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Based on Life Safety Code survey, Parkview Lagrange Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18, New Health Care Occupancies.

This two story facility with a basement constructed in July 2008 was determined to be of Type II (111) construction and was fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility has a capacity of 25 and had a census of 20 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 25 patient room corridor doors would latch into the door frame or were provided with a device that exerts at least 5 pounds of pressure to keep the door tightly closed (see K 018), failed to ensure 1 of 1 storage room doors serving a hazardous area in the lab was self-closing to prevent the passage of smoke (see K 029), failed to ensure 3 of more than 20 smoke detectors were installed where air flow would not adversely affect its operation (see K 051), failed to ensure a complete written policy containing procedures to be followed to protect 25 of 25 patients in the event the automatic sprinkler system and fire alarm system have to be placed out of service for 4 hours or more in a 24-hour period (see K 154 and K 0155).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, policy and procedure review, and interview, the facility failed to ensure manufacturer's recommendations for discharging defibrillators was followed in two units toured (OB [obstetrics] and Med/Surg).

Findings:
1. review of the manufacturer's manual for the Philips HeartStart XL Defibrillator at 3:30 PM on 3/22/11 indicated:
a. in section 11, on page 11-3, it reads: "Every Shift: Perform a "Shift/System Check" every shift to verify that the HeartStart XL is functioning properly and to ensure that necessary supplies and accessories are present and ready for use. You should test every shock delivery method that is used with this unit..."

2. while on tour of the OB department in the company of staff members NB and NF at 11:00 AM on 3/23/11, it was observed that the clip board with the March 2011 "...Defibrillator & Code Cart Checklist indicated there were 12 of 23 days that the evening shift did not check the boxes: "Defib Checked" and "Pacer Checked"

3. review of the January and February 2011 checklists, for the OB nursing unit, indicated that:
a. January was lacking indication in the appropriate boxes that the Defibrillator was "checked' and the Pacer was "checked" for 15 of 31 evening shift notations
b. February lacked the same documentation on the evening shift 17 of 28 days.

4. on 3/22/11 at 1:30 PM, while touring the Med/Surg nursing unit in the company of staff member NU, it was observed that:
a. the clip board with the March 2011 "...Defibrillator & Code Cart Checklist, 11 of 22 days lacked a nurse signature and documentation in the appropriate boxes of Defibrillator discharges on the day shift
b. lacked the same documentation (as in a.) 4 of 22 days for the evening shift
c. lacked documentation of defibrillator checks by both shifts on 4 of 22 days

5. review of the January 2011 checklist for Med/Surg indicated that:
a. the day shift lacked 9 of 31 days of documentation on the checklist of having discharged the defibrillator
b. the evening shift lacked 1 of 31 days of documentation on the checklist of having discharged the defibrillator
c. both shifts lacked documentation on the checklist of having discharged the defibrillator
for 2 of 31 days

6. review of the February 2011 checklist for Med/Surg indicated:
a. the day shift lacked 9 of 28 days of documentation on the checklist of having discharged the defibrillator
b. the evening shift lacked 3 of 28 days of documentation on the checklist of having discharged the defibrillator
c. both shifts lacked documentation on the checklist of having discharged the defibrillator
for 5 of 28 days

7. review of facility (corporate) policy "Crash cart/Defibrillator/AED Checks" indicated:
a. in section II. "Definition:", it reads: "A. In areas that provide 24-hour patient care the check must be performed each calendar day. B. In areas that operate typically an 8 or 12-hour business day, the check must be performed each calendar day open for operation. On days the area is closed, write "closed" on the checklist for the days not in operation rather than leaving blank spaces..."

8. interview with staff members NS and NT at 4:45 PM on 3/23/11 indicated:
a. it was thought that the blank areas on the OB checklists might be when the area was closed, but the facility policy indicated that staff should write "closed" and that had not occurred
b. it is unclear why the corporate policy only requires a daily defibrillator check when the equipment at this facility requires an "every shift" check per the manufacturer's recommendations

Based on observation, interview and record review, the facility failed to ensure 1 of 25 patient room corridor doors would latch into the door frame or were provided with a device that exerts at least 5 pounds of pressure to keep the door tightly closed, failed to ensure 1 of 1 storage room doors serving a hazardous area in the lab was self-closing to prevent the passage of smoke, failed to ensure 3 of more than 20 smoke detectors were installed where air flow would not adversely affect its operation, failed to ensure a complete written policy containing procedures to be followed to protect 25 of 25 patients in the event the automatic sprinkler system and fire alarm system have to be placed out of service for 4 hours or more in a 24-hour period.

Findings:

1. Observation on 03/23/11 at 10:45 a.m. with MS1 and SC1 indicated the corridor door to the second floor patient room 207 was equipped with a latch which would not latch into the door frame.

2. MS1 and SC1 stated at the time of the observation, they were not aware of the problem.

3. Observation with MS1 and SC1 on 03/22/11 at 2:40 p.m. indicated the storage room door in the lab lacked a door closer. The room contained a large amount of combustibles which included lab supplies, reams of copy paper, copier ink and two gallons of white board wash.

4. MS1 and SC1 stated at the time of observation, they were not aware of the problem.

5. Observations with MS1 and SC1 on 03/23/11 between 10:00 a.m. and 11:20 a.m. indicated the smoke detector in the therapy storage room, in the second floor break area and in the med-surg soiled utility room were located within two feet of an air supply duct.

6. 5. was acknowledged by the maintenance supervisor and safety coordinator at the time of the observation.

7. Review of the facility's policy and procedure book with MS1 and SC1 on 03/22/11 at 1:55 p.m. indicated the fire watch procedure for an out of service automatic sprinkler system was incomplete. The procedure lacked the telephone number for the Indiana State Department of Health and the local fire department, and it did not include staff must be trained to perform fire watch rounds.

8. The interview with MS1 and SC1 at the time of the record review indicated no other policy or procedure was available to review.

9. Review of the facility's policy and procedure book with MS1 and SC1 on 03/22/11 at 1:55 p.m. indicated the fire watch procedure for an out of service automatic alarm system was not complete. The procedure lacked the required telephone numbers for the Indiana State Department of Health and the local fire department, and it did not include staff must be trained to perform fire watch rounds.

10. MS1 and SC1 stated at the time of record review, they had no other policy or procedure available to review.

Based on document review and interview, the facility's patient care policies lacked documentation to indicate they were developed and reviewed/revised by a group of professional personnel that included a physician, nurse practitioner, clinical nurse specialist, or that one member of the committee is not a member of the CAH staff.

Findings include:

1. Review of facility patient care policies on 3-22-11 through 3-24-11 lacked documentation that the patient care policies were developed and reviewed/revised by a group of professional personnel that included a physician, nurse practitioner, clinical nurse specialist, or that one member of the committee is not a member of the CAH staff.
2. Interview with #S2 on 3-24-11 at 1005 hours indicates the group that develops/reviews/revises patient care policies is comprised of nurses and does not include a physician, nurse practitioner, clinical nurse specialist, or that one member of the committee is not a member of the CAH staff.

Based on document review and interview, the facility failed to develop a system to effectively identify and control communicable diseases for 11 of 15 facility personnel files (#P1, #P4 - #P9, #P11, #P12, #P13, #P15) reviewed.

Findings include:

1. Review of facility policy titled: Varicella Zoster on 3-23-11 indicates the following: 1.a. EHS will determine past history of chickenpox infection of all pre-employees by either physician documentation or self-report. If immunity to Varicella Zoster is in question, EHS will order Varicella Zoster antibody titer. If antibody test shows no immunity, the employee will be offered vaccine at no charge through EHS unless contraindicated. If newly vaccinated employee develops a rash, the employee will need to come to EHS immediately for evaluation and may be placed off work until rash resolves.
2. Review of facility personnel files on 3-23-11 indicates 11 of 15 employees health files reviewed contain self-reported immunity to varicella and do not contain reliable documented proof of immunity to varicella.
3. Interview with #S16 on 3-23-11 at 0950 hours and #S14 on 3-24-11 at 1100 hours confirmed (#P1, #P4 - #P9, #P11, #P12, #P13, #P15) 11 of 15 employee health files contain self-reported immunity to varicella and do not contain reliable documented proof of immunity to varicella.

Based on document review and interview, the facility failed to review patient care policies at least annually.

Findings include:

1. Review of patient care policy titled: Nursing Practice Document Development on 3-23-11 indicates the following: N. All nursing practice documents will be reviewed minimally every three years or more frequently as evidenced based practices or governing bodies dictate.
2. Review of patient care policies on 3-22/24-11 lacked evidence of review, at least annually, by a group of professional personnel. Last review, December, 2009.
3. Interview with #S2 on 3-23-11 at 1100 hours confirmed that the patient care policies are not reviewed at least annually.

Based on review of facility medical staff rules and regulations, open swing bed patient medical records, and staff interview, the facility failed to ensure that a history and physical was performed for 1 of 6 patients (pt. N4).

Findings:
1. at 2:10 PM on 3/24/11, review of medical staff rules and regulations indicated:
a. on page 9 under "Section 4. The History and Physical", indicated in section A. "A History and Physical (H&P) is required for all inpatient admissions, observation patients, and outpatients undergoing invasive procedures. B. The History and Physical must be completed within 24 hours of admission, readmission, and or invasive procedure..."

2. review of open patient medical records on 3/22/11 at 2:00 PM indicated patient N4 was admitted as a swing bed patient on 3/11/11 and is lacking a history and physical for the swing bed admission

3. interview with staff members NB, NU and NV at 3:00 PM on 3/22/11 and 1:20 PM on 3/24/11, indicated:
a. the history and physical in the medical record for pt. N4 was the acute care history and physical
b. there was no swing bed history and physical for pt. N4 who was admitted to swing bed status 11 days prior to survey
c. the physician attending pt. N4 does not usually care for swing bed patients and may not be aware that an update, or new history and physical, needs to be done within 24 hours of admission to swing bed status
d. the medical staff rules and regulations section 4. regarding history and physicals, also applies to swing bed history and physicals, in that an update to the acute care history and physical is required, or a new history and physical is to be performed
e. there is nothing that specifically addresses swing bed patients related to history and physical expectations in the medical staff rules and regulations

Based on open and closed swing bed patient medical record review, facility policy and procedure review, and interview, the facility failed to ensure that patients were notified either prior to, or at the time of admission, of services available, as a swing bed patient, and items/services for which they may be charged in 11 of 11 swing bed records reviewed (pts. N1 through N6, N8, N9, N13, N14 and N15).

Findings:
1. review of the facility policy/procedure, "Nursing Swing Bed Plan Admitting", with a last revision date of 5/2010, indicated:
a. under section II. "Policy Statement", it reads in item "4.)": "The Case Management Department, Admitting Office and/or Nursing Staff will initiate with the patient/family either prior to or at the time of admission, the following: A.) Patient Rights B.) Medicare message C.) Admission papers D.) Services available in the facility, and related charges."

2. review of open and closed swing bed patient medical records through out the survey process of 3/22/11 to 3/24/11, indicated:
a. the authorization to treat form signed by swing bed patients is the same form used for acute care patient admissions
b. the authorization to treat form being utilized for swing bed patient admissions, is lacking information as written in facility policy (see 1. a. above)

3. interview with staff members NB and NV at 1:45 PM on 3/23/11 and 11:30 AM on 3/24/11 indicated:
a. the facility is utilizing the same authorization to treat form for both acute care admissions and swing bed patient admissions
b. there is nothing in the authorization to treat form currently being used that addresses patient rights, the medicare message or services available as a swing bed patient and any related charges specific to swing bed patients
c. it is assumed that patients being admitted from another acute care facility, to swing bed status at this facility, are being given this information before transfer to this facility
d. the information required by policy and regulation is being given to patients and families verbally, but is not documented in the medical record as having been given and is not clearly a part of the consent process
e. it cannot be determined that information, as required by policy (see. 1. above) and regulation, is afforded to patients as there is not documentation to support this in the medical records

Based on patient medical record review, facility policy and procedure review, and staff interview, it cannot be determined that patients, and/or family members, are allowed to participate in planning care and treatment for 11 of 11 swing bed patients (pts. N1 through N6, N8, N9, N13, N14 and N15).

Findings:
1. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual), "Initial Patient Assessment/Evaluation", indicated the policy lacked dialogue related to how the patient, and/or family, are included in planning/creating a treatment/care plan

2. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual), "Scope of Rehab Therapy Services", indicated under "Policy": "...Patient care is evaluated and reviewed every week in a weekly care conference meeting for inpatients..."

3. review of open and closed swing bed patient medical records, through out the 3/22/11 to 3/24/11 survey process, indicated:
a. pts. N1 through N6, N8, N9, N13, N14 and N15 were lacking indication/documentation of patient and/or family involvement in the initiation of a treatment plan or of attendance at weekly care planning meetings

4. interview with staff members NB, NC and NV at 2:30 PM on 3/24/11, indicated:
a. it is not clear in the medical record how the patient is involved in initiating or reviewing the treatment plan
b. patients and family members are not invited to the weekly treatment plan meetings--"they may request attendance, but are not invited"
c. it is not clear how the facility is including patient and family input of treatment plan needs and goals, and to any changes in the plan that are made as needed

Based on patient medical record review and interview, the facility failed to ensure that transfer patients are notified of their right to appeal or the information related to the State long term care ombudsman for one of one transfer patient record reviewed (Pt. N15).

Findings:
1. at 10:20 AM on 3/24/11, review of the closed swing bed patient medical record for pt. N15 indicated:
a. the 1/20/11 transfer form/consent document, used for this swing bed patient upon transfer to another acute care facility, was the same form used for acute stay patients when needing transfer
b. the transfer form is lacking a statement that the resident has the right to appeal the action to the State
c. the transfer form is lacking the name, address and telephone number of the State long term care ombudsman
d. there is nothing that addresses a swing bed patient who might have developmental disabilities in regards to information for the protection and advocacy of patients in relation to Part C of the Developmental Disabilities Assistance and Bill of Rights Act.

2. interview with staff member NU at 11:30 AM on 3/24/11 indicated:
a. the facility rarely transfers swing bed patients to other acute facilities
b. when a swing bed patient's condition deteriorates, they are transferred back to acute care and most likely to the facility CCU (critical care unit)
c. then, if the patient is transferred out of the facility, they are transferred as an acute care patient
d. pt. N15 was the only patient this staff member could remember recently being transferred from a swing bed status
e. the consent to transfer form is lacking information listed in 1. above (b., c., and d.) as per Critical Access Hospital regulations

Based on policy and procedure review, patient medical record review, and interview, the facility failed to ensure that patients were assessed for activities that would be therapeutic for swing bed patients and failed to ensure that an ongoing program of activities was available to its swing bed patients for 11 of 11 medical records reviewed (pts. N1 through N6, N8, N9, N13, N14 and N15).

Findings:
1. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual), "Scope of Rehab Therapy Services" indicated under "Policy": "...Activity therapy is provided to our inpatients under the supervision of a licensed O.T.R./Activity Coordinator..."

2. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual), "Initial Patient Assessment/Evaluation" indicated:
a. under "Procedure", "...The rehabilitation treatment plan includes the following components: Current clinical condition of the patient...past medical/surgical history,...Identified reason for rehabilitation services...Patient's personal rehabilitation goals...Rehabilitation goals and objectives in relationship to activities of daily living, learning and working. Realistic, attainable time frames...Criteria for discharge..."

3. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual) , "Activity Therapy General Policies" indicated:
a. under "Purpose/Objective:", it reads: "It is the policy...to provide and encourage a planned activity appropriate to individual needs of the patient to fulfill social, educational, creative, expressive, spiritual, physical and recreational activities to facilitate rehabilitation..."
b. under "Scope:", it reads: "Services are provided to swing bed patients of all ages. Activity hours are flexible to accommodate skilled therapies and nursing services."
c. under "Methods/Steps/Paper Trail:", it reads: "...Activity plan is made and documented in patients electronic medical record for each patient based on functional performance, emotional health, cognitive level, endurance and patient's interest."

4. at 12:25 PM on 3/22/11, review of policy and procedure (from the Swing Bed Policy Manual) "Activity Documentation", indicated:
a. under "Initial Activities Assessment: 1.) The Activity Coordinator/OT will make initial visits with Swing Bed patients within 72 hours to conduct an interview and describe Activity Department and OT [occupational therapy] (unless patient needs are more urgent). 2.) The Activity Coordinator/OT will complete the Initial Activity Assessment within 72 hours...The Activity plan of care will be documented..."
b. under the section, "Progress Notes:", it reads: "...3. Notes provide a record regarding the patient's interest and activity choices..."

5. at 12:25 PM on 3/22/11, review of policy and procedure (from the Swing Bed Policy Manual) "Nursing Swing Bed Plan Activities Patient Objectives", reads in the "Patient Objectives" section: "The purpose of the Activity Program shall be to provide a planned schedule of activities which shall encourage the following: 1.) Meaningful use of leisure time. 2.) Social experiences through group interaction. 3.) Assist the development of good interpersonal relationship,...to support the individual's feelings of self-worth and dignity...4.) To encourage the resumption of thinking and decision-making processes...8.) Provide play experiences for physical and mental satisfaction...14.) To provide educational and informative opportunities."

6. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab therapy policy manual), "Activity", indicated under "Purpose: Family/Friends Participation:" "Policy", "...B.) Be encouraged that leisure skills are within his/her skill level...E. Family and friends are an important motivator for the patient to become re-involved in leisure activities...G.) An activity helps to focus the visit on the patient. H.) An activity can help to divert visitors and be enjoyable for them too."

7. review of open and closed swing bed patient medical records through out the 3/22/11 to 3/24/11 survey process indicated:
a. pts. N1 through N6, N8, N9, N13, N14 and N15 were lacking indication/documentation:
A. in the OT assessment of patient interests, leisure activities the patient participates in, and care planning for activity processes
B. in the medical record progress notes, by nursing or OT, of any social, leisure, play, or other social activities being provided

8. interview with staff members NB, NC and NV at 2:30 PM on 3/22/11 and 10:20 AM on 3/24/11, indicated:
a. the OT assessment does include asking the patient about activities/hobbies the patient may be interested in, but this information is not documented in the patient's OT assessment or medical record
b. the "Initial Patient Assessment/Evaluation" policy does not include adding activities information to the rehabilitation treatment plan
c. the OT assessments for pts. N1 through N6, N8, N9, N13, N14 and N15 were all related to mobility needs and rehab therapies and lacking any other "activities" information
d. activities such as nail polishing, community entertainment, etc. occurs on the nursing unit, but is not part of the patient's care plan, nor is it documented in the patient's medical record
e. there are no scheduled activities plans/calendars available for patients admitted to swing bed status
f. the facility policies as stated in 1. through 5. above indicate activities, other than physical/mobility activities, will be assessed for patient needs on admission and available for the benefit of the patient
g. it is not clear what the facility expects, with regard to activities, in the policies as stated in 1. through 5. above and how activities, other than mobility/rehab, will be addressed by the facility

Based on facility policy and procedure review, swing bed patient medical record review, and staff interview, the facility failed to implement its policy related to weekly care planning meetings for 4 of 4 current patients (pts. N1, N3, N4 and N5).

Findings:
1. at 10:20 AM on 3/24/11, review of the policy and procedure (from the Rehab Therapy Policy Manual), "Scope of Rehab Therapy Services" indicated under "Policy": "...Patient care is evaluated and reviewed every week in a weekly care conference meeting for inpatients..."

2. at 1:30 PM on 3/22/11, review of the N1, N3, N4 and N5 (open swing bed patients) medical records indicated:
a. there is no documented weekly care planning meeting noted in the medical records for these patients for March 16, 2011

3. interview with staff members NG and NV at 2:50 PM on 3/23/11 indicated:
a. pts. N1, N3, N4 and N5 were admitted to swing bed status prior to the March 16th weekly care planning meeting and should have documentation in the medical record of this care planning meeting
b. a hand written note of meeting discussion for 3/16/11 was provided to the surveyor, but pts. N1 and N4 are not on the note as having been discussed
c. the social services/case management staff take notes and make entries in the medical records related to the care planning meetings, but these staff members were absent from the 3/16/11 meeting
d. there is no plan in place to cover the social services department duties when these staff are off for sickness, on vacation, etc., to ensure that proper documentation occurs in the medical record for weekly care planning meetings

Based on facility policy and procedure review, job description review, patient medical record review, and staff interview, the facility failed to implement its policy related to beginning discharge planning at the time of admission and updated weekly at care conference, for 6 of 11 swing bed patient medical records reviewed (pts. N1, N2, N3, N4, N5 and N15).

Findings:
1. at 12:25 PM on 3/22/11, review of the policy and procedure (swing bed policy manual) "Nursing Swing Bed Discharge Planning", indicated:
a. under "II. Policy Statement", it reads: "1.) Discharge planning is the responsibility of the Social Services Discharge planner, the Swing Bed Coordinator, and the physician. 2.) Discharge Planning will begin at the time of admission and be updated weekly at the Care Conference. 3.) Discharge Planning will involve the patient, family if indicted, or other significant persons as necessary..."

2. review of the job description "Spiritual Care/Community Outreach Coordinator", for staff member NW, at 2:00 PM on 3/24/11, indicated:
a. under "Typical Duties", it reads: "1. Proactively visits patients, families and staff to assess and address their emotional, social and spiritual needs; and assists with the discharge arrangements and planning under the direction of the RN case manager."

3. review of swing bed patient medical records through out the survey process of 3/22/11 to 3/24/11 indicated:
a. pt. N1 was admitted on 3/13/11 and had:
A. a note entered on 3/13/11, by the "case worker", that the patient's admission status was reviewed and the "payer" was Medicare
B. a note by the "case worker"on 3/15/11 that reads: "Discharge Plan pending"
C. lacked documentation of discharge planning being discussed at the 3/16/11 weekly care planning meeting
D. had discharge planning discussed at the 3/23/11 weekly care planning meeting

b. pt. N2 was admitted on 3/17/11 and lacked any discharge planning notes until the 3/23/11 weekly care planning meeting

c. pt. N3 was admitted on 3/15/11 and lacked:
A. having discharge planning documented for the 3/16/11 weekly care conference
B. any discharge planning notes until the 3/23/11 weekly care planning meeting

d. pt. N4 was admitted on 3/11/11 and had the first discharge planning note documented on 3/15/11 (there was no documentation of having discharge planning discussed for this patient at the 3/16/11 weekly care conference meeting)

e. pt. N5 was admitted on 3/11/11 and had the first discharge planning note documented on 3/17/11 and was lacking documentation of having discharge planning discussed at the 3/16/11 weekly care planning conference meeting

f. N15 was admitted to swing bed status on 1/13/11 and discharged on 1/20/11, and was lacking any documentation in the medical record by staff member NW related to discharge planning

4. interview at 2:15 PM on 3/23/11 with staff member NB indicated:
a. staff member NW is not doing a good job of documenting patient/family discussions and input related to discharge planning needs and timelines
b. it is not clear in the medical record documentation how the patient, or family, is involved in discharge planning issues
c. there is no documentation in the medical records for pts. N1, N2, N3, N4, N5 and N15 to indicate that discharge planning began on the day of admission, as per facility policy
d. there is no plan in place to cover the social services department duties when these staff are off for sickness, on vacation, etc., to ensure that proper documentation occurs in the medical record for discharge planning needs being discussed at weekly care planning conferences

Based on document review and interview, the facility lacked a process to assist residents in obtaining routine and 24-hour emergency dental care.

Findings include:

1. Review of facility documents on 3-22-11 through 3-24-11 lacked evidence that the facility had a process in place to assist residents in obtaining routine and 24-hour emergency dental care.
2. Interview with #S2 on 3-23-11 at 1415 hours confirms the facility does not have a process in place to assist residents in obtaining routine and 24-hour emergency dental care.