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Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure 4 of 4 travel staff reviewed (#5, #6, #7, and #8) were licensed and had received orientation to the facility prior to working in the facility. Failure to ensure licensing and orientation of travel staff prior to working does not ensure qualified staff provided quality care to residents, and may adversely affect the care provided to residents.

Findings include:

Review of a random sample of travel staff's licensure and orientation to the CAH occurred on 08/29/17. The CAH lacked verification of licensure and completion of the checklist for orientation of two nurses (#5 and #6), and two certified nursing assistants (#7 and #8).

On 08/29/17 at 5:20 p.m., an administrative nurse (#1) indicated the following regarding these staff members:
* Staff #5, started the first week of August
* Staff #6, started more than two years ago
* Staff #7, started a few months ago
* Staff #8 started one month ago

On 08/29/17, an administrative nurse (#1) stated one of the travel agencies (from which three of the four are employed) does not provide information to ensure licensure of travel staff and stated other travel staff come with a packet for the facility. The administrative nurse (#1) stated all travel staff get a minimum eight hours of orientation, and identified a nurse orienting last evening scheduled for three shifts of orientation. The staff member agreed the facility should monitor for the completion of orientation. When asked if she knew if Staff #5, #6, #7, and #8 had current licenses she could not verify nor confirm.

Upon request, on the morning of 08/30/17, the administrative nurse (#1) provided verification of licensure for each of the travel staff (#5, #6, #7, and #8). The printed copies for three of the four showed the verification occurred on 08/30/17, the last day of the complaint survey.

Based on review of medical records, review of facility policy and procedure, observation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the patient's right to be free of physical restraints for 1 of 1 swing bed patient (Patient #1) observed with a side rail and a bolster in bed. Failure to ensure staff completed an initial assessment for a side rail and bolster used in bed placed Patient #1 at risk for accident/injury and/or non assessment of restraint use.

Findings include:

Review of the CAH's "Restraint Policy" occurred on 08/30/17. This policy, dated June 2009, stated, "To ensure safety is provided to each patient/resident regarding the use of side rails. PROCEDURE: 1. It is the policy of [CAH] that full side rails will not be used for patients/resident. 2. Upon admission to the facility, each patient/resident will be assessed for the need of side-rails during the admission process. The assessment will be documented on appropriate form. 3. Side rails will not be used for the sole purpose of preventing falls 4. 1/2 Side rails may be used to assist resident with positioning or for hanging the call light. 5. The need for side rails will be reassessed and evaluated quarterly in care conference by the interdisciplinary team or with any significant change. 6. The resident or family does not have the right to request side-rails if not deemed medically necessary 7. If using siderails for other than approved needs, the restraint form needs to be filled out by the nurse and signed by the provider."

Observation on 08/28/17 at 7:30 p.m. showed Patient #1 in bed with a half side rail located in the middle of the exit side of the bed and a large triangular bolster placed in the bed along the side rail, and a fall mat placed on the floor beside the bed. Staff had wrapped the call light cord around the side rail, but not within the patient's reach. The wall side of the bed showed a small side rail at the head of the bed.

Observation on 08/29/17 at 7:45 a.m. showed Patient #1 in bed with a half side rail located in the middle of the exit side of the bed and a large triangular bolster placed in the bed along the side rail. Observation at 8:30 a.m. showed the patient required an extensive assist of one for dressing, bed mobility, and personal hygiene and assist of two for ambulation with a front-wheeled walker and toileting.

Review of Patient #1's medical record occurred on August 29-30, 2017 and showed no initial assessment for the identified side rail or bolster used in bed. Nursing documentation showed "bed mobility" for the side rail use, but failed to identify the bolster.

During an interview on 08/30/17 at 3:30 p.m., an administrative nurse (#1) stated staff failed to complete the required initial side rail assessment on Patient #1's admission. The nurse stated staff should complete a side rail assessment on admission, then at least yearly or with a change in patient status.

Based on review of the swing bed admission packet, policy and procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff immediately reported an incident involving Patient #11, which resulted in an injury to the patient. This failure delayed timely assessment and treatment of Patient #11's injury and limited the CAH's ability to ensure all staff implemented its abuse prohibition and prevention policy.

Findings include:

Review of the facility "ABUSE PROHIBITION AND PREVENTION POLICY" occurred on 08/30/17. The policy, undated, stated, "[The CAH] will endeavor to provide a safe environment for its. . . residents that is free from abuse, mistreatment, and neglect. Any instances of such treatment are to be reported immediately. [The CAH] will not tolerate employee abuse or resident neglect . . . by anyone. . . . All allegations will be investigated promptly. . . . Physical Abuse includes hitting . . . Neglect means the failure to provide goods and services necessary to avoid physical harm . . . The facility must have evidence that all alleged violations are thoroughly investigated. . . . All staff is responsible to report any allegations . . . The Care Center Supervisor, Director of Nursing, Social Services Designee, and Administrator will be involved in the investigation . . . Allegations of abuse will be reported to the State Health Department . . . immediately (within 24 hours) to the Department of Health. 2. A follow-up report on the findings of the investigation must be made to the Department of Health within five working days. . . . 4. Injuries of unknown source are regarded in the same regulatory light as mistreatment, neglect, and abuse, and are to be reported to the State Survey and Certification Agency if there is reasonable cause to believe or suspect that an injury has been inflicted by a nurse aide or another individual used by the facility. . . ."

Review of the "Incident/Accident Reporting on Patients, Visitors, or Others" policy occurred on 08/30/17. This policy, undated, stated, ". . . An occurrence is defined as: An event not consistent with the routine operation of the health care organization in delivering the health care to a particular patient . . . When an incident or accident occurs on the hospital property to patients . . . the appropriate form must be filled out. Patient . . . incident/accident requires the completing of the Occurrence Form. All incidents should be brought to the attention of the charge nurse and she will decide if the physician and/or the director of nursing need to be immediately called . . ."

Review of the swing bed admission packet, provided to all Swingbed patients upon admission occurred on 08/30/17. The packet contained the "Admission Agreement Jacobson Memorial Hospital Care Center [JMHCC] Swing Bed Program," dated May 2015. The packet stated, ". . . [CAH] believes that . . . quality, commitment and accountability are the foundation by which a healthcare provider should practice . . . Nursing Services . . . Nursing serves [sic] are provided by . . . nurses . . . certified nursing assistants . . . Social Services . . . The social service designee is involved with . . . serving as an advocate for the patient and family. . . ."

Review of Patient #11's active swing bed record occurred on 08/29/17. The record identified the patient as non-communicative and bed/chair bound, and required total assistance with all activities of daily living. The record identified nursing staff utilized a Hoyer lift, a total body lift, to transfer Patient #11 from the bed to a geri-chair (geriatric chair).

Review of a social services note, dated 07/17/17 at 3:52 p.m., stated, "I heard a noise knocked on the door and the to [sic] male CNA's [certified nursing assistants] were in with [Patient #11]. [Patient #11] was sitting in his chair but not straight. The lift was tipped toward [Patient #11]. . . . CNA came in with me and we helped get the straps unhooked from the sling and [Patient #11]. [Patient #11] was fine no yelling out during this time."

Review of a nurse note, dated 07/19/17 at 3:10 p.m. (two days later), stated, "In report this AM, it was discussed that resident had a bruise on upper lip, it was discussed in report that resident may have bit upper lip. While incident was being discussed today, [a staff member (#10 - the Social Service Designee (SSD), also a CNA] stated that she walked into residents room Monday just as she explained that it had looked like resident had gotten hit in the mouth/jaw area with the lift, she reports at this time that [a staff (#8)], CNA and [a staff (#9)], CNA were present. On 7/17/17, nothing was brought to charge nurses attention. I was informed of situation today as [the SSD staff (#10)] CNA walked through the nurse station and she reported what she had seen Monday, also reference chart note made on resident 7/17/17. After this discussion, [a staff (#8)] CNA came to this nurse and reported to me what had happened. He stated that the legs on the lift were not spread open while they were putting him in the chair and resident almost tipped, he explained that him and [a staff (#9)] prevented him from falling and got him into the chair by holding the sling. He explains that the sling is what caused the bruise. [An administrative nurse (#1)] RN DON [Director of Nursing] is notified. [Name of Provider] is notified. Attempted to call residents mother to notify, phone is busy."

Review of another nurse's note, dated 07/17/17 at 3:36 p.m., stated, "Resident in small dining room (chapel) being fed breakfast (0900) and it was brought to this nurse's attention that he had a bruise on his face. In report this AM it was reported that he had possibly bit his lip. Resident had purple circular bruise under his nose on top lip and in the left corner of his mouth, also has a deep purple circular bruise on chin, midline. There is noted to be a small amount of edema to the area directly below his nose. Upon reading the nurse notes for this resident I noticed a note by [a staff (#10)], CNA [also SSD] that on 07/17 she heard a noise outside the room and entered to find two aids [sic] had tipped the lift as they were transferring resident to his geri chair. I spoke with [the staff (#10)] and confirmed that she had in fact walked into the room with . . . CNA to find lift tipped on 7/17 and resident in geri chair. Spoke to [the staff (#8)], CNA and he stated that the lift had tipped when they were transferring resident and the sling had hit him in the face as the two of them prevented him from falling and called . . . a CNA on walkie Talkie to come to the room to assist. Resident is asymptomatic at this time with no [signs and symptoms] of pain upon assessment. Reported findings to charge nurse. Will continue to monitor."

During an interview on 08/29/17 at 5:30 p.m., an administrative nurse (#1) stated she heard about the incident with Patient #11 and talked to all staff members (#8, #9, and #10) involved. She stated all staff members should have reported the incident immediately and filled out an occurrence report. The nurse (#1) stated she educated the two CNA's (#8 and #9) about the incident, but not the other staff member (#10) as she is not responsible for management of that individual.

Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 1 patient (Patient #1) with behaviors and as needed (PRN) Ativan received social services to maintain their highest practicable physical, mental, and psychosocial well-being.

Findings include:

Review of the facility's policy titled "Care Planning Process CAH" occurred on 08/29/17. This policy, dated July 2013, stated, "The Care Planning Process is in place to ensure that a resident/patient is given appropriate treatment and provided services in order to maintain or improve his/her abilities to function with their every day activities. . . . Those attending the conference will be the . . . Social Service representative . . . The care plan is updated on a continual basis. 10. Changes in patient/resident plan of care will be immediately documented on the care plan via written entry. . . ."

Review of Patient #1's medical record occurred on August 29-30, 2017 identified an admission date of 09/29/16 and a current physician's order for Ativan injection 1 milligram (mg) every daily PRN and Ativan 1 mg by mouth every six hours PRN. The current care plan failed to address the patient's behaviors and non-pharmacological (non-pharm) interventions prior to the use of PRN Ativan.

Review of the medication administration record for July through August 29, 2017 showed the following:
* Ativan injection 1 mg
- Administered once - Failed to assess behavior/need and use of non-pharm interventions prior to the administration.
* Ativan 1 mg by mouth
- Administered eight times - Failed to assess behavior/need and use of non-pharm interventions prior to the administration.

During an interview on the morning of 08/30/17, an administrative nurse (#1) stated the facility has no behavior management policy.

Based on observation, record review, review of facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to review and revise the nursing care plan for 2 of 20 swing bed patient (Patient #1 and #4) records reviewed. Failure to review and revise care plans limited the CAH's ability to manage patient's needs, communicate treatment approaches, and ensure continuity of care.

Findings include:

Review of the facility's policy titled "Care Planning Process CAH" occurred on 08/29/17. This policy, dated July 2013, stated, "The Care Planning Process is in place to ensure that a resident/patient is given appropriate treatment and provided services in order to maintain or improve his/her abilities to function with their every day activities. . . . The care plan is updated on a continual basis. 10. Changes in patient/resident plan of care will be immediately documented on the care plan via written entry. . . ."

- Observation on 08/28/17 at 7:30 p.m. and on 08/29/17 at 7:45 a.m. showed Patient #1 in bed with a half side rail located in the middle of the exit side of the bed, a large triangular bolster placed in the bed along the side rail, and a fall mat placed on the floor beside the bed.

Review of Patient #1's medical record occurred on August 29-30, 2017 identified an admission date of 09/29/16 and a current physician's order for Ativan injection 1 milligram (mg) every daily as needed (PRN) and Ativan 1 mg by mouth every six hours PRN. The current care plan failed to address the patient's half side rail, bolster, fall mat, and outcomes and interventions for the PRN Ativan.

- Observation on 08/28/17 at 7:00 p.m. showed a personal heating pad located in a chair in Patient #4's room. The patient stated he used the heating pad on his neck for pain relief.

Review of Patient #4's medical record occurred on August 29-30, 2017 identified an admission date of 06/30/16. The current care planned failed to address the patient's use of a personal heating pad.

During an interview on 08/30/17 at 3:30 p.m., an administrative nurse (#1) confirmed Patient #1's care plan failed to address the side rail, bolster, fall mat and the PRN Ativan, and Patient #4's care plan failed to address the patient's heating pad. The nurse agreed the heating pad needed an assessment for facility/patient safety.

Based on a professional reference, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess the need and document the effectiveness of an antianxiety medication administered on an as needed (PRN) basis for 1 of 1 patient (Patient #1) record reviewed receiving PRN Ativan. Failure to assess before administering Ativan and evaluate the patient's response to the Ativan limited the nursing staffs' ability to assess whether the medication achieved the desired effect, or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

Kozier & Erb's "Fundamentals of Nursing, Concepts, Process and Practice," 10th Edition, 2016, Pearson, Boston, Massachusetts, page 773, stated, ". . . Ten 'Rights' of Medication Administration . . . Right Assessment . . . Some medications require specific assessments prior to administration . . . Medication orders may include specific parameters for administration . . . Right Evaluation . . . Conduct appropriate follow-up (e.g., was the desired effect achieved or not? Did the client experience any side effects or adverse reactions?). . . ."

Review of Patient #1's medical record occurred on August 29-30, 2017 and identified an admission date of 09/29/16 and a current physician's order for Ativan injection 1 milligram (mg) every day PRN and Ativan 1 mg by mouth every six hours PRN.

Review of the medication administration record for July through August 29, 2017 showed the following:
* Ativan injection 1 mg
- Administered once - Failed to assess need and effectiveness of medication
* Ativan 1 mg by mouth
- Administered eight times - Failed to assess need and effectiveness of medication

During an interview on 08/29/17 at 3:30 p.m., an administrative nurse (#1) agreed staff failed to consistently assess behaviors before administering the PRN Ativan and failed to evaluate the effect of the PRN Ativan after administration.

Based on observation, review of facility policy and procedure, staff interview, and information from the complainant, the facility failed to ensure staff served meals to patients in a timely manner for 2 or 2 breakfast meals (August 29 and 30, 2017) observed. Failure to serve meals in a timely manner may result in unpalatable food due to decreased temperature, patients' increased waiting time for breakfast, and may affect all patients' nutritional status.

Findings include:

Review of the information from the complainant identified the breakfast meal delayed from 8:00 a.m. until 10:00 a.m. for some patients.

Review of the facility policy titled "Meal Time and Snacks" occurred on 08/30/17. This policy, dated May 1977, stated, "Three meals are served to residents at designated times in adherence with state and federal regulations . . . Breakfast: Hospital: 8:10 am [and] Swing bed: 8:00 a.m. Dinner: Hospital: 12 AM [noon] [and] Swing bed: 11:45: am. Supper; Hospital: 5:45 pm [and] Swing bed: 5:30 pm. 2. AM Snacks 9:30 AM. PM snacks 2:30 PM. HS [bedtime] snack carts will be delivered to nurses station at 7:00 PM. . . . If a resident does not wish to eat at these meal times, efforts are made to accommodate requests for meals at other times . . . If the facility has more than 14 (up to 16) hours between these two meals, a 'nourishing snack' is required. . . ."

Observation on 08/29/17 from 8 a.m. to 9:15 a.m. showed the first food cart delivered to the swing bed dining room at 8 a.m. and the second food cart delivered at 8:10 a.m. A staff member (#4) began serving the food trays for the patients currently sitting at the dining room tables at 8 a.m. At 9:15 a.m. staff delivered the last room tray from the second food cart.

During an interview on 08/29/17 at 1:50 p.m., a dietary manager stated the kitchen delivers the breakfast food cart to the patient floor at 8 a.m. for swing bed patients (including their room trays), and the kitchen delivers another food cart at 8:10 a.m. with trays for patients needing assistance and for hospital admissions. The manager expected the food temperatures of the food would start decreasing after 10 minutes on the cart and the facility has verbally educated staff to offer to microwave patients' trays if serving is delayed and/or food is not hot enough.

During an interview on 08/29/17 at 4 p.m., an administrative nurse (#1) stated staff should deliver the breakfast trays as soon as possible or within 15 minutes.

Observation on 08/30/17 from 8 a.m. to 8:45 a.m. showed the food carts delivered to the patient floor at 8 a.m. and 8:10 a.m. At 8:10 a.m. a staff member (#4) began serving the food trays to the patients sitting at the dining room tables. At 8:40 a.m. staff delivered the last tray to the patients sitting in the dining room. At 8:45 a.m. staff delivered the last room tray.

Failure to ensure patients received breakfast trays in a timely manner has the potential to result in nutritional deficiencies for all patients.