x-ray machine.

2. Review of the CAH policy "Radiation Protective Barriers and Accessories," dated 4/2019, revealed in part, "Control panel and exposure switch must be arranged so that it is not possible to make an exposure if operator is outside the protective barrier."

3. During an interview on 8/6/19 at 1:55 PM. the Supervisor of Imaging confirmed the staff failed to secure the radiation exposure cord and would allow staff to access into the x-ray room during x-ray procedures.

Based on review of Medical Staff Bylaws, patient medical records, and staff interviews, the Critical Access Hospital administrative staff failed to ensure the Hospitalist providers (attending physician) documented in the patient's medical records an accurate physical examination for 5 of 5 CAH swing bed patient medical records reviewed (Patient #4, Patient #7, Patient #8, Patient #9, and Patient #10). Failure of the Hospitalist (attending physician) to perform a physical assessment could potentially result in the attending physician potentially failing to fully assess the patient and potentially failing to identify physical abnormalities which may have aided the attending physician in the ability of the physician the patient's medical condition. The CAH administrative staff identified a census of 2 swing patients at the beginning of the survey. The CAH administrative staff identified 76 swing bed admissions for FY 2019 (July 1, 2018 through June 30, 2019).

Findings include:

1. Review of Medical Staff Bylaws, approved 11/20/18, revealed in part, "Medical Records: ... Attending Practitioner Duties. The attending practitioner shall be responsible for the preparation of a complete medical record for each patient. This record shall include ... physical examination ..."

2. Review of patient medical records revealed in part the following:

a. Patient #4, admitted 8/3/19 to swing bed services, revealed Hospitalist J documented the History and Physical on 8/3/19. The history of present illness revealed Hospitalist J admitted Patient #4 to swing bed status following laparoscopic surgery for gastric perforation. Hospitalist J documented "Patient has been identified and has consented to be seen vial telehealth for this visit ... Abdomen: soft, non-distended; mild tenderness on deep palpation to RUQ and midepigastric region; no rebound or guarding .. .Pulses: 2+ and symmetric ..."

b. Patient #7, admitted 6/27/19 to swing bed services, revealed Hospitalist J documented the History and Physical on 6/27/19. The history of present illness revealed Hospitalist J admitted Patient #7 to swing bed status for on going cares and therapies following acute exacerbation on 6/22/19. Hospitalist J documented "Patient has been identified and has consented to be seen vial telehealth for this visit ... Abdomen: soft, non-tender; nondistended ..."

c. Patient #8, admitted 7/5/19 to swing bed services, revealed Hospitalist J documented the History and Physical on 7/5/19. The history of present illness revealed Hospitalist J admitted Patient #8 to swing bed status for further therapies following a stroke. "Patient has been identified and has consented to be seen vial telehealth for this visit ... Exam was completed via telehealth with the assistance of RN [Registered Nurse] at facility... Abdomen: soft. He exhibits no distension. There is no tenderness. There is no guarding. Musculoskeletal: ... He exhibits no edema or tenderness ..."

d. Patient #9, admitted 6/27/19 to swing bed services, revealed Hospitalist J documented the History and Physical on 6/28/19. The history of present illness revealed Hospitalist J admitted Patient #8 to swing bed status for rehabilitation following an appendectomy with peritonitis (infection of the abdomen). "Patient has been identified and has consented to be seen vial telehealth for this visit ... Abdomen: soft, non-tender ..."

e. Patient #10, admitted 8/1/19 to swing bed services, revealed Hospitalist J documented the History and Physical on 8/1/19. The history of present illness revealed Hospitalist J admitted Patient #10 to swing bed status for continued antibiotics and rehabilitation following a surgery for a knee infection. "Patient has been identified and has consented to be seen vial telehealth for this visit ... Abdomen: soft, non-distended ... Pulses: 2+ and symmetric ..."

3. During an interview on 8/7/19 at 9:31 AM, the Care Manager acknowledge the Hospitalist conducts the physical assessment of the patient via telemedicine by directing the nurse in the patient's room to palpate (manually touch and assess) the patient's abdomen. The nurse tells the Hospitalist their findings of the abdominal findings, as well as the nurse's assessment of the patient's legs.

4. During an interview on 8/7/19 at 11:00 AM, Hospitalist J revealed they worked remotely and used specialized visual and auditory equipment to perform the entire history and physical examination for all patients admitted to the CAH. Hospitalist J relied on the nurse to assist during the physical examination.

Hospitalist J explained that when examining a patient's abdomen, Hospitalist J did not actually perform the hands-on exam. Hospitalist J could see the patient and nurse while the nurse performed the assessment. Hospitalist J directed the nurse where to place their hands and how deep to palpate as the nurse pressed on the patient's abdomen to check for any tenderness. Hospitalist J used the same process to assess the patient for pitting edema (severe swelling of the legs).

Hospitalist J totally relied on the nurse's assessment of the patient's nose and throat as Hospitalist J could not see anything in the patient's nose and throat while the nurse performed an assessment of the patient's nose and throat.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged patients that received anesthesia to the company of a responsible adult for 2 of 5 surgical patients reviewed (Patients #2 and Patient #3). The facility staff reported an average of 40 surgical patients that received anesthesia per month. Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed.

Findings included:

1. Review the policy "CHI Post-Procedure Patient Care" protocol, effective 10/2018, revealed in part, "Sedated patients (e.g. general anesthesia, moderate sedation, nerve blocks): The patient who received sedation will only be discharged to the care of a responsible party and are advised not to drive."

2. Review of patient medical records revealed the following:

a. Patient #2 received anesthesia for a surgical procedure on 7/24/19. The surgical staff discharged Patient #2 on 7/24/19 at 3:12 PM. Patient #2's medical record lacked documentation the surgical services staff discharged Patient #2 in the company of a responsible adult.

b. Patient #3 received anesthesia for a surgical procedure on 7/19/19. The surgical staff discharged Patient #3 on 7/19/19 at 11:42 AM. Patient #3's medical record lacked documentation the surgical services staff discharged Patient #3 in the company of a responsible adult.

3. During an interview on 8/7/19 at 8:15 AM, the OR Supervisor confirms Patient #2's and Patient #3's medical records lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 17 of 17 patient care services provided (Nursing, Pharmacy, Surgery, Anesthesia, Radiology, Emergency Department, Dietary, Respiratory Therapy, Laboratory, Specialty Clinic, Diabetic Education, Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Activities, and Infusion). Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided at the CAH. The CAH staff identified a current census of 6 inpatients at the start of the survey.

Findings include:

1. Review of the CAH policy "Annual Critical Access Review Program," dated 8/2019, revealed in part, "The annual program evaluation will be conducted yearly by the Critical Access Hospital (CAH) Advisory Committee for ... CHI Missouri Valley and the evaluation will consist of: ... A random sample of both active and closed medical records will be reviewed for completeness and appropriateness of diagnosis and treatment."

2. Review of the "Critical Access Hospital Annual Program Evaluation FY 2018 [Fiscal Year July 1, 2017 to June 30, 2018]" revealed the annual program evaluation lacked documentation the CAH staff reviewed a sample of both active and closed clinical records for Nursing, Pharmacy, Surgery, Anesthesia, Radiology, Emergency Department, Dietary, Respiratory Therapy, Laboratory, Specialty Clinic, Diabetic Education, Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Activities, and Infusion.

3. During an interview on 8/8/19 at 9:25 AM, the CAH President verified the annual evaluation of the CAH Annual Program Evaluation lacked documentation the CAH staff performed a review of a sample of both active and closed records for Nursing, Pharmacy, Surgery, Anesthesia, Radiology, Emergency Department, Dietary, Respiratory Therapy, Laboratory, Specialty Clinic, Diabetic Education, Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Activities, and Infusion.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the evaluation of 3 of 21 patient care services for quality of care (Anesthesia, Specialty Clinic, and Health Information Management and 3 of 4 contracted patient care services for quality of care (Magnetic Resonance Imaging [MRI], and PET/CT [Positron Emission Tomography/Computed Tomography]). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care. The CAH staff identified approximately 240 patients received anesthesia per year, approximately Specialty Clinic patient visits 4875 per year and approximately 560 inpatient admissions per year. The CAH staff identified the contracted staff performed and average of 22 MRI procedures per month and and average of 2 PET/CT procedures per month.

Findings include:

1. Review of the "Quality, Safety, and Performance Improvement Plan FY 2019," dated 8/2018, revealed in part, "Each Hospital will have a framework which: Assesses the care, treatment, and services furnished by facility staff. Assesses the services provided under contract."

2. Review of the Quality, Patient & Employee Safety, Fall Prevention and Infection Control Meeting minutes from August 30, 2018 through May 30, 2019 revealed the meeting minutes lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Anesthesia, Specialty Clinic, and Health Information Management and contracted patient care services for MRI, and PET/CT.

3. During an interview on 8/8/19 at 9:55 AM, the Quality Improvement Specialist acknowledged the Anesthesia, Specialty Clinic, and Health Information Management and contracted patient care services for MRI, and PET/CT failed to participate in the CAH's quality assurance process, which included ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for the contracted services.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 6 active physicians selected for review (Physician D), received outside entity peer review, by the appropriate entity, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received outside entity peer review by the appropriate entity, affects the CAH's ability to assure physicians provide quality care to the CAH patients. The CAH administrative staff identified Physician D provided care to 869 patients from 2/2019 to 7/2019.


Findings include:

1. Review of Physician D's credential file (a personnel file for physicians) revealed the CAH staff sent 1 medical record to an outside entity for external peer review. The CAH staff received the external peer review on 11/1/18.

The documentation indicated the CAH staff requested a physician at another CAH in the network perform the external peer review, instead of a physician at an acute care hospital in the network.


2. During an interview on 8/7/19, at 10:40 AM, the Vice President of Patient Care Services verified the CAH staff requested a physician at another CAH in the network for the external peer review performed on 11/1/18. The Vice President of Patient Care Services acknowledged the CAH staff should have requested a physician at an acute care hospital in the network perform the external peer review for Physician D.




II. Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 General Surgeons that underwent recredentialing, selected for review (Surgeon C), received outside entity peer review prior to reappointment, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received outside entity peer review, in the appropriate time frame, affects the CAH's ability to assure physicians provide quality care to the CAH patients. The CAH administrative staff reported Surgeon C provided services to 228 patients from July 2018 to June 2019.

Findings include:

1. Review of the CAH policy "Physician Quality Peer Review," effective 10/2018 revealed in part "These external peer reviews must be completed prior to the consideration of the physician reappointment. Reappointment may not be finalized until the external peer review is completed and available to the medical staff and Board of Directors for review and consideration ..."

2. Review of Surgeon C's credential file and external peer review revealed the medical staff approved Surgeon C's re-appointment to the Medical Staff on 10/03/18 and the governing body approved Surgeon C's re-appointment to the Medical Staff on 10/12/18.

Surgeon C's credential file lacked evidence the CAH staff received the external peer review of Surgeon C's care for patients at the CAH prior to the Medical Staff and Governing Body reappointed Surgeon C to the CAH's Medical Staff.

3. During an interview on 8/07/19, at 10:40 AM, the Vice President of Patient Care Services confirmed the CAH staff failed to ensure they received Surgeon C's external Peer Review prior to the Medical Staff and Governing Body reappointing Surgeon C to the CAH's Medical Staff.

Based on review of policies, patient medical records, and staff interview, the Critical Access Hospital (CAH) swing bed staff failed to develop a comprehensive activities care plan for 2 of 2 (Patient #4 and #10) open and 3 of 3 (Patient #7, #8, and #9) closed swing bed patient medical records. Failure to develop a comprehensive activities care plan that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified 76 swing bed admissions and an average length of stay 14 days in FY 2019. The CAH administrative staff reported a census of 2 swing bed patients on entrance.

Findings include:

1. Review of the swing bed policy "Swing Bed Activities Program," effective 8/2019, revealed, in part, "The Activities Program must be ongoing and designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well being of each swing-bed patient.... Activities planned will occur within the context of each swing-bed patient's Comprehensive Assessment and Plan of Care...."

2. Review of swing bed patient medical records on 8/5/19 revealed the following information:

a. The CAH staff admitted Patient #4 to swing bed services on 8/3/19. The Activity Coordinator completed an initial activities assessment for Patient #4 on 8/3/19. Patient #4's medical record lacked evidence the CAH staff created an activities care plan that directed staff to provide individual or group activities chosen by the patient.

b. The CAH staff admitted Patient #10 to swing bed services on 8/1/19. The Activity Coordinator completed an initial activities assessment for Patient #10 on 8/1/19. Patient #10's medical record lacked evidence the CAH staff created an activities care plan that directed staff to provide individual or group activities chosen by the patient.

c. The CAH staff admitted Patient #7 to swing bed services on 6/27/19. The CAH staff discharged Patient #7 from swing bed services on 7/1/19. Registered Nurse K completed an initial activities assessment for Patient #7 on 6/29/2019. Patient #7's medical record lacked evidence the CAH staff created an activities care plan that directed staff to provide individual or group activities chosen by the patient.

d. The CAH staff admitted Patient #8 to swing bed services on 7/5/19. The CAH staff discharged Patient #8 from swing bed services on 7/29/19. Registered Nurse K completed an initial activities assessment for Patient #8 on 7/8/2019. Patient #8's medical record lacked evidence the CAH staff created an activities care plan that directed staff to provide individual or group activities chosen by the patient.

e. The CAH staff admitted Patient #9 to swing bed services on 6/27/19. The CAH staff discharged Patient #9 from swing bed services on 7/4/19. Registered Nurse K completed an initial activities assessment for Patient #9 on 6/29/2019. Patient #9's medical record lacked evidence the CAH staff created an activities care plan that directed staff to provide individual or group activities chosen by the patient.

3. During an interview on 8/7/19 at 10:39 AM, the Occupational Therapist, who directed the swing bed actives services, acknowledged Patient #4's, Patient #10's, Patient #7's, Patient #8's, and Patient #9's medical records lacked evidence the staff created or implemented an activities care plan.