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Based on observation and interview, the facility failed to ensure emergency supplies were secured in a manner to prevent unauthorized access for one patient care area (Medical Unit) of two patient care storage areas observed. The facility also failed to ensure outdated emergency supplies were removed from potential patient use from storage areas on one unit (Emergency Department [ED]) of three unit storage areas reviewed. These failures had the potential to allow unauthorized access to emergency supplies, as well as allow expired emergency supplies to be used during patient care, and could affect all patients. The facility census was two.

Findings included:

1. Even though requested, the facility failed to provide a policy on expired supplies and prevention of unauthorized access to supplies and medications.

Observation on 05/14/19 at 9:00 AM, on the Medical Unit, showed the crash cart in the hallway with nine unsecured bins sitting on the crash cart that contained intravenous (IV) catheters, normal saline prefilled syringes, numerous packaged sharp and blunt needles, tourniquets, laboratory blood collection tubes, six and ten milliliter (ml, unit of measure) packaged syringes.

2. Observation on 05/14/19 at 8:50 AM, in the ED's trauma #1 room, showed the following expired supplies:
- Chest decompression set (emergency supplies used after trauma to the chest) with an expiration date of 04/30/19;
- Central venous catheter set (supplies used to place a small plastic tube in a large vein) with expiration dates of 04/30/19;
- One, 1000 milliliter 5% dextrose IV bag (fluids administered through the vein) with expiration dates of 02/2019.

Observation on 05/14/19 at 9:47 AM in the ED's soiled room, showed a Morgan lens kit (eye wash station) with 500 milliliter normal saline IV bag with an expiration date of 09/2017.

During an interview on 05/14/19 at 10:35 PM, Staff B, ED Nursing Supervisor, acknowledged the expired supplies and stated that staff should remove all expired items from potential use on patients.

During an interview on 05/15/19 at 4:15 PM, Staff K, Chief Nursing Officer (CNO), stated that supplies should be secured to prevent unauthorized use and expired supplies should be removed to prevent potential use on patients.


39562

Based on observation, interview, record review, policy review and review of the United States Pharmacopeia (USP) Chapter 797 the facility failed to:
- Ensure that staff followed the infection prevention standards for the USP for compounded sterile preparations and secured medications to prevent access by unauthorized staff. (C-276)
- Ensure that staff followed infection control policies and infection prevention standards. (C-278)
- Follow the standard of practice and provide consistent cardiac (heart) monitoring for one patient (#7) of one patient observed, who was being monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm) (C-294).

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services. The facility census was two.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 05/14/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 05/14/19, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- On 05/14/19 at 5:00 PM, immediate training took place with all current nursing staff and non-clinical staff on the Medical/Surgical floor that included review of the facility Clinical Alarms Policy, Cardiac Monitoring Procedure in Lippincott Manual and documentation of strips at a minimum of every shift.
- Staff would be trained that a person must monitor the telemetry and if alarms sounded, the nurse would be paged/notified immediately for appropriate interventions.
- Telemetry alarms would not be disabled at any time and monitors would be observed on a continual basis when a telemetry patient was a current inpatient.
- A six question written test was developed and administered to staff related to training and education.
- All nursing staff would be trained prior to their next scheduled shift and staff would not be allowed to work until training occurred.

Refer to the 2567 for additional information.

Based on observation, interview, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination), the facility failed to ensure that staff followed the facility's policy and the infection prevention standards when they failed to:
- Ensure the work area (buffer area) was kept uncluttered and free from particle-generating (potential contaminants) materials.
- Document and clean the buffer area (sterile zone in the pharmacy where CSPs are prepared) on days that medications were compounded;
- Have a documented growth media (test to ensure proper cleaning technique) sampling;
- Have a documented successful glove fingertip test (test to ensure staff who process CSPs were able to prevent contamination of the CSP); and
- Secure medications to prevent access by unauthorized individuals from two medication storage areas (one anesthesia cart and one Emergency Department [ED] storage room) of four areas observed for unsecured medications.
- Remove expired medications from one medication storage area (ED) of four medication storage areas observed.
These failed practices had the potential to increase the risk of cross contamination in CSPs that could result in patient harm and/or death, and increased the risk of medications being diverted (theft for personal use) which placed all patients at risk. The facility performed approximately one CSP per month. The facility performed approximately 58 procedures per month in the Operating Room (OR) and Surgery Procedural Area. The facility census was two.

Findings included:

1. Review of the USP, Chapter 797, dated 2008, showed that:
- Particle shedding objects (pencils, corrugated cardboard, paper, and cotton items) are prohibited in the buffer area.
- The buffer area floors should be cleaned daily, walls monthly, ceilings monthly, storage shelving monthly and documented on a cleaning log.
- Sampling plans that included surface disinfection sampling (growth media requirements) should be performed on a periodic basis, at a minimum, annually.
- Low risk compounding required a successful glove fingertip test prior to performing CSPs, and annually.

Review of the facility's policy titled, "Sterile Preparations," dated 12/2018, showed no general operational guidelines for the disinfection of the buffer area that followed the recommended guidelines by USP Chapter 797, which are enforceable by regulation. The policy stated that all sterile preparations shall be prepared within a clean Laminar Flow Hood (enclosed work bench which prevents contamination of medications when the medication is mixed or prepared) and aseptic technique (process that is maintained free of germs or bacteria) shall be strictly observed.

Observation on 05/15/19 at 10:00 AM in the pharmacy and the pharmacy buffer room, showed the following:
- The Primary Engineering Control (PEC, Laminar Flow Hood) was housed in a separate room outside of the pharmacy (buffer area);
- In the buffer area were opened cardboard boxes (particle shedding material), paper towels (particle shedding material) and an unlabeled plastic spray bottle that contained a liquid used to clean the inside and outside of the laminar flow hood.
- There was no log that demonstrated when the buffer area was cleaned; and
- There was no log that demonstrated a successful glove fingertip test.

During an interview on 05/15/19 at 2:15 PM, Staff P, Pharmacist, stated that he:
- Rarely performed CSPs, and only prepared approximately one a month.
- Was familiar with USP 797 guidelines.
- Was not familiar with growth media sampling and did not have a documented growth media sampling.
- Was not familiar with gloved fingertip testing and did not have a documented successful glove fingertip test.
- Did not have a cleaning log for the buffer area.
- Was unaware that sampling plans should have been performed at a minimum of every six months and documented.

2. Review of the facility's undated policy titled, "Medications - Security," showed the following:
- Medications must be kept safe from contamination and diversion.
- All controlled substances must be locked within a secure area regardless of whether a patient care area is staffed or actively providing patient care.
- No medications will be left unsecured and unattended.

Observation on 05/15/19 at 9:00 AM in the Surgery Procedural Room, following an endoscopy (procedure to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera), showed an unlocked anesthesia cart left unattended. The cart contained multiple 20 milliliter (ml, unit of measure) bottles of Propofol (medication used to cause decreased level of consciousness and sleepiness during surgical procedures), two ml vials of Midazolam (medication used to help patients relax or sleep before and during surgery or medical procedures, and is a high risk drug for theft and personal use), two ml vials of Fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use).

Observation on 05/15/19 at 9:45 AM, in the same Surgery Procedural Room, following a second endoscopy, showed an unlocked, unattended anesthesia cart.

During an interview on 05/15/19 at 9:55 AM, Staff O, Certified Registered Nurse Anesthetist (CRNA), acknowledged that he forgot to lock the anesthesia cart before he left the procedural area and stated that the cart should be locked when he exited the room.

During an interview on 05/15/19 at 10:30 AM, Staff P, Pharmacist, stated that the anesthesia carts should not be left unattended and unlocked.

Observation on 05/14/19 at 10:30 AM in the ED main storage area, showed a door propped open by an empty oxygen tank holder. The main storage area contained the drug Lidocaine (medication used to numb tissue).

During an interview on 05/14/19 at 10:35 PM, Staff B, ED Nursing Supervisor, acknowledged the unsecured area and stated that the area and contents should be secured.

3. Even though requested, the facility failed to provide a policy on expired medications.

Observation on 05/14/19 at 9:30 AM, in the Medical Unit medication room, showed Humulin NPH insulin (an intermediate acting insulin given to diabetics to control their blood sugar level), with an expiration date of 02/2019.

During an interview on 05/14/19 at 10:35 PM, Staff B, ED Nursing Supervisor stated that staff should remove all expired items from potential use on patients.



37921

Based on observation, interview, record review, policy review and reviews of the United States Department of Agriculture (USDA) and ServSafe guidelines, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene after touching inanimate objects (non-living objects, such as keyboards, tables, etc.) between patient tasks and medication administration for two patients (#2 and #7) of two patients observed.
- Put on gloves for tasks involving intravenous (IV, in the vein) catheters (small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) and peripherally inserted central catheters (PICC, a long thin tube that goes into your body through a vein in your upper arm and ends in a large vein near your heart) for two patients (#2 and #7) of two patients observed.
- Date and time IV catheter sites for two patients (#1 and #7) of three patients observed;
- Ensure that staff labeled IV tubing with the date, time and staff initials for one patient (#2) of three patients observed.
- Ensure that blood glucose (blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) quality control (QC) vials (contains a solution used to ensure testing accuracy) and test strips were dated when opened.
- Maintain the cleanliness of two surgical scissors out of two observed and stored in the Medical Unit crash cart (mobile cart which contains emergency medical supplies and medications)
- Ensure that the dietary staff labeled with an acquisition date, and a date to be consumed, ready-to-eat foods that have been prepared onsite or commercially prepared and opened for refrigerated, frozen food, and dry storage areas.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another), and increased the risk of infection and foodborne illness. The facility census was two.

Findings included:

1. Review of the facility's policy titled, "Intravenous Therapy/Saline Locks (tubing that is used to administer medication into a vein)," revised 11/2018, showed the following:
- Wash hands, apply gloves, and maintain aseptic (contamination free) technique in handling sterile (germ free) IV equipment.
- Document the date, time and gauge (size) of the catheter used on the IV dressing site.
- Document date and time and initials on the IV tubing.

Review of the facility's policy titled, "Nursing procedures (Lippincott)," dated 01/2016, showed that the Lippincott Nursing Procedures Seventh Edition, will be the standard of practice for nursing procedures.

Review of the facility's standards of nursing practice titled, "The Lippincott Nursing Procedures, Seventh Edition - IV Catheter Maintenance and Peripherally Inserted Central Catheter Use," dated 10/06/15 showed that:
- The use of infection prevention techniques such as hand hygiene should be used for IV catheter maintenance.
- Gloves would be needed for changing solution in an IV catheter.
- When changing the dressing of an IV catheter, the nurse should label the dressing with the date and time of the procedure and the nurse's initials.
- Staff should perform hand hygiene and then put on gloves when working with a PICC line.

2. Observation on 05/14/19 at 9:05 AM, on the Medical Unit, showed Staff G, Registered Nurse (RN), touched the computer equipment then immediately flushed (to inject a solution) Patient #2's IV catheter, and failed to perform hand hygiene or put on gloves.

Observation on 05/14/19 at 10:15 AM, on the Medical Unit, showed Patient #7, with an IV catheter in her right forearm. The IV dressing was not labeled with a date, time or nurse initials.

Observation on 05/14/19 at 11:30 AM, on the Medical Unit, showed Staff G, touched the computer keyboard and scanner, then immediately administered oral medications without washing her hands. Staff G then touched Patient #7's PICC line and administered medication without washing her hands or applying gloves.

Observation on 05/15/19 at 8:39 AM, showed Patient #7's IV catheter dressing remained undated, untimed, and was not initialed.

During an interview on 05/14/19 at 4:50 PM, Staff G stated that:
- She did not put initials, dates, or times on IV sites when she changed the dressing.
- The only time she wore gloves when she worked with an IV catheter was when she put one in or took one out.
- She only wore gloves when she worked with a PICC line if she put one in or took one out.
- She was unsure of the hospital's policy on glove use and hand hygiene.
- She would refer to the Lippincott manual for glove and hand hygiene procedures.

Observation on 05/14/19 at 8:40 AM, showed Patient #2's IV tubing, attached to a bag of antibiotic (used to treat infections) solution called Zosyn, was not labeled with the nurse's initials, date, or time it was initiated.

Observation on 05/14/19 at 9:55 AM, in the Emergency Department (ED), showed Patient #1's IV catheter in the left antecubital (AC, the depression area in front of the elbow). The IV catheter dressing was not labeled with a date, time or nurse initials.

During an interview on 05/14/19 at 10:05 AM, Staff D, RN, stated that Patient #1's IV dressing was not labeled and should have been, as directed in the policy.

During an interview on 05/15/19 at 4:16 PM, Staff K, Chief Nursing Officer (CNO) confirmed that IV dressings and tubing should be labeled with the date and time initiated, along with the nurse's initials.

3. Review of the facility's undated document titled, "Glucose Meter Training Checklist," showed the directive for staff to date the test strip vial when opened with a 180 day expiration date. The QC vials should be dated when opened with a 90 day expiration date.

Review of the facility's policy titled, "Glucose in Whole Blood on the [brand name] System," dated 11/2018, showed the directive for staff to verify that the strip vial and QC vials were within the open expiration date and not to exceed the printed date on the vials.

Observation on 05/14/19 at 9:30 AM on the Medical Unit, showed an opened, undated test strip vial and two opened QC vials that were undated.

During an interview on 05/14/19 at 9:40 AM, Staff J, Staff Development Nurse, stated that her expectation of the nursing staff was to date the test strip and QC vials after they were opened. The staff were recently educated on this.

4. Review of the facility's policy titled, "Instrument Cleaning and Processing," dated 02/2017, showed that all instruments, equipment and supplies to be used for patient care and procedures must be appropriately processed to ensure they were free from infectious bacteria. After use on a patient, all instruments, equipment and non-disposable supplies will be washed and processed according to need for future use.

Review of the facility's policy titled, "Sterilization of Instruments and Supplies," dated 08/2017, showed that articles to be steam sterilized must be double wrapped (except where peel-pack was used), labeled, dated and initialed.

Observation on 05/14/19 at 9:00 AM of the Medical Unit crash cart, showed two unpackaged surgical scissors lying inside the crash cart. One of the scissors had a sticky residue and rust colored particles on the blade.

During an interview on 05/16/19 at 9:00 AM, Staff DD, Infection Control Nurse, stated that any reusable instruments in the crash cart should be packaged and dated to prevent possible cross contamination.

5. Review of the "USDA Food Code," updated on 09/09/16, stated that food shall be discarded if the food was not consumed before the expiration date and if it was in a container or package which does not bear a date.

Review of the "ServSafe essentials," 7th edition, showed that:
- Ready-to-eat foods that have been prepared onsite or commercially prepared and opened must be labeled with used by date to be consumed.
- All food will be labeled with received by dates and used by dates from manufacturer if in original container.
- If foods were removed from original containers or open, the product will be appropriately labeled and dated.

Review of the facility's policy titled, "Food Safety and Sanitation," revised 08/2018, showed that:
- The department follows the Department of Health's standards, regulations, and suggestions.
- The department follows other regulations and suggestions that were submitted by other official health agencies and organizations.
- All leftovers were labeled, covered, and dated when stored.

Observation on 05/15/19 at 9:04 AM, in the serving area, located in the kitchen, showed one pan of prepared cookies, with no prepared date or use by date.

Observation on 05/15/19 at 9:08 AM, in the reach in refrigerator, located in the kitchen, showed the following:
- Four prepared peach cobbler pies, with no prepared date or use by date.
- One leftover serving tub of broccoli, with no use by date.
- One leftover serving tub of parmesan cheese, with no use by date.
- One leftover serving tube of pickle relish, with no use by date.

Observation on 05/15/19 at 9:21 AM, in the reach in freezer, located in the kitchen, showed the following:
- One bag of strawberries, with no received by date or use by date.
- One open bag of cauliflower, with no open date or used by date.
- Three bags of prepared beans, with no prepared date or use by date.
- One bag of breaded chicken, with no use by date.
- One prepared beef stew, with no used by date.
- Two bags of garlic potatoes, with no received date or used by date.

Observation on 05/15/19 at 9:25 AM, of the spice rack, located in the kitchen, showed the following:
- One open bottle of ground cinnamon, with no open date or used by date.
- One open bottle of ground oregano, with no open date or used by date.
- One open bottle of organic sage, with no open date or used by date.

Observation on 05/15/19 at 9:35 AM, of the storage shelf, located in the kitchen, showed one open bag of bagels, with no open date or used by date.

Observation on 05/15/19 at 9:41 AM, in the walk in refrigerator, located in the kitchen, showed the following:
- Six, one gallon containers of milk, with no received by date or used by date.
- One open gallon of mayonnaise, with no received by date or used by date.
- One open gallon of mustard, with no received by date or used by date.
- One open bag of cheese, with no open date or used by date.

Observation on 05/15/19 at 9:50 AM, in the walk in freezer, located in the kitchen, showed the following:
- One open bag of broccoli, with no open date or used by date.
- One pan of prepared cookie dough, with no used by date.
- 11 bags of french fries, with no received by date or used by date.
- Three bags of chip fries, with no received by date or used by date.
- Three prepared key lime pies, with no prepared date or used by date.

Observation on 05/15/19 at 9:55 AM, in the dry storage area, located in the kitchen, showed the following:
- 13 boxes of dry, hot cereal, with no received by date or used by date.
- Nine boxes of devils cake mix, with no received by date or used by date.
- Six boxes of mashed potatoes, with no received by date or used by date.

During interviews on 05/15/19 at 9:04 AM and 10:05 AM, Staff W, Certified Dietary Manger, acknowledged the unlabeled foods, and stated that the kitchen staff were to follow Safe Serve guidelines and label and date all foods that were stored in the dry storage area, kitchen, refrigerators and freezers. She was unaware that all foods were to be labeled with a used by date.

During an interview on 05/16/19 at 9:09 AM, Staff DD, Infection Control Nurse, stated that dietary staff should follow USDA and Safe Serve guidelines to label foods stored in the kitchen.


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39562

Based on observation, interview, record review and policy review, the facility failed to follow the standard of practice and provide consistent cardiac (heart) monitoring for one patient (#7) of one patient who was monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm). This failure had the ability to affect all patients on cardiac telemetry, when the potential for abnormal changes in the heart's rhythm could go unnoticed. The facility census was two. The facility had an average of three patients a month monitored on cardiac telemetry.

Findings included:

1. Review of the facility's policy titled, "Patient Clinical Alarms," reviewed 11/2018, showed the following:
- All staff will utilize physiological monitoring alarms and patient care equipment alarms to ensure the safety and care of our patients was held in the highest regard.
- Clinical staff must ensure that all alarms are set to activate at appropriate settings for each patient and are sufficiently audible with respect to distance and competing noise within the unit.
- At no time shall staff bypass, shut off or adjust medical equipment alarm volumes to a level that cannot be readily heard when the alarm activates.

Review of the physician's orders and History and Physical (H&P) for Patient #7, dated 05/12/19, showed an order for telemetry monitor. Patient #7 was a 68 year old female admitted to the Medical Unit with shortness of breath, due to congestive heart failure (CHF, where the heart muscle doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (COPD, a lung disorder that persistently obstructs airflow). Electrocardiogram (EKG, test that checks for problems with the electrical activity of your heart) revealed possible left atrial (chamber in the heart) enlargement, and could not rule out if the patient had suffered a heart attack.

Observation on 05/14/19 at 9:45 AM, in the Medical Unit nurse's station, showed that Patient #7's heart rhythm was displayed on the cardiac telemetry monitor. No staff monitored the patient's heart rhythm and no sound was audible from the monitor.

During an interview on 05/14/19 at 9:50 AM, Staff I, Medical Unit Charge Nurse, stated that there was no dedicated telemetry staff to watch the monitors. The nurses looked at the monitor when they passed through the nurse's station or if they heard the monitor alarm.

Observation and concurrent interview on 05/14/19 at 9:55 AM, showed Staff L, Medical Unit Secretary, sat at the desk inside the nurse's station. The telemetry monitor was positioned on the opposite wall to her right. Staff L stated that she did not watch the telemetry monitor, she had no telemetry training and if she heard any alarms, she let the nurses know.

On 05/14/19 at 10:00 AM, Staff I tested Patient #7's telemetry alarm. Staff K, Chief Nursing Officer (CNO), stood by the telemetry monitor while Staff I disconnected the telemetry from Patient #7. No alarm sounded as the heart rhythm went to a flat line. Staff K, acknowledged that the alarm did not sound, should have alarmed and found that the volume alarm had been turned off.

During an interview on 05/14/19 at 10:10 AM, Staff K stated that the telemetry alarms should never be turned off or turned down and that staff should be continually monitoring telemetry.

Based on observation, interview, record review and policy review, the facility failed to ensure Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patients:
- Received a thorough, individualized, documented activity assessment for one current SB patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed, and failed to develop an activity care plan based on those assessed needs for one current SB patient (#2) and three discharged SB patients (#3, #4, and #6) of five reviewed. This failed practice prevented meaningful activities, which enriched the patients' minds and bodies, from being offered and/or planned, and had the potential to affect all Swing Bed patients. (C385)
- Received pertinent, individualized activities as determined via assessment of needs, interests and abilities for one current SB patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed. This failed practice prevented all Swing Bed patients from receiving stimulating, meaningful, and pertinent activities that could improve their quality of life and improve overall health. (C385)
- Received a monthly activity calendar for one SB patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed. This failed practice prevented patients from being aware of available activities on a given day, and could affect all Swing Bed patients. (C385)
- Received an appropriate, comprehensive nutritional assessment to maintain or improve nutritional status for one current SB patient (#2) and two discharged patients (#4 and #5) of five reviewed. This failed practice caused unplanned weight loss for two of five patients reviewed, and the potential for weight loss for one current patient related to poor appetite and lack of intake documentation that was not addressed per the patient's record. This had the potential to affect all Swing Bed patients. (C410)
- Received the required notice to appeal a discharge, per their patients' rights for one current SB patient (#2) and four discharged patients (#3, #4, #5, and #6) of five reviewed. This failed practice had the potential to prevent patients the knowledge to formalize an appeal process for premature discharge, and could affect all Swing Bed patients. (C373)
- Were notified of potential charges, with the cost of each, at admission, and periodically throughout their stay for one current SB patient (#2) and four discharged patients (#3, #4, #5, and #6) of five reviewed. This failed practice had the potential to cause patients to incur charges they were not aware of. This had the potential to affect all Swing Bed patients. (C361)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Swing Beds. The facility census was one acute and one SB. The facility had an average Swing Bed census of two patients per week, or 104 patients per year.

Based on interview and record review the facility failed to provide, in writing, items and services that could be potentially charged, with the cost of each, at admission, and periodically throughout their stay for one current (#2) and four discharged patients (#3, #4, #5, and #6) of five reviewed. This failed practice had the potential to cause patients to incur charges they were not aware of. This had the potential to affect all Swing Bed patients. The facility acute census was one. The facility SB census was one. The average SB annual census was 104.

Findings included:

1. Review of the facility's Swing Bed Program brochure, reviewed 04/2017, showed:
- The patient is fully informed at the time of admission, and during his/her stay of services available in the facility and of related charges, including any charges not covered.
- If the patient is entitled to Medicaid (a State funded insurance program for low income persons) benefits, the patient shall be informed in writing, either at the time of admission or upon becoming eligible for medicaid, of the items/services included under Medicaid and those which are not a Medicaid benefit but which are available, and the charge of each.
- This brochure failed to show those items/services that may cause the patient to incur a bill, and the charge for each.

Even though requested, the facility failed to provide a policy regarding SB non-covered services/items.

Review of current Patient #2's History and Physical (H&P) dated 05/13/19, showed the patient was admitted to SB on that date for intravenous (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) antibiotic therapy related to a post-surgical left knee infection.

Review of the SB admission packet (presented to all SB patients) showed utilization of hairdresser services would be at the patient's expense. The charge (amount not indicated) and arrangement for this service would be the responsibility of the patient/family. No other items/services were listed as a potential charge.

During an interview on 05/14/19 at 8:40 AM, Patient #2 said she did not recall receiving any list of chargeable items/services while a SB patient.

Review of discharged records for Patients #3, #4, #5 and #6 showed no documented evidence in their records that they received any notification of possible chargeable items/services while a SB patient.

During an interview on 05/15/19 at 10:38 AM, Staff EE, Social Worker, stated that she was not aware of any list of potential charges that was given to SB patients.

During an interview on 05/15/19 at 4:16 PM, Staff K, Chief Nursing Officer, stated that hair care services were available to SB patients, at a cost, arranged by family. However, no actual costs were provided of these or other services.

Based on interview and record review, the facility failed to provide the required notice to appeal a discharge, per their patients' rights, for one current (#2) and four discharged (#3, #4, #5, and #6) Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patients of five reviewed. This failed practice had the potential to prevent patients the knowledge to formalize an appeal process for premature discharge, and could affect all Swing Bed patients. The facility acute census was one. The facility SB census was one. The average SB annual census was 104.

Findings included:

1. Review of the facility's Swing Bed Program brochure, reviewed 04/2017, showed:
- The discharge of a patient will be made on the order of the attending physician when the patient no longer meets the criteria to receive skilled care.
- The patient is discharged only for medical reasons or for non-payment of his/her stay.
- The patient has the right to participate in discharge planning.
- This brochure failed to address how to, or whom to contact to appeal a discharge.

Even though requested, the facility failed to provide a policy regarding SB appeal of discharge.

Review of current Patient #2's History and Physical (H&P) dated 05/13/19, showed the patient was admitted to SB on that date for intravenous (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) antibiotic therapy related to a post-surgical left knee infection.

Review of the SB admission packet (presented to all SB patients) showed no evidence of a discharge appeal form.

During an interview on 05/14/19 at 8:40 AM, Patient #2 said she did not recall receiving any form that explained how to appeal a discharge, or to whom she would appeal.

Review of discharged records for Patients #3, #4, #5 and #6 showed no documented evidence in their records that they received a form notifying them of their ability to appeal a discharge.

During interviews on 05/15/19 at 2:05 and 2:40 PM, Staff Z, Director of Quality, stated that she was not aware of any appeal rights notice given to SB patients. Later, Staff Z confirmed the facility had not been providing discharge appeal notification to SB patients.

Based on observation, interview, record review and policy review the facility failed to:
- Conduct a thorough, individualized, documented activity assessment for one current Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed. This failed practice prevented meaningful activities, which enriched the patients' minds and bodies, from being offered and/or planned, and had the potential to affect all SB patients.
- Provide pertinent, individualized activities as determined via assessment of needs, interests and abilities for one SB patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed. This failed practice prevented all SB patients from receiving stimulating, meaningful, and pertinent activities that could improve their quality of life and improve overall health.
- Provide a monthly activity calendar, and provide activities on the weekends for one SB patient (#2) and four discharged SB patients (#3, #4, #5, and #6) of five reviewed. This failed practice prevented patients from being aware of available activities on a given day, and could affect all SB patients. The facility acute census was one. The facility SB census was one. The average SB annual census was 104.

Findings included:

1. Review of the facility's policy titled, "Swing Bed Program Documentation Requirements," dated 04/2016, showed admission assessments were to be documented, including the activity assessment.

Review of the facility's policy titled, "Skilled Nursing-Swing Bed Activities," Revised 11/2017, showed the following:
- Staff will identify each patient's interests and needs, via assessment, and involve each patient in activities that are designed to appeal to those interests to enhance the patient's highest practical level of physical, mental, and psychosocial well-being.
- It is the responsibility of the activity director to implement activities in accordance with each patient's needs/goals, complete the activity assessment, document activities and the patient's response.
- Activities will be adjusted, with documentation, based on their needs/ changes.
- The facility will maintain equipment and/or supplies that each patient needs in order to participate in their desired activities such as audio books, video player, etc.

The policy failed to address the provision of an activity calendar to each patient.

2. Observation and concurrent interview on 05/14/18 at 8:40 AM showed the following:
- Patient #2 stated she was admitted on 05/08/19, with a left knee infection.
- Patient #2 sat in a chair, in her room. There was no activity calendar posted.
- Patient #2 stated that staff had not given her a calendar, but she would like one.
- Patient #2 stated that she liked to do embroidery (hand sewing), word search puzzles, reading, enjoyed cooking, her grandchildren, and plants.
- Patient #2 stated that the only activity staff had provided was one word search book.

Review of Patient #2's activity documentation showed the following:
- Staff failed to document an activity assessment.
- Staff failed to document activity participation.
- Staff failed to identify and provide activities of particular interest to Patient #2.

During an interview on 05/14/19 at 9:30 AM, Staff G, Registered Nurse (RN) stated that the certified occupational therapy assistant (COTA) was the activity director (Staff H).

Review of Patient #3's discharged record showed the following:
- He was admitted on 02/25/19 with an unsteady gait, requiring therapies for strengthening.
- Staff failed to document an activity assessment.
- Staff failed to identify and provide activities of particular interest to Patient #3.
- Documented activity participation showed, "No wants or needs at this time," and "Dropped off newspaper to patient today." Family played cards with the patient one time; however, no other activities were noted through 03/08/19. Staff failed to provide activities on the weekend dates of 03/02/19 and 03/03/19.

Review of Patient #4's discharged record showed the following:
- She was admitted on 02/27/19 for intravenous (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) therapy, and for therapy for generalized weakness. Patient #4 was discharged on 03/02/19.
- Staff failed to document an activity assessment.
- Staff failed to identify and provide activities of particular interest to Patient #4.
- Documented activity participation showed, "Patient has no wants or needs this date," and "Dropped off newspapers and word search puzzles."
- No other activities were noted through 03/02/19. Staff failed to provide activities on the weekend date of 03/02/19.

Review of Patient #5's discharged record showed the following:
- She was admitted on 02/21/19 for IV therapy, and for therapy for generalized weakness.
- Staff failed to document a comprehensive, individualized activity assessment..
- Documented activity participation showed, "Patient has no wants or needs this date," and "Dropped off newspapers and word search puzzles."
- No other activities were noted through discharge on 03/02/19. Staff failed to provide activities on the weekend date of 03/02/19.

Review of Patient #6's discharged record showed the following:
- She was admitted on 04/12/19 and discharged on 04/23/19.
- Documentation by Staff G showed the patient would not verbally respond in order to complete an activity assessment. Staff failed to obtain activity interest information from potential family/friend sources.
- Documented activity participation showed, "Unable to participate," and "Has no wants or needs."
- Staff failed to provide activities that would enhance this patient's mental/physical health and did not offer activities on weekend dates.

During an interview on 05/15/19 at 8:47 AM, Staff H, Activity Director, stated the following:
- She had no real activity program, she just provided things for the patients to do.
- She typically provided a newspaper, or a holiday geared word search/trivia.
- The activity department did not have a video cassette recorder/player or audio players, but she did provide the internet password to patients.
- No activity calendar was provided.
- No activities were provided on the weekend days.

Based on observation, interview, record review and policy review the facility failed to develop activity and infection care plans based on those assessed needs for one current Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patient (#2). The facility also failed to develop activity care plans for three discharged SB patients (#3, #4, and #6) of five reviewed. These failures had the potential to cause poor activity and/or infection planning and intervention by staff, potentially affecting all patients admitted to SB. The facility acute census was one. The facility SB census was one. The average SB annual census was 104.

Findings included:

1. Review of the facility's policy titled, "Admission Assessment, Patient," revised 11/2017, showed the registered nurse (RN) is responsible for initiating and completing the admission assessment and initiating the SB care plan.

Review of the facility's policy titled, "Swing Bed Program Documentation Requirements," dated 04/2016 showed staff were directed to initiate care plans as soon as possible after admission.

Review of current Patient #2's History and Physical (H&P) dated 05/08/19, showed the patient was admitted to SB on that date for intravenous (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) antibiotic therapy related to a post-surgical left knee infection.

Observation and concurrent interview on 05/14/18 at 8:40 AM showed the following:
- Patient #2 stated she had been admitted on 05/08/19, with a left knee infection.
- The patient stated that she had been really ill with sepsis (a potentially life-threatening condition caused by the body's response to an infection) requiring long-term IV antibiotic therapy.
- The patient's left knee and leg were swollen and she had a bandage covering an incision on the knee.

Review of Patient #2's medication administration records dated 05/14/19, showed an order for IV Zosyn (antibiotic) every six hours.

2. Review of the patient's care plan dated 05/08/19, showed staff failed to initiate infection as a problem, with a goal and specific interventions to resolve it. Staff also failed to initiate activities as a problem, with a goal and specific interventions.

During an interview on 05/14/19 at 9:45 AM, Staff G, RN, stated that care plans were reviewed each shift and updated as necessary. Staff G stated that Patient #2's care plan should include infection as an identified problem.

Review of discharged records for Patients #3, #4, and #6 showed staff failed to develop a care plan for SB activities with a goal and interventions.

During an interview on 05/15/19 at 8:47 AM, Staff H, Activity Director, stated that activities should be included on all SB patients' care plans.

Based on interview, record review, policy review and dietary contract review the facility failed to:
- Ensure one of one current Swing Bed (SB, a specific type of reimbursement for patients that need a skilled service, such as therapy, but do not need the level of care in a regular patient bed) patient (#2) received comprehensive nutritional assessments to maintain nutritional status.
- Document meal intake for one of one current SB patient (#2).
- Weigh one of one current SB patient (#2) per their policy.
- Ensure patients received comprehensive nutritional assessments to maintain nutritional status and prevent weight loss for two discharged SB patients (#4 and #5) of four discharged SB patients's records reviewed.
This deficient practice had the potential to affect all SB patients, potentially resulting in malnutrition and/or weight loss. The facility acute census was one. The facility SB census was one. The average SB annual census was 104.

Findings included:

1. Review of the facility's policy titled, "Swing Bed Dietary Services," revised 04/2017, showed documentation of services is dated and signed by the registered dietitian (RD) and progress notes must be written weekly indicating any changes, treatment or status.

Review of the facility's contract for consulting dietician's services dated, 09/14/2016, showed the dietary consultant will:
- Perform services in compliance with applicable hospital policies.
- Spend at least sixteen (16) hours per week in the facility performing her duties as agreed.
- Identify problems and provide recommendation for improvement.
- Instruct patients, staff, and family regarding the patient's diet and nutritional needs.

Review of current Patient #2's History and Physical (H&P) dated 05/08/19, showed the patient was admitted to SB on that date for intravenous (IV, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the blood stream) antibiotic therapy related to a post-surgical left knee infection. The patient had been transferred to this SB program from another acute care facility after having been treated for sepsis (a potentially life-threatening condition caused by the body's response to an infection). The patient was diabetic (which could increase her potential for poor nutritional status related to restrictions).

During an interview on 05/14/19 at 8:40 AM, Patient #2 stated that:
- She had not been eating because she had been so sick related to her infection.
- Food sounded, "awful," and she became nauseated at the thought of food.
- She was on a diabetic diet.

During an interview on 05/14/19 at 8:40 AM, Staff G, Registered Nurse (RN), stated the following:
- Staff retrieved a finished meal tray and recorded intake percentage on a card that dietary placed on the tray before delivery.
- The dietary card, with the recorded intake percentage, was then given to the unit secretary for documentation in the patient's record.
- If the unit secretary was unavailable, the RN or technician documented the intake.
- SB patients were weighed twice weekly by the night shift staff.

2. Review of dietary intake, weight, and dietician assessment documentation from 05/08/19 through 05/14/19 showed:
- Patient #2 was weighed on admission.
- Staff failed to document the patient's daily meal intake, consistently, from 05/08/19 through 05/13/19.
- Staff failed to weigh the patient twice weekly per facility policy (only weight documented was on admission). (Review of the care plan dated 05/08/19, directed staff to weigh the patient daily, contradictory to the policy).
- The dietician's assessment, dated 05/09/19, failed to identify, any evidence of the patient's poor appetite, or a plan to resolve it.
Staff AA failed to re-assess Patient #2 from 05/09/19 through 05/16/19, even though the patient ate poorly.

During an interview on 05/15/19 at 3:28 PM, Staff AA, Registered Dietician (RD), stated the following:
- SB patients were weighed twice weekly, on Wednesdays and Saturdays.
- She was unaware if she had identified the lack of meal intake and weight documentation for Patient #2.
- She knew the Patient #2 had not been eating well.
- She could make recommendations to the physician if she had concerns, she had not made recommendations for Patient #2.

Review of Patient #4's Discharge Summary dated 03/02/19, showed she was admitted to SB on on that date with a diagnosis of diabetes. Patient #4 was discharged on 03/13/19.

Review of Patient #4's nutritional diagnostic documentation, dated 03/04/19, showed:
- The patient was a low risk for malnutrition.
- The patient had a fair appetite with a fair intake.
- The patient was on a regular diet to encourage intake.

Review of Patient #4's dietary intake documentation showed the following:
- On 03/02/19, the patient consumed 10% of the evening meal.
- On 03/03/19, the patient consumed 50% of breakfast, 25% of lunch, and 5% of the evening meal.
- On 03/04/19, the patient consumed 10% of breakfast, 25% of lunch, and 10% of the evening meal.
- On 03/05/19, the patient consumed 25% of breakfast, 100% of lunch, and 60% of the evening meal.
- On 03/06/19, the patient consumed 25% of breakfast, 30% of lunch, and 5% of the evening meal.
- On 03/07/19, the patient consumed 50% of breakfast, 50% of lunch, and 90% of the evening meal.
- On 03/08/19, the patient consumed 95% of breakfast, 25% of lunch, and 25% of the evening meal.
- On 03/09/19, the patient consumed 90% of breakfast, 25% of lunch, and 25% of the evening meal.
- On 03/10/19, the patient consumed 75% of breakfast, 50% of lunch, and 25% of the evening meal.
- On 03/11/19, the patient consumed 50% of breakfast, 25% of lunch, and 50% of the evening meal.
- On 03/12/19, the patient consumed 45% of breakfast, 10% of lunch, and 50% of the evening meal.
- On 03/13/19, the patient consumed 25% of breakfast, and 25% of lunch.

Review of weights from 03/02/19 through 03/13/19 showed the patient lost seven pounds from 03/06/19 through 03/13/19, (seven days).

Staff AA failed to re-assess Patient #4 from 03/04/19 through 03/13/19, even though the patient was losing weight and had poor intake.

Review of Patient #5's nutritional diagnostic documentation, dated 02/22/19, showed the following:
- He was admitted to SB on 02/21/19 with inadequate oral intake.
- He suffered from diarrhea and decreased intake related to side effects of cancer treatment drugs
- He had a fair appetite. The patient was considered a low risk for malnutrition.

Review of Patient #5's dietary intake documentation showed the following:
- There was no documentation of intake on 02/21/19.
- On 02/22/19, the patient consumed 0% of breakfast, 30% of lunch, and 70% of the evening meal.
- On 02/23/19, the patient consumed 30% of breakfast, 10% of lunch, and 50% of the evening meal.
- On 02/24/19, the patient consumed 25% of breakfast, 25% of lunch, and 25% of the evening meal.
- On 02/25/19, the patient consumed 70% of breakfast, 50% of lunch, and 25% of the evening meal.
- On 02/26/29, the patient consumed 95% of breakfast, 25% of lunch, and 20% of the evening meal.
- On 02/27/19, the patient consumed 5% of breakfast.

Review of weights from 02/21/19 through 02/27/19 showed the patient lost four pounds.

Staff AA failed to re-assess Patient #5 from 02/23/19 through 02/27/19, even though the patient was losing weight and had poor intake.