HospitalInspections.org

Based on observation, review of policy and procedures, and staff interviews the CAH (Critical Access Hospital) maintenance staff failed to secure 4 of 10 small compressed air tanks in the oxygen storage area. The CAH administrative staff identified a census of 14 patients.

Failure to secure the compressed air tanks could potentially result in an explosion if the tanks tipped over.

Findings include:

Observation on 8/29/11 at 2:00 PM, with Staff J, Maintenance Supervisor, revealed a locked oxygen storage area with 4 of 10 unsecured small compressed air tanks.

Review of the policy titled, " Handling and Storage of Compressed Gas Cylinders " , approved on 10/1/09 stated in part ... " All freestanding cylinders, whether empty or full, shall be properly chained or supported. "

During an interview on 8/29/11 at 2:00 PM, Staff J verified failure to secure 4 small compressed air tanks in the oxygen storage area.

Based on review of documents and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure annual review of written administrative policies and procedures provided by the network hospital, Sanford Health, for the Sanford Sheldon Medical Center. The administrative staff failed to review the written policies and procedures developed and provided by the network hospital, Sanford Health, for patients admitted to Sanford Sheldon Medical Center.

Failure to ensure all policies are developed, approved and annually reviewed for the CAH could potentially cause a lack of communication regarding the operation of the facility in a safe and efficient environment resulting in a failure to provide the patient with the care and services needed to prevent patient harm.

The CAH administrative staff reported a census of 2 Swing Bed in-patients with a weekly average of 2.5 Swing Bed in-patients

Findings include:

1. The CAH administrative staff provided a list of Administrative policies and procedures with a heading "Sanford Health - SanfordConnect". The policies and procedures lacked documented evidence the Administrator developed, implemented and annually approved these policies and procedures Sanford Sheldon Medical Center.

Review of the CAH administrator job description, reviewed 10/08, revealed in part, "...For Critical Access Hospitals, [Chief Executive Officer-CEO] acts in the capacity of the "responsible individual' designation contained within the CAH guidelines...Develops and approves facility-wide and departmental guidelines, policies, procedures..."

2. During an interview on 8/31/11 at 8:30 AM, the CEO stated the Administrative policies were system policies and used by the Sanford Health Network. The Administrative policies used by the CAH are Sanford Health cooperate policies approved by the Governing Body for the Sanford Health. The CEO stated he approved the Administrative policies for Sanford Sheldon Center. The CEO stated, "I did not document they [Administrative policies] were approved". The CEO acknowledged the policies and procedures provided by the network hospital, Sanford Heath, lacked documented evidence of an annual review and approval for Sanford Sheldon Center by the CEO per delegation of authority by the Governing Body.

Based on observation, review of documentation, policy and procedures, and staff interview the CAH (Critical Assess Hospital) failed to ensure the cleanliness of the fans in the clean laundry area and dietary department. The CAH administrative staff identified a census of 14 patients.

Failure to ensure the cleanliness of the fans in the clean laundry area could potentially spread infectious materials to the clean linen used in patient care.

Findings include:

Observation on 8/29/11 at 10:00 AM, during the tour of the dietary department with Staff I, Dietary Manger, revealed 3 floor fans in the kitchen. All fans were in-use and contained a moderate amount of black-brown build-up of debris on the blades of the fans.

An additional observation on 8/29/11 at 2:00 PM, during the tour of physical environment with Staff J, Maintenance Supervisor, and Staff K, Director of Environmental Services, revealed 2 wall-mounted fans in the clean laundry room. Both fans were in-use and contained a moderate amount of black-brown build-up of debris on the blades of the fans.

Review of the policy titled, " Fans, Cleaning of " approved on 10/01/09 stated in part ... " Fans are to be cleaned periodically to remove build up of and dust and keep fan functioning properly ....Periodical cleaning of fans is documented in the cleaning checklists in each building/area that the fans originate. "
A review of the, " Laundry Weekly/Monthly Cleaning List " dated 8/11 showed weekly cleaning with initials of laundry staff completing the cleaning.
A review of the, " Nutrition and Food Services Cleaning Schedule " dated August 2011 showed weekly cleaning of all fans (floor, table and wall) with initials of dietary staff completing the cleaning.

During an interview on 8/29/11 at 10:00 AM, Staff I verified the floor fans in dietary needed cleaning.
During an interview on 8/29/11 at 2:00 PM, Staff J and K verified the wall-mounted fans in the clean laundry needed cleaning.
During an interview on 8/31/11 at 9:30 AM, Staff L, Infection Prevention Specialist, verified that all fans should be clean.

Based on review of contracts/agreements, documents and policies, the Critical Access Hospital (CAH) administrative staff failed to ensure a contract/agreement was in place with the entity that provided Magnetic Resonance Imaging (MRI) and tele-radiology services to the patients of the CAH.


Failure to ensure a contract was in place between the CAH and the Sanford Medical Center MRI and tele-radiologist providing care to the CAH's MRI and radiological patients could potentially result in lack of communication regarding the patient's condition, MRI and/or radiological results, and follow up professional services, as well as, the lack of coordination of patient care which could result in poor patient outcomes.

The CAH administrative staff reported MRI a monthly average of 14 MRI procedures and 459 radiological diagnostic procedures.

Findings include:

1. The CAH administrative staff provided a list of contracts upon entrance. The list failed to acknowledge a MRI and tele-radiological contract with Sanford Sheldon Medical Center.

2. Review of documentation, dated 8/30/11 presented by the Chief Executive Officer (CEO) to the survey team on 9/1/11, revealed in part, "...Sanford Clinic, also a subsidiary of Sanford, provides physician support to the facility in the way of radiologic interpretations. This may be through direct credentialed Sanford clinic physicians or through a tele-radiological contract with an independent group of credentialed physicians, with the contract being held by Sanford Clinic.
Sanford Medical Center, d/b/a...Sanford USD medical Center, also a subsidiary of Sanford and which is Joint Commission accredited, provides MRI services through a mobile service to Sanford Sheldon Medical Center and is guided by the policies and procedure of Sanford USD Medical Center."

3. During an interview on 8/30/1 at 11:00 AM, the CEO stated the CAH did not have a contract for the MRI services. The CEO stated, Sanford Corporation owned the MRI and the CAH so a contract would not be needed, since owned by the same corporation.

During interview, on 8/31/11 at 10:15 AM, the Radiology Manager reported that the CAH offers mobile MRI and Nuclear Medicine services. The CAH uses a network hospital to provide the mobile services but the CAH is responsible for patient billing. The Radiology Manager stated " because we use a network hospital it is as if we are doing the testing ourselves, therefore no contract is necessary " .

During a follow up interview on 8/31/11 at 4:30 PM, the CEO explained Sanford clinic held the contract with the tele-radiologist. The CEO stated the tele-radiologist's clinic was a clinic owned the Sanford Corporation, since the Sanford Corporation owned the CAH; the CAH used the services of the tele-radiologist. Therefore, the CAH did not a separate contract with the tele-radiologist or a contract for the MRI services.

Based on review of the Critical Access Hospital (CAH) policies, medical records and staff interviews the CAH nursing staff failed to follow orders written and signed by the Physician.

Failure to follow these Physician orders could potentially result in a decline in the patient's quality of life, health status and lengthen their hospital stay.


The CAH administrative staff reported a census of 2 Swing Bed in-patients with a weekly average of 2.5 Swing Bed in-patients

Findings for 2 of 2 Swing Bed in-patient (Patient #1 and 2) medical records and 2 of 5 closed Swing Bed patients (Patient #3 and 5) medical records reviewed include:

1. The CAH staff use policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

a. "Objectives of Nursing Service", no date noted, revealed in part, "...to cooperate with the physician in the preservation of life and the promotion of health by safely and promptly executing measures as ordered by the physician..."

b. "History Check for Transfusion Services" revised 1/10 revealed in part, "...Obtain an order for transfusion service... The form obtained should be filled out by the nurses as to the exact orders written by the physician. A signed physician order must be obtained...followed by any specific requirement for the blood to be transfused..."

2. Review of Patients #1, 2, 3, and 5's medical records revealed the Patients received Swing Bed care treatment while in the CAH. However, the medical records revealed the nursing staff failed to follow Physician orders as written.

a. Patient #1's Swing Bed medical record revealed Patient 1's admission to the Swing Bed care unit on 8/26/11 for wound care, Physical Therapy (PT) and Occupational Therapy (OT) due to a Rt. forefoot partial amputation.
Review of Patient #1's medical record revealed the Medication Reconciliation report/orders dated 8/26/11 and signed by the attending Physician revealed insulin orders "insulin, Novolog 100 units/mL: inject subcutaneously [SQ] with meals and snacks. SQ Novolog/carbohydrate ratio: 1 units/4 grams CHO [carbohydrates] for blood sugar less than 100, subtract 3 units for meals and snacks (30 grams of carbs or greater)..."

Review of the MAR on 8/31/11 revealed the nursing staff noted the order, "not given" since admission on 8/26/11.

During an interview on 8/31/11 at 11:00 AM, Staff E, Pharmacist, stated the nursing staff failed to follow the Physician order. Staff E called the Physician for clarification of the order, at this time the Physician discontinued the order. Staff E stated the nursing staff should have clarified the order during the patient's admission.

b. Patient #2's Swing Bed medical record revealed Patient 2's admission to the Swing Bed care unit, due to Clostridium difficile infection and worsening Anemia, on 8/19/11 for Antibiotic, blood transfusion, PT and OT. Review of Patient #2's medical record revealed, a Physician order dated 8/26/11, "see blood transfusion order sheet". A review of the blood transfusion sheet dated 8/26/11 revealed in part, "blood administration: Infuse each unit over 3 hours."
i. Review of the Blood Compatibility Form dated 8/26/11 at 10:35 AM, revealed the name of the transfusionists and another nurse checked the information needed prior to starting the infusion of blood. The form also revealed, "...time started 1105 (11:05 AM), Volume transfused 320 mL and time finished 1300 (1:00 PM)..."

ii. Review of the Blood Compatibility Form dated 8/26/11 1:00 PM revealed the name of the transfusionists and another nurse checked the information needed prior to starting the infusion of blood. The form also revealed, "...time started 1330 (1:30 PM), Volume transfused 320 mL and time finished 1530 (3:30 PM)..."

During an interview on 8/31/11 at 10:15 Staff F, Chief Nursing Officer (CNO), reviewed the medical record and acknowledged the nursing staff did not follow the Physician's order for the blood infusion rate.

c. Patient #3's Swing Bed medical record revealed Patient 3's Swing Bed care stay from 3/25/11 to 4/1/11, due to Right hip repair. During this Swing-Bed stay, Patient #3 received wound care, PT and OT rehabilitation. Review of Patient #3's "Swing Bed Admission" form dated 3/25/11 revealed a Physician order for "Thigh High Teds, bilat [bilateral] - off at HS". Review of the Medical Record lacked documented evidence the nursing staff followed the Physician order.

During an interview on 8/31/11 at 10:15 AM, Staff F reviewed the medical record and acknowledged the medical record lacked documented evidence the nursing staff followed Patient #3's Physician order for removing the thigh high teds at HS.


d. Patient #5's Swing Bed medical record revealed Patient #5's Swing Bed care stay from 5/2/11 to 5/6/11, due to Baker's cyst Left knee. During this Swing-Bed stay, Patient #5 received PT, OT and a blood transfusion. Review of Patient #5's "Blood Transfusion" for signed by the Physician on 5/3/11 revealed an order for blood transfusion of 2 units. The blood transfusion order lacked the infusion rate of the blood.

During an interview on 8/31/11 at 10:15, Staff F reviewed the medical record and acknowledged the medical record lacked documented evidence of an infusion rate. Staff F stated the nursing staff should have clarified the order with the Physician prior to the transfusion.

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) Rehabilitation (Rehab) Department staff failed to secure all medical records stored in the Rehab Department against unauthorized access. The CAH Rehab staff reported an average of 35 outpatients treated in the Rehab Department daily.

Failure to secure medical records against unauthorized access could result in identity theft or unauthorized disclosure of personal medical information.

Findings include:

1. Tour of the Rehabilitation Department on 8/30/11 from 11:30 AM, revealed 48 patent medical records sitting on a counter behind the open reception area. During an interview, at the time of the observation, the Director of Physical Therapy stated the medical records were records for patient receiving care that day and records readied for the next days appointments. The medical records contained information including, but not limited to: patient names, date of birth, medical record number, and confidential medical diagnosis.

2. During an interview on 8/30/11 at 11:30 AM, the Director of Physical Therapy reported housekeeping staff cleaned the Rehab Department in the evening, after the Department is closed, and the housekeeping staff is unsupervised. The Director of Physical Therapy acknowledged that housekeeping staff had access to patient medical records and did not have a need to know the patient's medical information.

3. Review of CAH policy titled, "Physical Therapy Records", updated 7/28/11, revealed in part, "B. Procedure: ... 5. Medical records shall be confidential, secure, current, authenticated, legible, and complete".

4. Review of CAH policy titled, "Records Retention and Destruction", updated 7/28/11, revealed in part, "Policy: ... 2.4 Records containing confidential and proprietary information shall be securely controlled and protected to prevent unauthorized access".

Based on record review and administrative staff interviews the CAH (Critical Access Hospital) failed to ensure completion of the outside peer review to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH for 3 of 17 practitioners reviewed (Practitioner A, B, C). The CAH radiology administrative staff reported a monthly average of --- diagnostic and ultrasound radiological exams, that included 31 reads by teleradiologists and 104 ultrasounds.

Failure to ensure completion of the external peer review for the practitioner could potentially result in failure to meet the established medical standards set by the CAH.

Findings include:

1. Review of the credentialing process for 3 of 17 practitioners revealed 2 teleradiologists (Practitioner A & B) and 1 radiologist (Practitioner C) failed to have an external peer review completed for the current credentialing period.
Review of the " Standard operating Procedure for Peer Reference Requirements for MD's, DO's, and Allied Health Professional of Regional Health Services," reviewed on 11/06, stated in part ... " All providers who apply for new or reappointment to any facility for SVRHS (Sioux Valley Regional Health Services) must have one MD or DO reference and if allied health professional, and additional peer reference in their field is required ... "

2. During and interview on 8/1/11 at 8:00 AM, Staff G, Chief Executive Officer, verified that the CAH administrative staff failed to complete external peer review for the teleradiologists and the radiologist that reads ultrasounds.

Based on review of job descriptions, policies, medical records and staff interviews, the Critical Access Hospital (CAH) activity staff failed to complete and/or date swing bed patient's comprehensive assessments.

Patient comprehensive assessments are used to determine the necessity of the service, the patient's needs, guide treatment, identify the patient's strengths, needs and interest and must be obtained or completed as necessary to be considered current. The comprehensive assessment information is then used for evaluation purposes to give consistent care and to meet the individual needs of the patient. Failure to complete an activity comprehensive assessment could potentially result in staff neglecting a patient's mental and psychosocial needs which could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 2 swing-bed patients with a weekly average of 2.5 swing-bed in-patients

Findings for 2 of 2 swing-bed in-patients (Patient #1 and 2 ) medical records and 3 of 5 closed swing-bed patients (Patient #3, 6 and 7) medical records reviewed include:

1. The CAH staff use job descriptions, policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

a. "Swing Bed Activity Program" approved 7/11 revealed in part, "...shall complete the activity history and resident assessment..."

b. "Activities Coordinator", job description created 4/11 revealed in part, "...oversees the day to day activities of staff...assists with collection of psych-social data for each resident...in collaboration with the interdisciplinary care team, assesses needs of patients in swing bed..."

c. "Skilled Care Program" booklet, dated 6/07, provided to the Swing Bed patients revealed in part, "...Residents Activities...The activity Director will meet with the resident after admission to skilled care and weekly thereafter. She will asses his/her activity needs and set up a plan of activities..."

2. Review of Patients #2, 3, 6 and 7's medical records revealed Patients #2, 3, 6 and 7 admission to swing-bed level of care while in the CAH. However, the medical records lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

a. Patient #1's Swing Bed medical record revealed Patient 1's admission to the Swing Bed care unit, due to a Rt. forefoot partial amputation, on 8/26/11 for wound care, Physical Therapy (PT) and Occupational Therapy (OT). Review of Patient #1's medical record lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 8/31/11 at 11:00 AM, Staff F, Chief Nursing Officer (CNO), reviewed Patient #1's Swing Bed medical record and acknowledged the lack of a comprehensive activity assessment.

b. Patient #2's Swing Bed medical record revealed Patient 2's admission to the Swing Bed care unit, due to Clostridium difficile infection and worsening Anemia, on 8/19/11 for Antibiotic, blood transfusion, PT and OT. Review of Patient #1's medical record lacked an comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 8/31/11 at 11:00 AM, Staff F reviewed Patient #2's Swing Bed medical record and acknowledged the lack of a comprehensive activity assessment.

c. Patient #3's Swing Bed medical record revealed Patient 3's Swing Bed care stay from 3/25/11 to 4/1/11, due to Right hip repair. During this Swing-Bed stay, Patient #3 received wound care, PT and OT rehabilitation. Review of Patient #3's medical record lacked an comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 8/31/11 at 11:15 AM, Staff F reviewed Patient #3's Swing Bed medical record and acknowledged the lack of a comprehensive activity assessment.

d. Patient #7's Swing Bed medical record revealed Patient #7's Swing Bed care stay from 5/9/11 to 5/25/11, due post pneumonia, pulmonary edema and atrial fib. Review of Patient #7's medical record lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #7's Swing Bed medical record and acknowledged the lack of a comprehensive activity assessment.

e. Patient #6's Swing Bed medical record revealed Patient #6's Swing Bed care stay from 4/5/11 to 4/10/11 due to Right Cerebral Vascular Accident (CVA), a fall and Hypertension (HTN). Review of Patient #6's medical record lacked a completion date for the comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 8/31/11 at 11:25 AM, Staff F reviewed Patient #6's Swing Bed medical record and acknowledged the lack of a date on the comprehensive activity assessment.

During an interview on 8/29/11 at 3:30 PM, Staff C, Activity Coordinator (AC) stated it is the responsibility of the Activity Designee or the nursing staff to complete the activity assessment.

During an interview on 8/29/11 at 3:30 PM, Staff D, Activity Designee, stated the nurse at the time of admission filled out the activity assessment form and placed it in the medical records. Staff D stated he/she did not review the medical record to assure the nursing staff filled out the activity assessment form.

During a follow up interview on 8/31/11 at 11:50 AM, Staff F, stated the nursing staff could fill out the activity assessment form, but the Activity staff should fill out the activity assessment form when they visit with the patient.

Based on review of policies, Swing Bed clinical records, Swing Bed care plans and staff interviews the Critical Access Hospital (CAH) Interdisciplinary team failed to ensure Swing Bed patient's care plans were individualized to meet the patient's physical, mental and psychosocial needs gathered from the comprehensive assessment.

The assessment determines the content of the care plan. All Swing Bed patients should have an individual care plan with individual related interventions gathered from the information in the comprehensive assessment. The individualized care plans sets realistic, measurable goals, patient interventions and should be patient-centered driven. Failure to create individualized care plans for Swing Bed patients could potentially result in staff neglecting a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 2 Swing Bed in-patients with a weekly average of 2.5 Swing Bed in-patients

Findings for 2 of 2 Swing Bed in-patient (Patient #1 and #2) medical records and 5 of 5 closed Swing Bed patient (Patient #3, 4, 5, 6 and 7) medical records reviewed include:

1. The CAH staff use the policies and procedures to provide guidance to the staff for consistent and continuity of care. A review of these policies and procedure revealed:

a. "Skilled Comprehensive Plan of Care" approved date 10/1/09 revealed in part, "...comprehensive care plan will be developed for each swing bed resident that includes measurable objectives and timetables to meet the resident's...physical, mental, psychosocial, spiritual, recreational and discharge needs that are identified in a comprehensive assessment..."

b. "Charting by Exception" revised date 2/11 revealed in part, "...the plan of care is initiated by the admitting RN [Registered Nurse]...any patient-specific, individualized needs are added to the plan of care...The Plan of Care or a summary of pertinent information thereof, is used during report...the patient's progress in relation to outcomes......The Plan of care is reviewed with the physician and the interdisciplinary team...to facilitate team coordination of care..."

c. "Assessment Protocol" revised date 11/10 revealed in part, "Discharge Planning...all discharge planning should be initiated on admission...involve discharge planner as soon as needs are assessed to help facilitate discharge planning..."

d. "Swing Bed Activity Program" approved on 7/28/11 revealed in part, "...resident activity interest will be documented in the resident's care plan for the nursing staff referral..."

2. Review of Patients #1, 2, 3, 4, 5, 6 and 7 medical records revealed Patients #1, 2, 3, 4, 5, 6 and 7 received Swing Bed care treatment while in the CAH. However, the medical records lacked an individualized care plan with individual interventions during the Swing Bed patient's hospital stay.

a. Patient #1's Swing Bed medical record revealed Patient 1's admission to the Swing Bed care unit, due to a Rt. forefoot partial amputation, on 8/26/11 for wound care, Physical Therapy (PT) and Occupational Therapy (OT). Review of Patient #1's medical record revealed a care plan, however, the care plan did not address Patient #1's individual likes and/or dislikes for activities, medical reason for contact isolation and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:00 AM, Staff F, Chief Nursing Officer (CNO), reviewed Patient #1's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

b. Patient #2's Swing Bed medical record revealed Patient 2's admission to the Swing Bed care unit, due to Clostridium difficile infection and worsening Anemia, on 8/19/11 for Antibiotic, blood transfusion, PT and OT. Review of Patient #2's medical record revealed a care plan, however, the care plan did not address Patient #2's individual activity likes and/or dislikes, C-Diff contact isolation precautions and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:00 AM, Staff F reviewed Patient #2's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

c. Patient #3's Swing Bed medical record revealed Patient 3's Swing Bed care stay from 3/25/11 to 4/1/11, due to Right hip repair. During this Swing-Bed stay, Patient #3 received wound care, PT and OT rehabilitation. Review of Patient #3's medical record revealed a care plan, however, the care plan did not address Patient #3's individual activity likes and/or dislikes, Ted hose schedule and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:15 AM, Staff F reviewed Patient #3's medical record and confirmed the care plan was incomplete and not individualized to the patient's needs.

d. Patient #4's Swing Bed medical record revealed Patient #4's Swing Bed care stay from 4/15/11 to 4/18/11, due to aspiration pneumonia. During this Swing-Bed stay, Patient #4 received PT, Speech therapy (ST) and Antibiotic therapy. Review of Patient #4's medical record revealed a care plan, however, the care plan did not address Patient #4's individual activity likes and/or dislikes, contact isolation, nutritional due to tube feeding and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #4's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

e. Patient #5's Swing Bed medical record revealed Patient #5's Swing Bed care stay from 5/2/11 to 5/6/11, due to Baker's cyst Left knee. During this Swing-Bed stay, Patient #5 received PT and OT rehabilitation. Review of Patient #5's medical record revealed a care plan, however, the care plan did not address Patient #5's individual activity likes and/or dislikes, and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #5's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

f. Patient #6's Swing Bed medical record revealed Patient #6's Swing Bed care stay from 4/5/11 to 4/10/11 due to Right Cerebral Vascular Accident (CVA), a fall and Hypertension (HTN). During this Swing-Bed stay, Patient #6 received wound care, PT, OT, and ST rehabilitation. Review of Patient #6's medical record revealed a care plan, however, the care plan did not address Patient #6's individual activity likes and/or dislikes, wound care and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:25 AM, Staff F reviewed Patient #6's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

g. Patient #7's Swing Bed medical record revealed Patient #7's Swing Bed care stay from 5/9/11 to 5/25/11, due post pneumonia, pulmonary edema and atrial fib. During this Swing-Bed stay, Patient #7 received PT, OT, and ST rehabilitation. Review of Patient #7's medical record revealed a care plan, however, the care plan did not address Patient #7's individual activity likes and/or dislikes, infection, nutritional and discharge plans during the patient admission in Swing Bed care.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #7's medical record and confirmed the patient's care plan was incomplete and not individualized to their needs.

During an interview on 8/29/11 at 3:30 PM, Staff C, Activity Coordinator (AC) stated it is the responsibility of the Activity Designee to develop an individualized activity care plan from the activity assessment. Staff C confirmed the care plan was incomplete nor individualized to the patient's needs.

During an interview on 8/29/11 at 3:30 PM, Staff D, Activity Designee, stated the activity care plans for Swing-Bed patients were all alike. Staff D acknowledged he/she did not individualize the patient's care plans.

During a follow up interview on 8/31/11 at 11:50 AM, Staff F stated the interdisciplinary team needed to develop the care plan from the various assessments so the care plan reflected the individual needs of the patients.

Based on review of policies, job description, Swing Bed clinical records and staff interviews the Critical Access Hospital (CAH) Interdisciplinary team failed to ensure care conferences by professional disciplines occurred to assess the various patient assessments and develop and/or update the individualized care plan.

Various professional disciplines, the patient and/or patient's family make up the Interdisciplinary team who attend the care conference and work together to develop an individualized care plan that best meets the needs of each Swing Bed Patient. This Care Conference is a patient-centered process that assesses each Swing Bed patient's individual need,s then creates a care plan that will enhance healing and lessen their stay at the hospital. Failure of the Interdisciplinary team to work together resulted in a lack of individualized care plans for the Swing Bed patients. Lack of an individualized care plan could lead to the neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the hospital.

The CAH administrative staff reported a census of 2 Swing Bed in-patients with a weekly average of 2.5 Swing Bed in-patients

Findings for 1 of 1 Swing Bed in-patient (Patient #2) medical record and 2 of 3 closed Swing Bed patients who's stay in the hospital included a Wednesday, the scheduled time of a weekly care conference, (Patient #3 and 5) medical records reviewed include:

1. The CAH staff use job descriptions, policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

a. "Skilled Comprehensive Plan of Care" approved date 10/1/09 revealed in part, "...the care plan will be prepared by an interdisciplinary team (IDT) that includes the attending physician, a registered nurse with responsibility for the resident, the Social Worker or designee, therapy/occupational therapy/speech therapy as appropriate. When practicable, the resident, the resident family or legal representative will participate.
...communication between multiple disciplines regarding resident care, progress, discharge plans and goals will be facilitated at the weekly care conference..."

b. "Activities Coordinator", job description created 4/11 revealed in part, "...in collaboration with the interdisciplinary care team, assesses needs of patients in swing bed...actively participates in care conferences with residents and families..."

2. Review of Patients #2, 3 and 5 Swing Bed medical records revealed Patients #2, 3 and 5 received Swing Bed care treatment while in the CAH. However, the medical records lacked documented evidence a care conference for 1 of 1 Swing Bed patient (Patient #1) or documented evidence of attendance by professional disciplines to create and/or update a comprehensive care plan for 2 of 3 closed Swing Bed medical records (Patients #3 and 5).

a. Patient #2's Swing Bed medical record revealed Patient 2's admission to the Swing Bed care unit, due to Clostridium difficile infection and worsening Anemia, on 8/19/11 for Antibiotic, blood transfusion, PT and OT. Review of Patient #2's medical record revealed, although Patient #2's hospital stay included a Wednesday, the medical record lacked documented evidence of a Care Conference meeting.

During an interview on 8/29/11 at 1:40 AP, Staff D, Activity Designee, stated the Swing Bed Patient Care Conferences held on Wednesday for all the Swing Bed patients to create or review their care plans. Staff D reviewed Patient #2's medical record and confirmed the lack of a care conference on 8/24/11, the Wednesday after admission. Staff D was not aware of what happened and stated, "I guess [Patient #2] fell through the cracks."

During an interview on 8/31/11 at 11:15 AM, Staff F, Chief Nursing Officer (CNO), reviewed Patient #2's medical record the lack of documented evidence of a care conference meeting for Patient #2.

b. Patient #3's Swing Bed medical record revealed Patient 3's Swing Bed care stay from 3/25/11 to 4/1/11, due to Right hip repair. During this Swing-Bed stay, Patient #3 received wound care, PT and OT rehabilitation. Review of Patient #3's medical record lacked documented evidence of an activity assessment, comprehensive care plan or the Activity Coordinator attendance at the Care Conference meeting to discuss and care plan the patient leisure activities.

During an interview on 8/31/11 at 11:15 AM, Staff F reviewed Patient #3's medical record and confirmed the medical record lacked documented evidence of an activity assessment, activity care plan or the attendance of the Activity Coordinator at the 3/31/11 Care Conference meeting to discuss Patient #3's individual needs including the patient's leisure activities. Staff F stated the Activity Coordinator should attend the care conference to ensure activities are included in the patient care plan and the staff completed the activity assessment.

c. Patient #5's Swing Bed medical record revealed Patient #5's Swing Bed care stay from 5/2/11 to 5/6/11, due to Baker's cyst Left knee. During this Swing-Bed stay, Patient #5 received PT and OT rehabilitation. Review of Patient #5's medical record lacked documented evidence of a comprehensive care plan or the names and/or departments of the Interdisciplinary team represented at the Care Conference meeting to discuss and care plan the patient individual social, medical and leisure activity needs.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #5's medical record and confirmed the medical record lacked documented evidence of an activity care plan or the attendance of the Interdisciplinary Team members at the 5/4/11 Care Conference meeting to discuss Patient #5's individual medical, social and leisure activities needs. Staff F stated conference note lacked documentation of the names and/or departments of the Interdisciplinary team members represented at the care conference.

During an interview on 8/31/11 at 1:15 PM, Staff F stated Interdisciplinary Team should review and update the Swing Bed patient's care plan at the Care Conference meetings. The Care Conference meetings should be where the Interdisciplinary Team works together to ensure a complete comprehensive care plan to meet all the medical, social and leisure activity needs for the Swing Bed patients.

Based on review of policies, medical records and staff interviews, the Critical Access Hospital (CAH) nursing staff failed to identify specific patient needs in the discharge instructions prior to Swing Bed patients discharged to home.

Discharge home instructions are the plan of care for the Swing Bed Patient and/or family to continue at home. The specific care instructions are a plan designed to meet the patient's individual needs after discharge from the hospital. Failure to complete the patient's specific care instructions could potentially disrupt patient care and/or delay the healing process potentially causing a return visit to the hospital.

The CAH administrative staff reported a census of 2 swing-bed patients with a weekly average of 2.5 swing-bed in-patients.

Findings for 2 of 2 swing-bed patients discharged home (Patient #3 and 4) medical records reviewed include:

1. The CAH staff use policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

a. "Discharge Instructions" revised 8/15/1, revealed in part, "...the patient discharge instruction sheet will include...instructions..."

b. "Nurse's Role in Patient Discharge" revised 8/15/11, revealed in part, "...it is Sanford Sheldon Medical Center's policy to make each patient's dismissal as efficient and pleasant as possible. Dismissal instructions should be written in language the patient can understand and reviewed with patient to make sure he/she understands...treatments to be continued after dismissal. Patient will also receive Care Notes..."

c. "Nursing Discharge/Transfer Summary" revised date 2/21/11 revealed in part, "...to document that the patient has and understands the information he/she and/or family needs in order to care for self or to get further help. When the patient is DISCHARGED to his/her own home...complete a "Patient Discharge Instruction Sheet"...include all information the patient and/or family needs to know to care for self outside the hospital. This should include...special care and/or procedures he will be expected to do..."

a. Patient #3's Swing Bed medical record revealed Patient 3's Swing Bed care stay from 3/25/11 to 4/1/11, due to Right hip repair. During this Swing-Bed stay, Patient #3 received wound care, Physical Therapy (PT) and Occupational Therapy (OT) rehabilitation. Review of Patient #3's medical record revealed a discharge instructions sheet dated 4/1/11. The discharge sheet lacked instructions on the physician order for Ted Hose, when they were to be on and taken off.

During an interview on 8/31/11 at 11:15 AM, Staff F reviewed Patient #3's medical record and confirmed the discharge instructions did not include specific instruction to the application of the Ted Hose.

b. Patient #4's Swing Bed medical record revealed Patient #4's Swing Bed care stay from 4/15/11 to 4/18/11, due to aspiration pneumonia. During this Swing-Bed stay, Patient #4 received PT, Speech therapy (ST) and Antibiotic therapy. Review of Patient #4's medical record revealed a discharge instructions sheet dated 4/18/11. The discharge sheet lacked instructions on the changes in the patient's tube feeding process and/or schedule.

During an interview on 8/31/11 at 11:45 AM, Staff F reviewed Patient #4's medical record and confirmed the discharge instructions did not include specific instruction to the changes in the tube feeding process and/or schedule.