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Based on the review of documentation and interviews with hospital administrative staff, it was determined that the governing body failed to ensure responsibility of monitoring policies governing the CAH's total operation and ensuring policies were administered so as to provide quality health care in a safe environment.

Findings include:

The governing body failed to ensure a process for the triennial review and revision as needed of the medical staff bylaws, rules and policies.

A review of the governing body documentation revealed five versions of rules with varying changes. Three documents were dated and signed 07/13/1998, 01/22/2004, and 06/21/2007. There were two documents in the same manual that included some regulatory revisions but these documents did not have a date noted nor information regarding the review or approval by the governing body.

These finding was discussed in the exit conference and with Employee #5 following the exit conference.

Based on interview and record review it was determined the facility failed to ensure substantial compliance with all of the SNF requirements contained in subpart B of 42 CFR Part 483. Findings include:

1. Resident Rights, 483.10(b)(3): Refer to Tag C 361.

2. Patient Activities, 483.15(f)(1): Refer to Tag C 385.

3. Social Services, 483.15(g): Refer to Tag C 386.

4. Comprehensive Assessment, 483.20(b)(1): Refer to Tag C 388.

5. Comprehensive Care Plan, 483.20(k)(1): Refer to Tag C 395.

6. Discharge Planning, 483.20(I): Refer to Tag C 399.

Based on interview and record review it was determined the facility failed to inform 4 of 6 sampled "swingbed" patients of their patient rights as required by CFR 483.10(b), (Patients 1, 2, 3 and 5). Findings include:

During the survey it was revealed that a variety of patients, including Patients 1 through 6 had received services in the hospital "swing-bed" program. Interview and record review determined that the facility had failed to inform all of those residents of their "swing-bed" rights as required.

CFR 483.10(b) Notice of Rights and Services states that "The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights ....during the stay in the facility." Record review determined that Patients 1, 2, 3 and 5 had not been informed of their "swing-bed" rights.

Record review revealed that the medical record of Patients 1 and 2 contained no documented evidence that they had been informed of their patient rights. The medical records of Patient 3 and 5 revealed that they had been provided a copy of the general hospital patient rights, but had not been provided the information regarding patient rights specific to the "swing-bed" program.

In interview on 8/11/11 at 8:45 am Witness 2 (Swing-bed Coordinator) acknowledged that there was no documented evidence Patients 1, 2, 3 and 5 had been provided oral and written information regarding their rights as a "swing-bed" patient.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities, in accordance with the comprehensive assessment, for 6 of 6 sampled "swingbed" patients, (Patients 1, 2, 3, 4, 5 and 6), and failed to ensure that the activities program was directed by a qualified individual. Findings include:

1. During the survey the medical records of six patients, Patients 1 through 6, who had received services in the "swing-bed" program were reviewed. That review revealed that the facility had not completed a comprehensive activities assessment for those patients as required.

Record review determined there was no comprehensive activity assessment that identified the activity interests of each "swing-bed" patient, as required. There was no written information or activity plan that identified the activities to meet the physical, mental and psychosocial well-being of each patient. In interview on 08/11/2011 Witness 1 (CNO) acknowledged that a comprehensive activities assessment and plan had not been completed for Patients 1 through 6.

2. During the survey it was revealed that the hospital had failed to ensure that the activities program was directed by a qualified individual as required by hospital policy. Policy review determined the hospital had a specific policy that described the activities program and services that were to be provided. That policy had not been implemented as planned for Patients 1 through 6.

Hospital policy, "Specialized Services for Swing Bed Patients: Activities," indicated that "an activities program consistent with the mental, physical, spiritual, emotional, and social need of the patient would be provided." Those services were reportedly to be provided based on "an assessment of an Occupational Therapist," (OT).

According to the policy the OT was to be the qualified individual designated as the activity director for the swing-bed program. However, in interview on 08/10/2011 Witness 1 indicated that the hospital no longer employed the services of an Occupational Therapist (OT).

Witness 1 further stated that the Swing-bed Coordinator (Witness 2) was now the qualified individual designated to complete the activity assessments and direct the program. However, it was determined that Witness 2 failed to meet the requirements to be a designated director of the activities program. Although Witness 2 was an experienced RN, she did not meet the specific requirements as outlined in rule.

In interview on 08/11/2011 at 0900 hours Witnesses 1 and 2 acknowledged that the hospital was not in compliance with the policy "Specialized Services for Swing Bed Patients: Activities," and that Witness 2 did not meet the requirements to be the "qualified professional" to direct the activities program.

Based on observation, interview and record review it was determined the facility failed to provide medically-related social services to attain the highest practicable well-being for 2 of 6 sampled "swing-bed" patients, (Patients 1 and 3) as required. Findings include:

During the survey it was revealed that a variety of patients had received services from the hospital "swing-bed" program, including Patients 1 through 6. Because of their terminal conditions, two of those patients (Patients 1 and 3) had very specific social service needs. It was determined that the facility failed to identify those specific social service needs, and failed to provide appropriate interventions to help meet those needs.

Review of the medical record of Patients 1 and 3 revealed that the comprehensive assessment completed as part of the "swing-bed" program had not identified any specific social service needs related to their terminal conditions. Although both patients were expected to live only for a short time, no specific interventions had been identified or implemented to assist the patients and/or family members to deal with their terminal condition.

In interview on 08/11/2011 at 1000 hours Witnesses 1 and 2 acknowledged that no specific social services had been provided to those patients.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment of resident's needs for 6 of 6 sampled "swingbed" patients as required, (Patients 1 through 6). Findings include:

According to "swing-bed" rules, "A facility must make a comprehensive assessment of a resident's needs ...The assessment must include at least the following:"

(i) Identification and demographic information.
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychosocial well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnoses and health conditions.
(xi) Dental and nutritional status.
(xii) Skin condition.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge potential.
(xvii) Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.
(xviii) Documentation of participation in assessment.

Review of the medical records for Patients 1 through 6 revealed that the comprehensive assessments completed for those patients failed to include all of the required information. Specifically those assessments failed to address the customary routine, vision, psychosocial well-being, dental and nutritional status, activity pursuit, discharge potential, and patient participation in the assessment.

In interview on 08/11/2011 at 1000 hours the Director of Nursing Services (Witness 1) acknowledged that the "swing-bed" assessments completed for Patients 1, 2, 3, 4, 5 and 6 failed to include all of the required components.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 6 sampled "swing-bed" patients, (Patients 1 through 6). Findings include:

During the survey it was revealed that a variety of patients received services from the hospital "swing-bed" program, including Patients 1 through 6. The "swing-bed" rules require that a facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs.

Review of the hospital records for Patients 1 through 6 determined that a comprehensive care plan that included all of the required components had not been developed for those patients. The hospital "problem list" that served as the plan of care for Patients 1 through 6 failed to include measurable objectives and timetables, as required. The "problem lists" also failed to include information regarding the mental and psychosocial needs of the patients.

In interview on 08/11/2011 at 9:45 am Witnesses 1 and 2 acknowledged that the hospital version of the plan of care for Patients 1, 2, 3, 4, 5 and 6 failed to include all of the required components.

Based on interview and record review it was determined the facility failed to complete a discharge summary for 3 of 6 "swing-bed" patients as required, (Patients 2, 3, and 4). Findings include:

According to "swing-bed" rules, "When the facility anticipates discharge a resident must have a discharge summary that includes:

(1) A recapitulation of the resident's stay;
(2) A final summary of the resident's status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and
(3) A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment."

Review of the medical records for Patients 2, 3 and 4 determined that a discharge summary had not been completed for those patients. There was no documented evidence in the record of a recapitulation of stay, a final summary or a post-discharge plan of care. The facility failed to complete a discharge summary for those patients as required.

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