HospitalInspections.org

Based on review of policies and medical record and staff interview it was determined the facility failed to ensure written and signed orders contained signatures, dates, and/or times for 7 of 23 sampled inpatients (#2, #3, #7, #20, #25, #36, and #37) whose records were reviewed. The lack of dates and times associated with orders made it difficult to determine if orders were carried out in a timely manner and interfered with the clarity of the medical record. Findings include:

1. Patient #37 was a newborn female delivered on 3/09/11 at 9:35 PM. Her medical record contained admit orders which were noted by the RN on 3/09/11 at 11:35 PM. It was not clear the orders were received as verbal orders prior to being noted by the RN. The physician signed and dated the orders on 3/10/11, but did not indicate the time the orders were signed.

The Interim CNO reviewed Patient #37's medical record on 6/30/11 at 3:40 PM. She stated the orders noted by the RN on 3/09/11 were probably received as a verbal order and should have been documented as such. She verified the time the physician signed the orders was not indicated.

Orders were not clearly documented as verbal orders and the physician authentication of the orders was not timed.

2. Patient #20 was a 21 year old female admitted to the hospital on 3/09/11 to delivery her baby. Her medical record contained "Oxytocin Induction Orders," received as a telephone order by an RN on 3/08/11 at 10:30 AM. The orders indicated Patient #20 was to be admitted 3/09/11 just after midnight to begin induction of labor. The orders were noted by an RN on 3/09/11 at 1:50 AM. The physician signed the orders but did not date and time them. The medical record also contained "Antepartum Orders" which were also signed by the physician but were not dated or timed.

The Interim CNO reviewed Patient #20's medical record on 6/30/11 at 3:40 PM. She verified the physician did not date or time when the "Oxytocin Induction Orders" were cosigned. She also verified the "Antepartum Orders" did not contain the date and time the physician signed the orders.

Orders were not authenticated with the dates and/or times.

3. Patient #36 was a newborn male delivered on 3/13/11 at 12:44 PM. His medical record contained admission orders signed, but not dated or timed, by the physician.

The Interim CNO reviewed Patient #36's medical record on 6/30/11 at 3:40 PM. She verified the admission orders were signed by the physician but were not dated or timed.

4. Patient #7 was a 76 year old female admitted to the hospital on 6/26/11. She was admitted for care of a hip fracture and her past medical history included congestive heart failure, chronic atrial fibrillation, reactive airway disease, and pulmonary hypertension. Examples of incomplete orders in her medical record include the following:

- On 6/27/11 a physician wrote orders to not let Patient #7 have anything to eat or drink after midnight and to have an antibiotic on hold for possible hip surgery for Patient #7 the following morning. There was no indication what time the orders were written.

- On 6/27/11 telephone orders were received by an RN from an NP. The NP ordered an inhaler for use as needed and oxygen was to be provided to keep Patient #7's oxygen saturation level greater than 90%. The time the order was received was not documented.

- On 6/28/11 a telephone order from a physician was documented by an RN. The order indicated surgery was cancelled for that day, Patient #7 could eat a regular diet, and ordered a lab draw for the next morning. The time the order was received was not documented. The physician authenticated the order but did not date or time when the order was authenticated.

- A different physician wrote additional medication orders on 6/28/11 to change IV fluids and add Lasix 20 mg a day and Potassium Chloride 10 meq a day. The time the orders were written was not documented.

During an interview on 6/30/11 at 3:20 PM, an RN on the medical/surgical unit reviewed Patient #7's medical record. She confirmed the above telephone orders were incorrectly documented and lacked the time of receipt of the order. She confirmed the physicians did not document the date and time orders were cosigned, or the time orders were written.

Orders were not dated and/or timed.



00023

5. Patient #2's medical record documented a 60 year old male who was admitted to the hospital on 6/15/11 for acute neurological changes from a CVA. He was discharged and admitted to swing bed status on 6/18/11. He was discharged from the CAH on 6/28/11. Orders including "Increase Lisinopril to 20 mg...[nitroglycerin paste] 1 inch...DC-alcohol withdrawl protocol, Lorazepam 1 mg..." were dated 6/18/11 but were not timed. The nurse documented the orders were noted at 5:50 PM on 6/17/11. It was not clear when the orders were written. An order in Patient #2's medical record for potassium 20 mg to be administered immediately was dated 6/16/11 but was not timed. Without a time, it could not be determined if the medications were administered in a timely manner.

The Interim CNO reviewed the record beginning at 2:50 PM on 6/30/11. She confirmed the lack of documented times on orders.

Patient #2's orders were not timed.

6. Patient #3's medical record documented a 67 year old male who was admitted to the hospital on 4/01/11 for emphysema, kidney failure, pleural effusions, and liver failure. He was discharged to swing bed status on 4/11/11. He died on 4/13/11. His medical record contained an order, dated 4/02/11 but not timed, for potassium 40 meq to be infused over 2 hours and then to have his potassium level checked an hour later. The order also stated to administer Bumex 1 mg IV immediately. Without a time, it could not be determined if the medications were administered in a timely manner. Also, an order to "Restart Metaprolol" was dated 4/08/11 but was not timed. The time the nurse noted the order was also not documented.

The Interim CNO reviewed the medical record beginning at 2:50 PM on 6/30/11. She confirmed the lack of documented times on orders.

Patient #3's orders were not timed.

7. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Orders for 9 different medications were dated 5/05/11 but were not timed. In addition, the orders did not contain documentation of the time they were noted by a nurse.

The Interim CNO reviewed the record beginning at 2:50 PM on 6/30/11. She confirmed the lack of documented times on orders.

Patient #25's orders were not timed.

4. Patient #20 was a 21 year old female admitted to the hospital on 3/09/11 to delivery her baby. She received medication to induce labor and delivered her baby girl via a vaginal delivery on 3/09/11 at 9:35 PM.

The medical record did not contain a "PROBLEM LIST." However, a section of the "PATIENT PROGRESS NOTES" entered by nursing staff was titled "PROBLEMS/GOALS." The problems included ""Risk of infections R/T IV site...Alteration in Comfort R/T LABOR PROCESS...Knowledge deficit r/t care of self and newborn." The nurse documented goals related to each of these problems and if the problem was evaluated, verified, or resolved. The medical record did not contain a POC which included interventions to guide staff in caring for these problems or reaching the established goals.

The Director of Health Information was interviewed on 6/30/11 at 4:55 PM. She reviewed Patient #20's electronic medical record and verified a "PROBLEM LIST" had not been generated for this Patient #20.

A comprehensive nursing care plan had not been developed for Patient #20.

5. Patient #7 was a 76 year old female admitted to the hospital on 6/26/11. She was admitted for care of a hip fracture and her past medical history included congestive heart failure, chronic atrial fibrillation, reactive airway disease, and pulmonary hypertension. The H&P, completed by the NP on 6/26/11, indicated Patient #7 was placed on telemetry (to monitor heart rhythms) and was to have blood work to monitor her for bleeding. The NP also indicated Patient #7 was at risk for skin breakdown.

Patient #7's medical record contained a "PROBLEM LIST" which included "Risk of infection R/T IV site...Risk of infection R/T indwelling foley catheter...Risk for falls...Fear/Anxiety."
The list of problems contained goals related to the problem but did not contain direction for staff regarding care for the patient. The "PROBLEM LIST" did not address issues related to Patient #7's potential for pain, potential for impaired skin integrity, and potential issues related to her respiratory or circulatory status.

The Interim CNO reviewed Patient #7's problem list on 6/28/11 at 4:25 PM. She stated she would have expected risks related to cardiac and respiratory issues, as well as pain, to be included in the problem list for Patient #7. She verified these issues and related interventions and goals were missing from Patient #7's medical record.

A comprehensive nursing care plan had not been developed for Patient #7.

6. Patient #38 was a 42 year old female admitted to the hospital on 4/11/11 to deliver her baby. The baby was delivered vaginally on 4/13/11 at 5:00 PM. Patient #38 received a vaginal laceration as a result of the delivery and was discharged home on 4/14/11. The medication administration record indicated Patient #38 received pain medications throughout her hospitalization.

Patient #38's medical record contained a "PROBLEM LIST" which included "Risk of infection R/T IV site...Risk for falls...Discharge Planning Needs." The list of problems contained goals related to the problem but did not contain direction for staff regarding care for the patient. The problem list did not include interventions and goals related to pain or comfort.

The Interim CNO was interviewed on 6/30/11 at 3:40 PM. She stated occasionally obstetric patients did not have issues with pain, however, for most obstetric patients she expected to see pain addressed in the problem list. She confirmed pain was not addressed in Patient #38's medical record.

A comprehensive nursing care plan had not been developed for Patient #38.

7. Patient #26 was an 81 year old female admitted to the hospital on 3/17/10. She was admitted for acute treatment of cellulitis. The physician documented in the H&P, completed on 3/17/11, that Patient #26 suffered from dementia and had a significant history of coronary artery disease. She was discharged on 3/19/11.

Patient #26's medical record did not contain a "PROBLEM LIST," or any documentation related to interventions or goals for the nursing care provided during her hospitalization.

The Director of Health Information was interviewed on 6/30/11 at 4:55 PM. She confirmed no "PROBLEM LIST," or documentation related to a problem list, was found in Patient #26's medical record.

A comprehensive nursing care plan had not been developed for Patient #26.

8. The "Care Plans/Patient Plan of Care/Problem Activity List," policy, last reviewed on 3/27/11, was reviewed. According to the policy, "An individualized plan of care/problem activity list with measurable goals to meet the needs of the patient will be provided within 24 hours of admission and reviewed/revised every 24 hours or as the patient's condition warrants." In addition, "Each care plan/problem activity list will include expected outcomes (measurable short and long term goals) for each problem/need that has been identified with the patient." The policy did not state interventions would be developed related to the listed problems to guide nursing staff in the care of the patient. The policy did not include the process for documentation of updating the plan of care with the end result of the resolution of established goals.

The Interim CNO was interviewed beginning at 2:50 PM on 6/30/11. She stated the CAH patient records did not contain a document labeled plan of care. She stated the electronic medical record did not have a mechanism for nurses to include interventions in a document for all nursing staff to follow.

The CAH did not develop complete POCs.




00023

Based on staff interview and review of medical records and CAH policies, it was determined the CAH failed to ensure nursing care plans were developed and kept current for 7 of 19 acute care inpatients (#7, #19, #20, #22, #26, #35, and #38), whose records were reviewed. This resulted in a lack of direction to staff and the inability of nursing staff to provide consistent care. Findings include:

1. Patient #19's medical record documented a 44 year old female who was admitted to the CAH on 6/25/11 and was discharged on 6/26/11. Her discharge summary, dated 6/28/11, stated she had been assaulted and her diagnoses included closed head injury, left orbital blowout fracture, double vision, alcohol intoxication, and insulin dependent diabetes. Her medical record contained a "PROBLEM LIST" which included "Risk of infections R/T IV site...Fear/Anxiety...Risk for falls...Need for Pain Management...Skin Integrity." The list of problems contained goals related to the problems but did not contain direction in the form of interventions for nursing staff to implement. The medical record also contained a typed note which stated "Do Not let ANYONE in room EXCEPT LAW ENFORCEMENT per [physician]." A plan related to Patient #19's security was not documented. A plan to monitor Patient #19's vision and neurological status was not documented.

The Interim CNO was interviewed beginning at 2:50 PM on 6/30/11. She reviewed Patient #19's medical record and confirmed a POC with directions to staff as to how to care for her was not documented.

A comprehensive nursing care plan had not been developed for Patient #19.

2. Patient #22's medical record documented a 64 year old male who was admitted to the CAH on 5/20/11 and was discharged on 5/21/11. His discharge summary, dated 5/21/11, stated he had been admitted for hypertension with chest pressure. He also had a diagnosis of Acute Alcohol Withdrawal Syndrome. His blood pressure was noted to be as high as 260/139 on 5/19/11 at 11:33 PM. His "PROBLEM LIST" included "Risk for falls...Risk of infections R/T IV site...Fear/Anxiety." The list of problems contained goals related to the problems but did not contain direction for staff in the form of interventions for nursing staff to implement. A plan to assess Patient #22 for vertigo and neurological symptoms related to his elevated blood pressure was not documented.

The Interim CNO was interviewed beginning at 2:50 PM on 6/30/11. She reviewed Patient #22's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

A comprehensive nursing care plan had not been developed for Patient #22.

3. Patient #35's medical record documented a 79 year old male who was admitted to the CAH on 5/13/11 and was discharged on 5/16/11. His discharge summary, dated 5/16/11, stated he had been treated at an acute care hospital. He had fallen and suffered an intercranial bleed which required surgery to remove the clot. Following release, he had been found down at home and subsequently was admitted to the CAH. A CT scan, conducted on 5/13/11, showed the subdural hematoma (clot) had re-accumulated. His "PROBLEM LIST" included "Risk of infections R/T IV site...Discharge Planning Needs...NEURO INSTABILITY POTENTIAL WITH SUBDURAL HEMORRHAGE." The list of problems contained goals related to the problems but did not contain direction for staff in the form of interventions for nursing staff to implement.

The Interim CNO was interviewed beginning at 2:50 PM on 6/30/11. She reviewed Patient #35's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

A comprehensive nursing care plan had not been developed for Patient #35.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program had been completed. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 6/28/11 beginning at 12:50 PM. An evaluation of the CAH's total program was not present. The Quality Manager stated an evaluation had not been completed. She stated no policy required an evaluation or specified how it would be done. She stated the CAH's Quality Improvement Plan did not address an annual evaluation. She stated she was not aware an evaluation was required.

The CAH did not conduct an evaluation of its total program.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program, including the utilization of CAH services, had been completed. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 6/28/11 beginning at 12:50 PM. An evaluation of the CAH's total program, including the utilization of CAH services, was not present. The Quality Manager stated an evaluation of the utilization of CAH services, including at least the number of patients served and the volume of services, had not been completed. She stated the CAH did not have a policy requiring an evaluation or specifying how it would be done. She stated she was not aware an evaluation was required.

The CAH did not conduct an evaluation of its total program, including the utilization of services.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program, including a sample of both active and closed clinical records, had been completed. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 6/28/11, beginning at 12:50 PM. An evaluation of the CAH's total program, including the utilization of CAH services, was not present. The Quality Manager stated an evaluation of its total program, including a sample of both active and closed clinical records, had not been completed. She stated no policy required an evaluation or specified how it would be done.

The CAH did not conduct an evaluation of its total program, including a sample of both active and closed clinical records.

Based on staff interview and review of policies and quality assurance documents, it was determined the CAH failed to ensure an evaluation of its total program, including a review of the CAH's health care policies, had been completed. This resulted in a lack of feedback to persons responsible for the operation of the CAH. Findings include:

Quality assurance documents were reviewed with the Quality Manager on 6/28/11, beginning at 12:50 PM. An evaluation of the CAH's total program, including a review of the CAH's health care policies, was not present. The Quality Manager stated an evaluation of its total program, including a review of the CAH's health care policies, had not been completed. She stated no policy required an evaluation or specified how it would be done.

The CAH did not conduct an evaluation of its total program, including a review of the CAH's health care policies

Based on staff interview and review of policies and medical records, it was determined the hospital failed to ensure the rights of 4 of 4 swing bed residents (#2, #3, #25, and #27) were protected by informing them of their rights. In addition, the CAH failed to develop systems to inform non-English speaking residents of their rights in a language that the resident understands. The CAH failed to develop systems to allow residents to access all records pertaining to themselves, including current clinical records, within 24 hours and to obtain copies of those records. Finally, the CAH failed to specify how patients' rights would be protected if they were adjudged to be incompetent. This resulted in the inability of the CAH to provide guidance to staff regarding how residents' rights would be protected. Findings include:

1. A form titled "SWING BED PATIENT/FAMILY BILL OF RIGHTS /RESPONSIBILITY-SWING BED PROGRAM," approved 8/30/2007, contained a list of rights and responsibilities. This form was given to all swing bed residents. The form did not include the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. The form did not include the right to not work or provide services for the CAH. The form did not include the right of residents to access their clinical records within 24 hours or their right to purchase photocopies of their records at a reasonable cost.

During an interview with the Swing Bed Admissions Coordinator, beginning at 9:00 AM on 7/06/11, she confirmed the notice of rights form given to patients did not include the above rights.

The form used to notify swing bed residents of their rights was not complete.

2. Swing bed resident records did not contain complete resident rights forms. Examples include:

a. Patient #2's medical record documented a 60 year old male who was admitted to swing bed status on 6/18/11 and was discharged on 6/28/11. His diagnosis was CVA. His medical record did not contain documentation that he had been notified of his rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights, his right to not work or provide services for the CAH, and his right to access access his clinical record within 24 hours and to purchase photocopies of his records at a reasonable cost.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #2's record and stated he was given an incomplete rights form.

b. Patient #3's medical record documented a 67 year old male who was admitted to swing bed status on 4/11/11. He died on 4/13/11. His diagnoses included emphysema, kidney failure, pleural effusions, and liver failure. His medical record did not contain documentation that he had been notified of his rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights, his right to not work or provide services for the CAH, and his right to access access his clinical record within 24 hours and to purchase photocopies of his records at a reasonable cost.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #3's record and stated he was given an incomplete rights form.

c. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Her medical record did not contain documentation that she had been notified of her rights.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #25's record and stated she was not able to find documentation that a rights form had been given to Patient #25.

d. Patient #27's medical record documented a 59 year old male who was admitted to swing bed status on 6/01/11 and was discharged on 6/06/11. His diagnosis was wound infection. His medical record did not contain documentation that he had been notified of his rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights, his right to not work or provide services for the CAH, and his right to access access his clinical record within 24 hours and to purchase photocopies of his records at a reasonable cost.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #27's record and stated he was given an incomplete rights form.

Resident records did not contain documentation they had been notified of their rights.

3. The Swing Bed Admissions Coordinator was interviewed beginning at 9:00 AM on 7/06/11. She stated a policy addressing rights for swing bed residents had not been developed. She stated how the rights of residents, who were adjudged incompetent, would be protected was not addressed in policy. She stated how the CAH would inform non-English speaking swing bed residents of their rights orally and in writing was not addressed in policy. She also stated how non-English speaking residents would be informed of their health status, including their medical condition, in a language they could understand, was not included in policy.

The CAH did not have a system to inform swing bed residents of their rights.

Based on staff interview and review of policies and medical records, it was determined the hospital failed to ensure the transfer and discharge rights of 4 of 4 swing bed residents (#2, #3, #25, and #27) were promoted by defining those rights and by informing residents of their rights. This resulted in the inability of the CAH to ensure residents would not be transferred inappropriately. Findings include:

1. The Swing Bed Admissions Coordinator was interviewed beginning at 9:00 AM on 7/06/11. She stated a policy addressing transfer rights for swing bed residents had not been developed.

2. Swing bed resident records did not contain documentation residents had been notified of their transfer rights. Examples include:

a. Patient #2's medical record documented a 60 year old male who was admitted to swing bed status on 6/18/11 and was discharged on 6/28/11. His diagnosis was CVA. His medical record did not contain documentation that he had been notified of his transfer and discharge rights.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #2's record and stated he had not been notified of his transfer rights.

b. Patient #3's medical record documented a 67 year old male who was admitted to swing bed status on 4/11/11. He died on 4/13/11. His diagnoses included emphysema, kidney failure, pleural effusions, and liver failure. His medical record did not contain documentation that he had been notified of his transfer and discharge rights.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #3's record and stated he had not been notified of his transfer rights.

c. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Her medical record did not contain documentation that she had been notified of her transfer and discharge rights.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #25's record and stated she had not been notified of her transfer rights.

d. Patient #27's medical record documented a 59 year old male who was admitted to swing bed status on 6/01/11 and was discharged on 6/06/11. His diagnosis was wound infection. His medical record did not contain documentation that he had been notified of his transfer and discharge rights.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #27's record and stated he had not been notified of his transfer rights.

The CAH had not defined the transfer and discharge rights of residents and did not have a system to inform swing bed residents of their rights.

Based on staff interview and review of policies and medical records, it was determined the hospital failed to ensure 4 of 4 swing bed residents (#2, #3, #25, and #27) were informed of their rights related to physical and chemical restraints. This resulted in the inability of the CAH to ensure residents would not be restrained inappropriately. Findings include:

1. The Swing Bed Admissions Coordinator was interviewed beginning at 9:00 AM on 7/06/11. She stated soft restraints and chemical restraints were used at the CAH. She stated a policy addressing restraints and the rights of swing bed residents in relation to restraints had not been developed.

2. Swing bed resident records did not contain documentation residents had been notified of their rights in relation to restraints. Examples include:

a. Patient #2's medical record documented a 60 year old male who was admitted to swing bed status on 6/18/11 and was discharged on 6/28/11. His diagnosis was CVA. His medical record did not contain documentation that he had been notified of his rights in relation to restraints.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #2's record and stated he had not been notified of his rights in relation to restraints.

b. Patient #3's medical record documented a 67 year old male who was admitted to swing bed status on 4/11/11. He died on 4/13/11. His diagnoses included emphysema, kidney failure, pleural effusions, and liver failure. His medical record did not contain documentation that he had been notified of his rights in relation to restraints.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #3's record and stated he had not been notified of his rights in relation to restraints.

c. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Her medical record did not contain documentation that she had been notified of her rights in relation to restraints.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #25's record and stated she had not been notified of her rights in relation to restraints.

d. Patient #27's medical record documented a 59 year old male who was admitted to swing bed status on 6/01/11 and was discharged on 6/06/11. His diagnosis was wound infection. His medical record did not contain documentation that he had been notified of his rights in relation to restraints.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #27's record and stated he had not been notified of his rights in relation to restraints.

The CAH did not have a system to inform swing bed residents of their rights in relation to restraints.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident was developed for 4 of 4 swing bed residents (#2, #3, #25, and #27) whose records were reviewed. This resulted in the lack of an organized approach to providing activities for swing bed residents. Findings include:

1. The Occupational Therapist, who was in charge of activities for swing bed patients, was interviewed on 6/30/11 beginning at 1:40 PM. She stated an organized activities program for swing bed residents had not been developed.

2. Swing bed resident records did not contain documentation residents had been received activities assessments or had activity plans. Examples include:

a. Patient #2's medical record documented a 60 year old male who was admitted to swing bed status on 6/18/11 and was discharged on 6/28/11. His diagnosis was CVA. His medical record did not contain documentation of an activity assessment or plan.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #2's record and stated he did not have a documented activities assessment or plan.

b. Patient #3's medical record documented a 67 year old male who was admitted to swing bed status on 4/11/11. He died on 4/13/11. His diagnoses included emphysema, kidney failure, pleural effusions, and liver failure. His medical record did not contain documentation of an activity assessment or plan.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #3's record and stated he did not have a documented activities assessment or plan.

c. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Her medical record did not contain documentation of an activity assessment or plan.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #25's record and stated she did not have a documented activities assessment or plan.

d. Patient #27's medical record documented a 59 year old male who was admitted to swing bed status on 6/01/11 and was discharged on 6/06/11. His diagnosis was wound infection. His medical record did not contain documentation of an activity assessment or plan.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #27's record and stated he did not have a documented activities assessment or plan.

The CAH did not develop and implement an activities program.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure a comprehensive care plan was developed for 4 of 4 swing bed residents (#2, #3, #25, and #27) whose records were reviewed. This resulted in a lack of guidance to nursing staff caring for swing bed residents. Findings include:

1. Patient #2's medical record documented a 60 year old male who was admitted to swing bed status on 6/18/11 and was discharged on 6/28/11. His diagnosis was CVA. His medical record contained a "PROBLEM LIST" which included "Impaired Verbal Communication RE TO STROKE...Risk for falls...Noncompliance-agitation, confusion...ANXIETY RELATED TO GOING HOME ALONE." The list of problems contained goals related to the problems but did not contain direction in the form of interventions for nursing staff to implement. For example, under the problem of Impaired Verbal Communication, goals included Patient #2 would be able to answer yes or no questions and would regain additional expressive speech. But no plan was present regarding strategies staff might use to communicate with Patient #2.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #2's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

Patient #2 did not have a comprehensive care plan.

2. Patient #3's medical record documented a 67 year old male who was admitted to swing bed status on 4/11/11. He died on 4/13/11. His diagnoses included emphysema, kidney failure, pleural effusions, and liver failure. His medical record contained a "PROBLEM LIST" which included "Risk for falls...Risk of infections R/T IV site...Fluid Volume-Excess...Need for Pain Management." The list of problems contained goals related to the problem but did not contain direction in the form of interventions for nursing staff to implement. His discharge summary, dated 4/13/11, stated Patient #3 was very ill and could not be treated aggressively at the CAH. His family made the decision to provide only palliative care and move him to swing bed status. The discharge summary, dated 4/13/11, stated Patient #3 developed projectile vomiting on 4/12/11 that was not controlled with medication. A POC for the patient's impending death and the projectile vomiting were not documented.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #3's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

Patient #3 did not have a comprehensive care plan.

3. Patient #25's medical record documented a 91 year old female who was admitted to swing bed status on 5/05/11 and was discharged on 5/17/11. She was admitted following a stay at an acute care hospital where she underwent hip surgery. Her medical record contained a "PROBLEM LIST" which included "Risk for falls...Need for Pain Management...Risk for infection R/T surgical incision site...Skin Integrity...Altered Family Processes." The list of problems contained goals related to the problems but did not contain direction in the form of interventions for nursing staff to implement.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #25's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

Patient #25 did not have a comprehensive care plan.

4. Patient #27's medical record documented a 59 year old male who was admitted to swing bed status on 6/01/11 and was discharged on 6/06/11. His diagnosis was wound infection. His medical record contained a "PROBLEM LIST" which included "Risk for falls...Need for Pain Management...Risk for infection R/T IV site...Risk for infection R/T surgical incision site...Knowledge deficit..." The list of problems contained goals related to the problems but did not contain direction in the form of interventions for nursing staff to implement.

The Swing Bed Admissions Coordinator was interviewed beginning at 9:30 AM on 6/30/11. She reviewed Patient #27's medical record and confirmed a POC with directions to staff as to how to care for him was not documented.

Patient #27 did not have a comprehensive care plan.

The CAH failed to develop POCs for swing bed residents.