HospitalInspections.org

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Based on observation, interview, and record review, the governing body failed to ensure that hospital swing bed patients located in the long term care area were cared for under the same services and policies that patients in other areas of the hospital receive, that hospital services maintained adequate oversight of care offered to those patients, and to administer the swing bed program in a way that ensures all requirements are met.

Failure to ensure all hospital patients receive care under the same scopes of services, that hospital departments maintain adequate oversight of services offered to all patients, and to comply with requirements for swing bed patients places patients at risk for inadequate care and potential harm.

Findings included:

1. The governing body approved the palcement of eight critical access hospital beds in the long term care facility.

2. The governing body failed to ensure that swing bed patients in the long term care area received the same care and operated under the same scopes of services as swing bed patients in the hospital.

3. The governing body failed to ensure that policies and procedures governing care for swing bed patients in the long term were consistent with policies for other patients in the hospital.

4. The governing body failed to ensure that the hospital pharmacy services maintained adequate oversight of pharmaceutical services delivered to swing bed patients in the long term care area.

5. The governing body failed to ensure that infection control activities for swing bed patients in the long term care area were overseen by hospital personnel and integrated into the hospital program.

6. The governing body failed to ensure that staff caring for swing bed patients in the long term care area were dedicated staff that did not concurrently care for long term care patients.

7. The governing body failed to ensure that patients admitted to swing bed status in the long term care area followed the requirements for swing bed admission.

Cross Reference: Tags 0241, 0253, 0271, 0273, 0276, 0278, 0350

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Based on observation, interview, and record review, the governing body failed to ensure that hospital swing bed patients located in the long term care facility were cared for under hospital scopes of services and policies and procedures by integrating those beds within the long term care service (Item #1) and failed to ensure that peer review was performed on practitioners prior to reappointment as outlined in the hospital medical staff bylaws (Item #2).

Failure to ensure that swing bed patients in the long term care area receive the same care as swing bed patients in the hospital and failure to ensure that providers medical work is adequately reviewed prior to reappointment places patients at risk of inadequate care from unqualified staff and delay in placement to the most appropriate healthcare facility to meet their needs.

Findings included:

Item #1 - Integration of Hospital Swing Beds into Long Term Care

1. Record review of the board of commissioners meeting minutes from 09/22/15 showed that a draft analysis of the benefits of converting long term care beds into critical access hospital swing beds in order to change to acute care reimbursment rather than long term care reimbursment was presented to the board.

Record review of the board of commissioners meeting minutes from 10/27/15 showed that the board approved the conversion of eight beds in the long term care facility to critical access hospital swing beds with a goal of 01/01/16.

2. Record review of the document titled, "Forks Community Hospital Organizational Chart," no date, showed that long term care is a unit under the purview of the chief nursing officer. The chief nursing officer also has direct oversight of the hospital acute/swing bed services.

3. Record review of a hospital floor plan, no date, showed that rooms 214 through 217 were located in the long term care facility and are used for hospital swing bed patients.

4. Record review of the document titled, "Scopes of Services: Administration," no policy number, effective 02/11, did not show a service for swing bed patients in the long term care facility and how they are administered by the hospital. The review showed that the swing bed section described the program as a five bed service offering post-acute recovery for patients needing extended care.

5. Record review of long term care scopes of services showed that hospital swing bed patients in the long term care facility were cared for under scopes of services outlined specific for long term care patients rather than hospital patients.

Cross Reference: C-0273

5. On 06/11/19 from 8:00 AM to 8:30 PM, Investigators #2 and #9 toured the hospital and counted beds. The hospital had 25 beds. Eight critical access hospital beds were located in the long term care facility, and the hospital considered these beds to be swing beds. The beds were in rooms 214 through 217 of the long term care facility.

6. On 06/11/19 at 8:35 AM, Investigators #2 and #9 interviewed the Quality Director (Staff #201) and the Long Term Care Director (Staff #202). Staff #201 stated that when a patient moves to swing bed status in the acute care unit, they are there to receive restorative or physical therapy services. Staff #201 stated that patients needing a longer-term or permanent placement are placed in a swing bed in the long term care area. Staff #202 stated that the eight swing beds in the long term care area are treated in the same way as the long term care beds with no differentiation between the two bed types. Staff #202 also stated that the long term care facility employees provide daily services to those swing bed patients in the long term care facility, but all employees are employed by the hospital and can float between the hospital and the long term care facility as needed.

7. On 06/12/19 at 11:38 AM, Investigators #2 and #9 interviewed the Chief Executive Officer (CEO) (Staff #211) regarding the swing beds in the long term care area. The CEO stated that the hospital reclassified the beds for financial reasons as advised by an outside accounting firm. The CEO stated that the swing bed patients are "custodial swing bed" patients and receive the same care as long term care patients. The CEO stated that the hospital is following the rules and regulations for "custodial swing beds" but was unable to provide specific rules when asked.

ITEM #2 - Medical Staff Provider Peer Review

1. Record review of the Medical Staff Bylaws, revised 01/23/18, showed that the Peer Review and Credentials Committee is required to conduct peer review of providers at reappointment.

2. Record review of the credentialing files for a podiatrist (Staff #209) reappointed to the medical staff on 11/29/17 showed that the peer reviewer never conducts review prior to reappointment.

3. On 06/13/19 from 9:40 AM to 10:10 AM, Investigator #2 reviewed medical staff credentialing files with the Foundation Coordinator (Staff #209). Staff #209 confirmed that the peer review document was incomplete at the time of review.

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Based on record review and interview, the hospital failed to ensure that staff serving the needs of hospital swing bed patients in the long term area were not concurrently caring for long term care patients and that staff position descriptions accurately reflected job duties necessary to care for swing bed patients.

Failure to ensure that swing bed patients have access to adequate staffing and staff that are prepared to meet their care needs places patients at risk for unsafe or inadequate care and potential deterioration in condition.

Findings included:
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1. Record review of personnel files showed that 4 of 5 hospital staff (Staff #202, #204, #205, and #206) had position descriptions stating that they were long term care facility employees. The review showed the following:

a. The director of the long term care and the hospital swing bed patients in the long term care facility (Staff #202) had the job title of "Long Term Care Director," revised 05/07/19. Review of the job description showed that the long term care director is responsible for overseeing care of the long term care patients and following all appropriate regulatory requirements for long term care. The job description does not mention hospital swing bed patients.

b. The activities director in the long term care facility that also houses hospital swing bed patients (Staff #205) had the job title of "Long Term Care Activities Director," revised 05/07/19. Review of the job description showed that the activities director implements resident programs for long term care patients as directed by the long term care director. The job description does not mention hospital swing bed patients.

c. The long term care charge nurse (Staff #204) had a job description titled, "Long Term Care Registered Nurse."

d. An additional RN in the long term care unit (Staff #206) had the job title, "Long Term Care Coordinator."

2. Record review of additional job descriptions showed that the long term care facility had specific job descriptions for nursing assistants, certified (revised 05/07/19) and licensed practical nurses (revised 05/07/19) which were different than those for equivalent positions designated as "acute." These long term care position descriptions do not reference job duties or responsibilities as they relate to hospital swing bed patients.

3. Review of the personnel files for 5 of 5 hospital staff (Staff #202, 204, 205, 206, and 210, a social worker) showed no specific swing bed training for any staff members.

4. On 06/11/19 at 8:40 AM, Investigators #2 and #9 interviewed the Quality Director (Staff #201) and Long Term Care Director (Staff #202) regarding the hospital swing bed patients in the long term care facility. Staff #201 stated that the hospital employs all staff working in the long term care facility and the staff can float between the long term care and swing bed patients as needed. Staff #202 stated that the hospital swing bed patients in long term care facility are treated the same as long term care patients by staff with no difference between the care provided.

5. On 06/13/19 from 8:50 AM to 9:40 AM, Investigator #2 reviewed personnel files with the human resources generalist (Staff #207) and human resources director (Staff #208). Staff #207 and #208 confirmed the job descriptions in the files were accurate for the staff reviewed.

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Based on observation, interview, and document review, the hospital failed to ensure that all critical access hospital patients received the same care due to placement of eight hospital beds in the long term care facility, utilizing long term care policies, procedures, and scopes of services for patients placed in the critical access hospital beds located in the long term care facility, and providing inadequate oversight of services offered to hospital patients placed in critical access hospital beds located in the long term care facility.

Failure to locate critical access hospital patients in an area within the hospital that allows them to receive the same care and oversight as other hospital patients places patients at risk for inadequate or substandard care.

Findings included:

1. The hospital failed to ensure that policies and procedures governing care for swing bed patients in the long term care facility were consistent with those for other hospital patients rather than those governing care of long term care residents.

2. The hospital failed to ensure that scopes of services governing care for swing bed patients in the long term care facility were consistent with those for other hospital patients rather than those governing care of long term care residents.

3. The hospital failed to ensure that the pharmacy department maintained adequate oversight of pharmaceutical services offered to swing bed patients in the long term care facility.

4. The hospital failed to ensure that the infection control program maintained adequate oversight of the infection control activities and analysis for swing bed patients in the long term care facility.

Cross Reference: Tags 0271, 0273, 0276, 0278

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Based on record review and interview, the hospital failed to ensure that policies directing care of swing bed patients were uniform for all swing bed patients in the hospital.

Failure to ensure that policies for swing bed patients are consistent throughout all areas of the hospital risks inadequate care from potentially contradictory patient care policies.

Findings included:

1. Record review of patient care policies showed that swing bed patients in the long term care facility were cared for under long term care policies rather than the same policies that would govern swing bed patients located in the hospital's acute care unit. Review showed the following:

a. Review of the policy titled, "Admission Requirements, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, reviewed 03/17, showed that the long term care patients and swing bed patients in the long term care facility had the same admission policy. The policy did not specifically reference any differences in admission for long term care patients or "custodial" swing bed patients.

b. Review of the policy titled, "Restraints, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, reviewed 03/17, showed that the restraint policy is specific for the long term care facility. The policy does not reference any differences that may be required for restraining long term care patients or hospital patients located in the long term care faiclity.

c. Review of the policy titled, "Medication Administration, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 03/17, did not show that medication administration for swing bed patients in the long term care facility were specifically mentioned, but rather that all patients in that facility will receive the same medical administration procedures.

d. Review of the hospital policy titled, "Waiting List, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 03/17, showed that the hospital and long term care facility maintain a list of applicants waiting to be admitted into the facility. Review showed that patients in swing beds are given priority on the waiting list for long term care beds if they become available.

2. On 06/11/19 at 8:40 AM, Investigators #2 and #9 interviewed the Long Term Care Director (Staff #202) who stated that there was no differentiation in the care that the long term care patients and hospital swing bed patients located in the long term care facility received and that the staff used the same policies and procedures to care for the patients on the unit.

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Based on record review and interview, the hospital failed to ensure that services provided to hospital swing bed patients in the long term care facility were furnished according to the same scopes of services that applied to other patients in the hospital.

Failure to ensure that all hospital patients receive the same services risks unsafe patient care from different processes, procedures and services that might not meet the full needs of patients.

Findings included:

1. Record review of the hospital's scopes of service showed the following:

a. Review of the document titled, "Infection Control Program, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 04/17, showed that the long term care unit, which houses eight hospital swing beds, conducts its own infection control program in concert with the overall hospital infection control program. The long term care facility employs its own infection preventionist nurse. The long term care infection preventionist and control program will report to quality and hospital infection control with assistance from the medical director and acute care infection preventionist.

b. Review of the document titled, "Pharmacy Services, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 03/17, showed that pharmacy services are provided to the long term care facility per a contracted service. Review also showed that pharmacy services has its own set of policies and procedures. The scope of services does not mention how the service is provided to swing bed patients in the long term care area.

c. Review of the document titled, "Quality Assurance and Performance Improvement, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 03/17, showed that the long term care facility and hospital swing beds in the long term care area are one unit under the quality program. The document did not provide any details on how or if the quality program stratifies the patient information for quality assurance or performance improvement purposes.

d. Review of the document titled, "Scope of Practice: Physical Rehabilitation Services," no policy number, reviewed 03/15/18, showed that the physical rehabilitation department provides services to the long term care unit, or, in the event that formal services are not needed, will provide recommendations to the long term care unit. The scope of services did not mention swing bed patients in the long term care facility and how the department provides services to those patients.

e. Review of the document titled, "Scope of Social Services, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, reviewed 08/17, showed that the social services department provides services to the hospital and the "long term care facility." The scope of services did not mention services provided to swing bed patients.

2. On 06/11/19 at 8:40 AM, Investigators #2 and #9 interviewed the Long Term Care Director (Staff #202) who stated that there was no differentiation in the care that the long term care patients and hospital swing bed patients, located in the long term care facility, received and that the staff used the same policies and procedures to care for all patients located in the long term care facility.

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Based on interview and review of policy, the Critical Access Hospital (CAH) failed to identify and designate an individual who has overall responsibility for the CAH's pharmacy services, including development of the rules governing pharmacy services.
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Failure to ensure oversight of the CAH pharmacy services could lead to poor patient outcomes related to drug therapy.
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Findings included:
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ITEM #1- Pharmacy Services
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1. Document review of the hospital's policy titled, "Medication Administration-Long Term Care/Custodial Swing Bed Unit," No policy number, Revised 03/17, showed that all medication orders are filled by a pharmacy contract service. The Pharmacy Products and Services Agreement states, "this 'Agreement' dated as of 06/18/17 (the 'Commencement Date') is by and between Evergreen Pharmaceutical, LLC doing business as Omnicare of Seattle, located at 12674 Gateway Drive South Tukwila, WA 98168 ("pharmacy") and Clallam County Hospital District #1 doing business as Forks Community Hospital-LTC Unit, Located at 530 Bogachiel Way Forks WA 98331 ("Facility").This is an offsite pharmacy service, which per the contract with the facility, provides services to the Long Term Care (LTC) Unit of the CAH which includes swing bed (SB) patients located on the LTC unit.
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2. Document review of the hospitals policy titled, "Long-Term Care Medications," Policy # MM.1.620 Revised 01/18 showed that the CAH pharmacy supplies LTC with medications not provided by the LTC pharmacy (1) if a new prescription is needed before the next delivery from the long-term care pharmacy (2) and over the counter medications as floor stock.
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3. On 06/12/19 at 9:30 AM, Investigator #9 inspected the CAH pharmacy and interviewed the Pharmacist (Staff #903). Staff #903 verified that the CAH pharmacy supplies over the counter (floor) stock supplies to the LTC facility and inspects the medication room in the LTC facility monthly. She noted that the pharmacy does not inspect the medication carts used to store prescribed medication for LTC patients.
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ITEM #2 -Adverse Event Analysis
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1. Document review of the hospital's policy titled, "Medication Administration-Long Term Care/Custodial Swing Bed Unit," No policy number, Revised 03/17, showed that if a medication error occurs the hospital risk manager would review the report with the hospital pharmacist if necessary, and the Director of Nursing and LTC nursing staff would evaluate errors, and the Quality/Risk manager would be available to consult.
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2. On 06/12/19 at 9:30 AM, Investigator #9 inspected the CAH pharmacy and interviewed the hospital Pharmacist (Staff #903). Investigator #9 asked if adverse drug events or drug errors that occurred in the LTC facility were reported to her for tracking and trending. She stated that the Quality/Risk Director (Staff #902) receives these reports via an online error reporting system, but the pharmacy was not tracking that data. This was confirmed with Staff #902 during a Quality Meeting on 06/13/19 at 1:00 PM.

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Based on record review and interview, the hospital failed to ensure that the infection control program had complete oversight of hospital patients located in the long term care facility.

Failure to maintain adequate oversight of hospital patients risks patient infection.

Findings included:

1. Record review of the document titled, "Infection Control Program, Department: Long Term Care/Custodial Swing Bed Unit," no policy number, revised 04/17, showed that the long term care facility conducts its own infection control program in concert with the overall hospital infection control program. The long term care facility employs its own infection preventionist nurse. The long term care infection preventionist and control program will report to hospital quality and infection control program with assistance from the hospital medical director and hospital infection preventionist.

2. On 06/12/19 at 2:30 PM, Investigators #2 and #9 interviewed the hospital infection preventionist (Staff #203) regarding the infection control program. Staff #203 stated that the eight swing beds in the long term care facility are included in the overall hospital infection prevention workload, but the long term care charge nurse (Staff #204) handles the daily oversight of program activities for the long term care patients and hospital swing bed patients located in the long term care facility. Staff #203 showed the investigators data for the infection control program and confirmed that data for long term care and hospital swing bed patients located in the long term care facility are combined for analysis purposes.

Based on observation and interview, the Critical Access Hospital (CAH) used different electronic medical records (EMR) for patients located in the acute care portion of the hospital and the hospital patients located in the swing-bed portion of the long term care facility.

Failure to have EMRs that interface for all patients admitted to the CAH could lead to suboptimal care and harm for patients.

Findings included:

1. On 06/12/19 at 11:00 AM, Investigator #9 reviewed the medical records of the 8 swing bed patients that were located in the LTC facility. Investigator #9 noted that the swing bed patients' EMR system (Pointclickcare), the program used for the 8 swing bed patients in the LTC facility, was different from the EMR system (Meditech) used for the CAH patients.

2. At the time of the observation, Investigator #9 questioned the Quality/Risk Manager (Staff #901) and the Charge Nurse of the LTC (Staff #902) about the different EMRs. They confirmed that the systems were different and did not interface or share information. They also stated that the Pointclickcare EMR was a system designed for use with LTC patients.

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Based on interview, record review and hospital policy review, the Critical Access Hospital failed to provide evidence of compliance with the Condition for Participation at 42 CFR 485.645: "Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds")" for 8 of 8 swing-bed patients in the long term care facility (Patients #901, #902, #903, #904, #905, #906, #907 and #908).
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Failure to comply with special requirements for CAH Long-Term Care Services (Swing-Beds) could lead to suboptimal care and services for patients placed in Swing-Bed status.
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Findings included:
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1. Document review of the hospital's policy titled, "Swing Bed Admission Protocol," no policy number, effective 10/2008, showed that Medicare patients are to have: (1) a 3 day acute hospital stay prior to Swing Bed (SB) (2) be admitted for the same condition as original acute care admission (3) have a physician's order to admit to SB.
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2. Open record review of patients in Swing-beds located in the Long Term Care facility showed the following:
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a. Patient #901 admitted from home on 02/24/17 with an order for long-term care by the hospital provider. Her diagnosis is dementia, arthritis, and diabetes. The patient is currently occupying a hospital SB located in the LTC facility. There was no documentation in the patient's medical record indicating why the patient was admitted to a hospital SB rather than a LTC bed.
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b. Patient #902 was admitted to a SB on 08/24/15 due to weakness and anemia. She was discharged from SB and admitted to LTC on 08/26/15. Document review of nursing progress notes for 11/07/16 showed that the patient was admitted to a hospital SB from a LTC bed.
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c. Patient #903 was admitted from home to LTC per his choice for terminal care on 08/27/18. The patient is currently occupying a hospital SB in the LTC facility. There was no documentation in the patient's medical record indicating why the patient was admitted to a hospital SB rather than a LTC bed.
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d. Patient #904 was admitted from a nursing home to LTC on 01/24/18. He was briefly seen in the Emergency Department on 01/25/19 for episodes of non-responsiveness. On 01/26/18, the patient was readmitted to LTC per physician order but currently occupies a hospital SB in the LTC facility.
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e. Patient #905 was transferred from another nursing home to the LTC facility on 01/29/15 with a diagnosis of high blood pressure, cerebral vascular accidents, aortic valve disease, and degenerative joint disease. On 11/08/16 the patient was transferred from the LTC bed to the hospital SB located in the LTC facility.
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f. Patient #906 was admitted from an assisted living facility in 2010 to the LTC facility. On 11/07/16 there was an order to transfer the patient from the LTC bed to the hospital SB located in the LTC care facility.
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g. Patient #908 was transferred from a nursing home on 04/01/19 to the LTC facility with a diagnosis of hypertension, history of strokes, diabetes, dementia and hip fracture repair in 2018. Her admission orders were for admission to the LTC facility. There was no order for admission to the hospital but the patient currently occupies a hospital SB located in the LTC facility.
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h. Patient #907 was admitted to the hospital on 12/19/14 into SB status following hospitalization for cardiac issues. On 01/05/15 the patient was transferred from hospital to the LTC facility. On 11/08/16 the provider wrote an order to transfer the patient to "Long Term Swing Bed" status. The patient currently occupies a hospital SB located in the LTC facility.
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3. On 06/12/19 at 11:00 AM, Investigator #9 interviewed the LTC charge nurse (Staff #902) regarding Patients #902, #905, #906, and #907 being placed into SB status on 11/07/16 or 11/08/16. She stated that the LTC staff were told by administration to place these patients in hospital swing beds located in the LTC facility as a financial move and classify the patients as "custodial swing bed patients."

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Based on interview and review of hospital documents, the critical access hospital failed to provide hospital swing bed patients with a complete list of their patient rights upon admission to swing bed status as required.
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Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.
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Findings included:
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1. On 06/12/19 at 10:00 AM, during open record review, Investigator #9 found documents titled, "Swing Bed Resident Rights" and "The Right to Exercise Your Rights." Investigator #9 questioned which form was used for the 8 hospital patients located in the LTC facility. The hospital's Director of Quality/Risk (Staff #901) and the Charge Nurse, for Long Term Care (LTC) (Staff #902) stated that the hospital swing bed patients received the same rights/ information as the LTC patients. They stated it was their belief they were the same document with different titles.
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2. Document review of the LTC facility patient rights showed that the list did not include all the elements of patient's rights identified in the Medicare regulations. The broucher did not include the following patient rights:
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§483.10(c) to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition;
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§483.10(d) to choose his or her attending physician;
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§483.10(e)(4) to share a room with his or her spouse;
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§483.10(g)(8) to send and receive mail
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3. On 06/12/19, during open record review, Investigator #9 found that 4 of 8 patients (Patients #901, #903, #904, and #908) had not received the hospital swing bed rights upon their admission.

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