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Based on a review of Quality Improvement Plan, Medical Staff meeting minutes, and interview, it was determined the Governing Board failed to:

1. Assume responsibility for ensuring the quality program was implemented according to the approved plan and holding the medical staff responsible for their delegated authority for the quality plan implementation and
2. Ensure the medical Staff followed their bylaws in ensuring the medical committees identified in the bylaws were conducted according to the bylaws.

Findings include:

1. The Governing Board Bylaws revealed the following: "...The Board shall: 3. Review the results and effectiveness of Quality Improvement conducted by the Medical and other professional staffs, evaluate changes, which should be made to improve the quality and efficiency of patient care within the Hospital, and take appropriate action based on this review and evaluation...."

The Quality Improvement Plan dated 2012 revealed the following: "... The Board of Directors is ultimately responsible for assuring the hospital provides high quality care to patients of the White Mountain Community. The Quality Improvement Plan originates with the Quality Council, followed by a review from the Medical Staff Executive Committee. The Board of Directors grants final approval of the Quality Improvement Plan...."

The Quality Improvement Plan dated 2012 revealed the Medical Staff Executive Committee responsibilities. These included: "... The Medical Staff Executive Committee approve the Quality Improvement Plan, reviews the quarterly quality reports ... The Medical Staff Executive Committee is responsible for making recommendations to the Quality Director and the Governing Board of Directors concerning the Quality Improvement Plan, quality reports ...."

A review of the Medical Executive Committee minutes for January 2011 revealed there was documentation of a Quality Report outlining the 4th Quarter of 2010 outcomes for the indicators that were monitored. There was no documented evidence of action related to the overall indicators presented in the report. The minutes provided no evidence of action the committee would recommend to the Governing Board or to the Quality Leadership team of the hospital. The following month meeting of February 2011 the Medical Executive Committee did approve the report as presented with no discussion or recommendations to the hospital team or evidence of recommendations to the Governing Board.

There was no further documentation in the meeting minutes of quality information to the Medical Executive Committee.

A review of the monthly Medical Executive committee meeting minutes for the months of January through July 2012 revealed in March 2012 meeting minutes the CEO (Chief Executive Officer) reported the Quality Improvement report. The minutes reflected a discussion on the completion of medical records only. There was no discussion, recommendation(s), or action on the indicators that were not meeting the thresholds/benchmarks. The June 2012 meeting minutes revealed the monthly Quality Improvement Report was included in the packet given to the Medical Staff. The discussion included there were several departments who had failed to report on their indicators for the month. There was no documented recommendations from the Medical Executive Committee to approve the report or recommendations to the Governing Board as stated in the Quality Plan.

A review of the Governing Board meetings minutes for the year 2012 revealed in the March meeting the hospital CEO and Quality Director provided the Governing Board with the quality report for the first quarter. The report has the indicators, thresholds/benchmarks, and the outcomes of the quality reviews. There were several indicators that were not within the benchmark/threshold. The minutes revealed the CEO informed the board members the documents were attached and the indicators marked in red were measures requiring significant improvement. There was no documented action provided by the board to to the hospital team regarding the quality report.

The May 2012 meeting minutes of the Governing Board revealed the CEO presented the Quality Improvement report for review and the document was attached for the board members to review. The CEO commented in the meeting minutes that the agenda for the May meeting was to be brief, therefore the Quality Director was not required to attend the meeting to provide an oral report. The CEO again indicated the items in red required significant improvement. The board action was documented as approval of the Quality Improvement report. There was no documented discussion of the indicators where significant improvement would be required or direction provided to the hospital team.

The red indicators included and not limited to the following: Readmissions to the hospital within 30 days; Influenza vaccination of inpatients 50+ who were discharged from the hospital; Number of unplanned readmits within 24 hours with same/similar diagnosis; Number of emergency patients discharge who returned as inpatients within 7 days with same/similar diagnosis; Percent of Critical results called to the provider or registered nurse within 30 minutes; and Meal temperatures.

The Governing Board meeting minutes for June 2012 revealed there was a Quality report by the interim CEO. The report revealed the same "red" indicators. The minutes revealed the monthly report as approved there was no action or direction provided to the hospital team by the Governing Board.

The Governing Board meeting minutes for September, October and November of 2011 were reviewed. There was no discussion of the Quality improvement plan in the meeting minutes of September and November. The October meeting minutes revealed discussion by the hospital Quality Director who shared some of the indicators that were opportunities for improvement. There was no documented action taken by the governing board to approve the presentation or make recommendations.

The Governing Board meeting minutes, Medical Staff meeting minutes and the Medical Executive Committee meeting minutes revealed from October 2011 through July 2012 revealed the respective committees were provided with quality indicators requiring significant improvement with no documented discussion and recommendations. All indicators had direct or indirect impact on patient care provided during this time period.

The Governing Board had delegated in the Quality Plan the review of the hospital department's quality reports to the Medical Staff. There was no documented evidence the Medical Staff engaged in the quality to make recommendations and report to the Governing Board as identified in the plan.

2. A review of the Medical Staff Bylaw Rules and Regulations revealed Article Nine - Committees 9.1 Designation Structure and Function the following: "... All Committees shall maintain a record of attendance at their meetings, maintain a record of their proceedings and submit timely reports of their activities and if pertinent, copies of their meeting minutes to the regularly scheduled Medical Staff meeting... 9.4 Medical Staff Committees shall be as follows: ... Surgical Case/Tissue and Transfusion/ Cancer/Anesthesia Review/ Mortality Morbidity committee; Pharmacy and Therapeutics Committee; Emergency Department Committee; Infection Control Committee; Bylaws Committee; Intensive Care Unit Committee; Credentials Committee ..."

Inteview with the Director of Medical Staff conducted on 09/06/2012 revealed the Medical Staff meetings were held on a quarterly basis. The Director confirmed if there were committee reports the report would be identified in the minutes of the Medical Staff meetings.

A review of the 2011 and 2012 Medical Staff meeting minutes revealed the following committee reports: Emergency committee reported in January 2011; Surgical Committee reported in April, July, and October of 2011 and Pharmacy and Therapeutics reported in January of 2012. There was no documented evidence the committees reported their actions to the Medical Staff on a timely basis. No committee reports for since January 2012 and only one committee reported in 2012.

There was no documented evidence the Medical Staff followed the bylaws with reporting on the committees activities as required.

Based on a review of personnel files, patient medical records, and interview, it was determined the hospital failed to assign registered nurses to pediatric patients who had documented pediatric competencies documented in the personnel file. (Employee #8 and #1)

Findings include:

The hospital policy revised on 07/2011 revealed the following: "... It is the policy of White Mountain Regional Medical Center Nursing Administration, that pediatric patients will be admitted to the hospital within the scope of the facility and staff.

The Medical Executive Committee meeting minutes of April 2012 revealed the Chief Nursing Officer (CNO) discussed the Pediatric rooms and service. ... (Name of CNO) reported nursing staff with pediatric training will be designated to care for the pediatric patients...."

The May 2012 Medical Executive Committee meeting minutes revealed discussion on Pediatric policies. The CNO presented the policies and porecedures for review. One of the physician member suggested that the statement "whenever possible" be added to the Policy as it relates to the assignement of pediatric nurses for pediatric patients.

Interview with the Chief Nursing Officer and the Chief Executive Officer conducted on 09/05/2012 revealed when pediatric patients were admitted to the hospital the nursing staff assigned to the patient would have the clinical competencies to care for pediatric patients.

A review of the personnel files for staff member #8 and 1 revealed there was no documented evidence of age specific competencies. There was no documented evidence of pediatric inservice education or validation of clinical pediatric skills and competencies.

On 09/06/2012 the registered nurse responsible for training was asked to review the personnel files to validate there was no documented competencies related to pediatrics and this was confirmed by her review as well as the surveyors review.

Employee #8 and 1 were each assigned to care for the following pediatric patients during one or more shifts of the patient's hospitalization.

A review of the medical records for Patients # 16. 17. and 18 revealed Employees #8 and 1 had cared for each patient during the patient's hospitalization.

Patient #16's medical record revealed a 12 year old admitted to the emergency department on 08/21/2012. The clinical impression documented by the emergency physician was acute asthma exacerbation with pneumonia and hypoxemia.

Patient #17's medical record revealed a 5 year old admitted to the hospital from the emergency department on 08/25/2012.

Patient #18's medical record revealed the patient was admitted to the hospital on 07/19/2012 with a diagnosis of concussion and memory loss with intractable headache and nausea.

Based on a review of the medical records, electronic record process, and interview, it was determined the hospital failed to require the electronic medical record allow the nursing personnel to document response to pain intervention when delivered or administered as evidenced in two of two medical records reviewed for pain medication administration.

Findings include:

Nursing policy and procedure revealed the response to pain interventions was to be documented in the medical record.

Interview with the Charge Nurse on 09/06/2012 revealed the hospital had implemented an electronic medical record a couple months ago and since this implementation it has been a challenge to document the patient's response to pain intervention.

On 09/06/2012 demonstration of the electronic medical record by the hospital information technologist was completed. The Charge Nurse and the surveyor along with the information technologist could not find a process within the new electronic medical record that allowed the nursing staff to accurately describe the patients response to pain intervention.

A review of medical record for Patient #11 and 22 revealed the patient's were administered pain medication during their hospitalization and there was no documentation of the effectiveness of the pain medication.

Based on a review of medical record documents, interview and hospital policy and procedure, it was determined the hospital failed to provide a ongoing program of activities based on the comprehensive assessment and the interests of the resident in 3 of 3 medical records reviewed. (Resident's #1, #22, and #23)

Findings include:

The Swing Bed Policy manual revealed a policy and procedure for Activities that was revised in March of 2010. The policy revealed the Activities will be documented on the Activities Documentation form and addressed in the Care Plan.

There was no documented evidence of a comprehensive care plan where activities would be included in Patient .

The procedure revealed that at the end of each Interdisciplinary Team meeting the Activities Coordinator will document on the Interdisciplinary Activity Care Plan Form. This form would be used by the team to evaluate the Problem. Goal/Plan of the resident throughout their hospitalization to include an update on the activities plan.

The activities plan for each of the three patient records reviewed was identified was the initial plan. There was no documented evidence of updates included in this plan for the residents as a result of the team meetings.

The procedure identified there would be a structured format Monday through Friday. There was no evidence of a structured activities format available to the surveyor at the time of the survey.

Resident #1 was admitted to the hospital on 08/10/2012. The Swing Bed Coordinator completed an assessment of the patient's interests and documented the data on the assessment form. This form was faxed to the consultant who is the hospital's contracted therapeutic recreation specialist. The contracted therapeutic recreation specialist returned the document with a plan on 08/19/2012. This was 9 days after the patient was admitted to the hospital.

There was no documented evidence of a plan until 08/19/2012 which read as follows: Room visits daily; provide music/radio when family not visiting; daily chronicles and discuss current events; and family and religious associates to visit.

The medical record revealed a Daily Activity form. This form revealed three dates with activities associated with the plan. This included August 19, 26, and 27, 2012 newspaper 2 minutes. There was no documented evidence of music being provided or discussion of current events.

There was no documented evidence of a coordinated plan of activities between the disciplines providing services to the patient.

Resident #23 Admitted to the Swing Bed on 08/06/2012 from an acute care hospital. The documentation revealed the Activity assessment was completed on 08/08/2012 by the Swing Bed coordinator and verified by the Activities Director on the same date. The plan was to have room visits daily to build rapport and encourage involvement; present art project that could be done independently; and provide music, radio in the patient room with encouragement from family involvement. The Individual Resident Daily Activities Documentation Record revealed the newspaper was provided to the patient on 08/09/2012 and 08/26/2012. The Individual Resident Daily Participation Record revealed on 08/15/2012 patient was given the newspaper and "reading" at 0800 to 0815.

There was no documentation of presenting art project that could be done independently or providing music and radio in the patient room.

Resident #22 admitted to the Swing Bed on 07/04/2012 from the inpatient nursing unit. The activities evaluation was completed on 07/04/2012 and revealed the patient liked animals/pets and crocheting. Other activity preference included cards; cultural events; dominoes; reading music; gardening; visits from family and friends; sing-a-longs; social parties and volunteering. This was documented by the occupational therapist on 07/04/2012. There was no documented evidence of an activities calendar.

The Individual Resident Daily Participation Record revealed on 07/15/2012 there was a 15 minute event of sensory orientation. The Individual Resident Daily Activities Documentation Record revealed on 07/04/2012 attendance at the parade and lunch with family in the dining room; on 07/07/2012 visitors; 07/11/2012 visitor for 30 minutes; 07/12, 13, 14, 15, and 16/2012 newspaper provided to the patient. There were several additional family and friend visitations documented on the visitors sign in log.

There was no documentation of activities provided to the patient that had been identified on the activities list.

Interview with the Swing Bed Coordinator conducted on 09/05/2012 revealed the activities are being conducted and the electronic medical record, the hospital has been utilizing for the past 2 months, has the activities documented within the narrative notes. A review of the narrative notes failed to reveal compliance with the plan for activities for Patients #1, 22, and 23.

There was no documented evidence of ongoing activities plan individualized and implemented for the three patients.

Based on medical record review, policy and procedure, and interview, it was determined the hospital failed to develop and maintain a documented comprehensive care plan for each resident admitted to the swing bed status. (Residents' #1, 22, and 23).

Findings include:

The Swing Bed Resident Care Plan Procedure revised in March of 2011 revealed the following: "... It is the policy of White Mountain Regional Medical center to develop an Interdisciplinary Plan of Care for Swing Bed residents that will lead to a positive outcome and is aimed to discharge goals...."

The procedure indicated the plan would be developed for residents within 7 days of completion of the comprehensive assessment using the interdisciplinary team approach with weekly meetings to review and update the care plan initiated by the members of the team.

There was no documented evidence in the electronic or paper medical records of a comprehensive care plan for Residents' #1, 22, and 23. The medical records revealed an initial plan of care documented by nursing. There was a plan established by the therapy department for each of the records. There was no documentation comprehensive plan that addressed nursing and therapy goals along with the social, financial, nutritional needs with objective goals for each of the patient needs.

The medical record revealed the interdisciplinary team meeting for each of the residents. The meeting minutes demonstrated involvement from the family, therapies, Swing Bed Coordinator, nursing, and nutrition; however this interdisciplinary team discussions were not formulated into a coordinated comprehensive plan for the patient available to all care providers and available to the patient and family.

Interview conducted with the Swing Bed Coordinator confirmed there was no single comprehensive plan available in the resident's record that pulled all of the disciplines plan together for the resident.

On 09/05/2012 the surveyor attended the Interdisciplinary Team meeting for Resident #1. The meeting discussed progress and new plans; however there was no comprehensive plan to update that would have demonstrated the resident's progress and new goals. Each department has established their own plan of care, which had not been transitioned to a comprehensive interdisciplinary plan of care.

Medical records were reviewed on 09/06/2012 with the Charge Nurse and the Chief Nursing Officer with the assistance of the information technician. There was no documented evidence of a comprehensive plan of care in the residents' medical records.

Based on review of medical record, policy and procedure, and interview, it was determined the hospital failed to document the provision of physical therapy services for mobility and wound care in one of one resident medical records reviewed. Resident #1

Findings include:

Resident #1's physician ordered physical therapist to work with the patient to pivot on left leg. The patient has two documented stage 2 wounds, one on the left lower leg and one on the right hip from the surgical wound.

Interview with the Swing Bed Coordinator on 09/05/2012 revealed the physical therapist was responsible for the documentation of the wound assessments and the specialized teaching and physical support for the pivoting training as ordered by the physician.

The medical record revealed there was no documentation of physical therapy assessments of the resident's wound from 08/27/2012 through 09/05/2012, 8 days. There was no documented assessment and physical therapy assistance with the activity order of pivoting from 08/31/2012 through 09/04/2012, 5 days.

The policy and procedure for documentation in the medical record revealed care must be documented when provided. There was no documentation to demonstrate the wound had been assessed during the 8 days or that the patient's had the specialized therapy teaching and training for a period of 5 days.