HospitalInspections.org

Based on interview, the hospital failed to ensure Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of non-physical intervention skills.

Findings:

Review of the ED's patient log dated 1/11/18 through 4/23/18 revealed 31 patients who required a Physician Emergency Certificate hospital admission for psychiatric treatment.

During an interview on 4/24/18 at 12:15 p.m., S7ERDir stated the ED direct patient care staff are not trained in the use of non-physical interventions.

Based on record review and interview, the hospital failed to ensure that the credentialing process requirements were followed for reappointments to the medical staff by failing to ensure that the candidate completed and the medical staff reviewed a request for clinical privileges for 3 of 7 practitioners whose credentialing files were reviewed (S15DO, S16MD, S17MD). Findings:

Review of the Medical Staff Bylaws Part 14.01 Privilege Delineation Procedure revealed each application for appointment or reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant or staff member ...

Review of the medical staff credentialing files of S15DO (11/22/16 reappointment), S16MD (05/28/17 reappointment) and S17MD (01/25/18 reappointment) revealed no documented evidence that a clinical privileges request was completed by the applicant or reviewed by the medical staff.

On 04/25/18 at 11:40a.m., an interview with S13HR, who is responsible for the credentialing process and maintenance of files, confirmed that the clinical privileges request is not currently being completed by staff requesting reappointments.

Based on record review and interview, the hospital failed to ensure nursing personnel were qualified and competent to provide nursing care to each patient as evidenced by failing to have documented evidence of ongoing inservicing for 2 (S2ADON, S14SurgDir) of 5 nursing personnel files reviewed, skills competency testing for 5 (S2ADON, S7ERDir, S11DON, S14SurgDir, S19RN) of 5 nursing personnel files reviewed, and annual evaluations for 2 (S11DON, S14SurgDir) of 5 nursing staff whose personnel and training records were reviewed. Findings:

Review of the personnel files for S2ADON and S14SurgDir revealed no documented evidence of ongoing inservices during the past year.

Review of the personnel files for S2ADON, S7ERDir, S11DON, S14SurgDir and S19RN revealed no documented evidence of an annual skills competency assessment.

Review of the personnel files for S11DON and S14SurgDir revealed no documented evidence of an annual performance evaluation.

On 04/25/18 at 3:30 p.m., an interview with S12HR confirmed the above inservicing, competency skills assessments and annual evaluations had not need completed.

Based on record review and interviw, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care for 1 (#8) of 3 (#8,#9,#10) sampled patients reviewed for sliding scale insulin administration out of a total patient sample of 35.

Findings:

Review of Patient #8's electronic medical record revealed an admission date of 4/21/18 with an admission diagnosis of Hypoglycemia, right lower lobe pneumonia and a co-morbid diagnosis of Diabetes.

Review of Patient #8's physician's orders revealed an order to check the patient's capillary blood sugar every 6 hours. Further review revealed the following sliding scale insulin order:
If blood glucose is less than 150: no coverage administered;
151-200: 2 units of Regular insulin - subcutanous injection;
201-250: 4 units of Regular insulin - subcutanous injection;
251-300: 6 units of Regular insulin - subcutanous injection;
301-350: 8 units of Regular insulin - subcutanous injection;
351-400: 10 units of Regular insulin - subcutanous injection; and
If blood glucose is 400 or greater give 12 units of Regular Insulin - subcutanous injection and call the physician.

Review of Patient #8's documented capillary blood glucose checks revealed the following:
4/24/18 at 5:26 a.m. - Capillary Blood Glucose of 162, coverage of 2 units should have been administered. Further review revealed no coverage was administered and no reason was documented for not administering coverage.
4/24/18 at 12:04 p.m. -Capillary blood glucose of 155, coverage of 2 units should have been administered. Further review revealed no coverage was administered and no reason was documented for not administering coverage.

Above referenced findings verified per S3LPN, chart navigator, during Patient #8's electronic medical record review on 4/24/18 at 2:00 p.m.

Based on policy review, observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area and locked. This was evidenced by a heart-monitoring cart with medications stored unsecured on the top of the cart in an unsupervised area and a crash cart left unlocked in an unsupervised area.

Findings:

Review of the hospital's policy titled Drug Storage Floor Stock revealed, in part, the following:

Policy: The use of floor stock drugs and drug-related supplies will be limited to those that are frequently used and/or those that are needed for immediate use.

Procedure: 8. Access to Floor Stock located in patient-care area will be limited to authorized personnel. Floor Stock medications will be secured and/or locked so as to prevent unauthorized access.

Observation on 4/23/18 at 1:35 p.m. revealed the portable heart-monitoring cart had 4 bottles containing tablets of Nitrostat 0.4-milligram and 15 individual packets of 325 milligram Aspirin left unsecured and accessible on the cart.

During an interview on 4/23/18 at 1:36 p.m., Mark Todd RN ER Director acknowledged the medication on the portable heart-monitoring cart were readily accessible to patients and were not secure.

Observation on 4/23/18 at 1:55 p.m. revealed an unlocked crash cart stored in an unsupervised area with its entire contents accessible. The top drawer of the crash cart was opened and contained, in part, syringes containing Atropine, Epinephrine and Amiodarone.

During an interview on 4/23/18 at 2:00 p.m., S7ERDir acknowledged the Crash Cart was stored unlocked in an unsupervised area, which allowed access to all the medications stocked in the crash cart.

Based on observation and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not be available for patient use.

Findings:

Observation of the Emergency Department's Trauma exam room on 4/23/18 at 1:45 p.m., accompanied by S7ERDir, revealed two 500-milliliter bags of Dextrose 5% water with an expiration date of 9/2016.

During an interview on 4/23/18 at 1:50 p.m., S7ERDir acknowledge outdated drugs should not be available for patient use.

Based on hospital policy, record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's electronic medical record for 1 patients (#33) of 2 patients (#32, and #33) hospital identified medication errors reviewed.

Findings:

Review of hospital's policy Medication Error Identification and Reporting revealed, in part, the following:

Policy: All medication errors will be documented, reported, and investigated.

Procedures and Responsibilities: 2. Notify the physician and Nursing Supervisor immediately either face to face or by telephone.

Review of hospital's variance report dated 1/9/18 revealed, in part, the following: Respiratory therapist notified staff that patient #33 had taken a home medication from her purse. Patient stated she took her Synthroid. Patient's Synthroid medication had already been administered at 6:00 a.m.

Review of patient #33 chart failed to reveal the doctor was notified of the medication error.

During an interview on 4/26/18 at 11:00 a.m., S2ADON acknowledged, after reviewing patient #33's chart, the doctor was not notified regarding patient #33's medication error.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button (a red cross symbol) located on the handrails of the beds on all patient beds.

Findings:

On 4/24/18 at 11:30 a.m. an observation was made of the hospital's inpatient rooms. The observation revealed that the patient bed in room "a" had a non-functional nurse call feature (a red cross symbol) on the siderail of the bed. The red cross symbol was pressed during the observation and no alert of any type was generated when it was pressed.

In an interview on 4/24/18 at 11:30 a.m., during the observation, S1Adm confirmed the red cross nurse call feature on the siderails of the inpatient beds was not functional. He reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S1Adm indicated he understood what the surveyor was saying when asked if having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance. S1Adm confirmed all 37 of the hospital's inpatient beds (the bed observed in room "a" was included in that number) were the same and all had the non-functional nurse call feature on the hand rails.

Based on observation, record review, and interview, the infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failure to ensure expired supplies were not available for patient use in the hospital's Emergency Department;
2) failure to maintain radiology equipment to enable disinfection/failure to clean equipment;
3) failure to maintain a chemical testing log for the triple sink sanitizing concentration testing and failure to ensure sanitizing concentrations in the water used for cleaning/sanitizing of kitchen preparation items was greater than "Zero" on chemical test strips; and
4) failure to maintain a sanitary environment.

Findings:

1) Failure to ensure expired supplies were not available for patient use in the hospital's Emergency Department.

Observation on 4/23/18 at 1:45 p.m., accompanied by S7ERDir, revealed the following in the Emergency Department's Trauma room:
a. 7 French Percutaneous Sheath kit with an expiration date of 11/2017.
b. Central Line Drape with an expiration date of 11/2017.
c. Percutaneous Tracheotomy Introducer Kit with an expiration date of 8/2017.

During an interview on 4/23/18 at 2:00 p.m., S7ERDir acknowledged the expired supplies were an infection control issue and should not have been available for patient use.


2) Failure to maintain radiology equipment to enable disinfection/failure to clean equipment.

Observation on 4/24/18 at 10:10 a.m., with S6RadDir in attendance, revealed the following:
a. X-ray table pad had multiple tears to the material on both sides of the pad.
b. Fan circulating air in the ultrasound room was covered with grime

During an interview on 4/24/18 at 10:30, S6RadDir acknowledged the torn pad and the dirty fan were an infection control issue.

Observation of the Nuclear Medication Service room on 4/24/18 at 1:54 p.m., with S6RadDir present reveal the following:
a. Peeling wallpaper below the left windows with a black speckled substance on the wallpaper and black speckled substance on the surface.
b. Exhaust vent fens of the air conditioning wall unit on the left side of the room under the windows was covered with a black speckled substance and the air unit was on and circulating air within the room.
c. The air system on the right side under the windows was covered with a soiled lead apron and a stack of washcloths covered with debris. The air unit was on and blowing into the items stacked on and covering the exhaust vents.
d. A small fan with a thick layer of dust and debris on the fan blades.
e. Oxygen tubing on multiple patient use ventilation/perfusion scan injection chamber device not dated.

During an interview on 4/24/18 at 2:00 p.m., S6RadDir acknowledged the dirty air conditioning units, the dirty fan and the black speckled substance on the wallpaper, and the undated oxygen tubing was an infection control issue.

3) Failure to maintain a chemical testing log for the triple sink sanitizing concentration testing and failure to ensure sanitizing concentrations in the water used for cleaning/sanitizing of kitchen preparation items was greater than "Zero" on chemical test strips.

Observation tour of the kitchen on 4/24/17 at 7:40 a.m. with S18DM revealed the following:
a. No chemical testing log for the automated wash machine was noted.
b. During the observation sanitizing concentration tests were performed with two separate test strips. The first test was performed with a bottle of test strips that were already open at the time of the observation. The second test was performed with a test strip from a newly opened test strip package and the test was performed after the sink was refilled with fresh rinse solution. Both of the sanitizing concentration tests revealed the triple sink rinse measured "Zero" with the color indicator strip.

During an interview on 4/24/18 at 8:15 a.m. S18DM acknowledged a log was not kept for the automated washer and the triple sink rinse solution had not been maintained correctly to prevent food borne illness.


4) Failure to maintain a sanitary environment.

Room "a"
On 4/23/18 at 11: 25 a.m. an observation was made of a strip of cloth (gauze) tied to the broken chain that was connected to the patient over bed light pull cord to extend the length of the cord.

S1Adm confirmed in interview, during the observation on 4/23/18 at 11:25 a.m., that the strip of gauze could be an infection control issue due to multiple patients having to wrap their hands around the gauze strip in order to turn the light on and off and being unable to disinfect the gauze strip properly between patients.

3rd floor clean supply room:
On 4/23/18 at 11: 30 a.m. observation of the supply room revealed 3 bedside commodes were stored with 4 folded metal framed folding chairs (one of the chairs had a cloth back and seat- unable to disinfect). One of the bedside commodes had a paper sign taped to the seat with clear adhesive tape- unable to be properly disinfect. The door to the clean supply room was ajar making the room completely open to the hallway.

S1Adm confirmed the above referenced findings, in interview, during the observation on 4/23/18 at 11:30 a.m. He agreed the cloth on the metal framed chairs could not be disinfected and that the paper signage and tape on the lid of the bedside commode could also not be disinfected.

Kitchen:
Observation tour of the kitchen on 4/24/17 at 7:40 a.m. with S15DietMgr revealed the following:
a. Ice machine with black grime on the entire length of the upper interior of the door opening.
b. Cans in dry storage covered with food particles.
c. Opened breadcrumb container with expired contents dated 7/10/15.
d. Fan covered with thick layer of dust/grime on both sides and blowing into food prep area.
e. Cups and bowels stored with dried food particles remaining on the interior surfaces.
f. Deep fryer contained food debris on the interior and outer surfaces remaining from the previous day.
g. Large and small steam table containers and metal mixing bowels stored wet.
h. Two containers of whipped topping opened and not dated.
i. Large plastic bag of cooked bacon bits not dated.
j. Gallon containers of dressings and sauces opened and not dated.
k. Fan covered with a thick layer of grime on the top and sides was blowing into the food serving area.
l. Grime and food particles noted to food prep table
m. One case of milk cartons with an expiration date of 4/21/18 in the milk refrigerator.
n. Open and undated dressing containers in the walk-in cooler.
o. Box containing chicken breast left uncovered and open to air in the walk-in freezer
p. Box containing hamburger patties left uncovered and open to air in the walk-in freezer.

During an interview on 4/24/18 at 8:15 a.m. S18DM acknowledged the kitchen preparation items were not properly cleaned and sanitized and the unlabeled, expired, and open containers created a food borne illness risk.

Based on record review, and interview, the hospital failed to ensure ongoing discharge planning/discharge plans were documented in the patient's medical record for 4 (#2-#5) of 5 (#1-#5) sampled discharged swing bed patient records reviewed from a total patient sample of 35.

Findings:

Review of the policy titled," Discharge Planning", revealed in part: Continuity of care requires thoughtful preparation by the entire healthcare team. Each patient's needs for continuing care are assessed in an ongoing fashion by all members of the healthcare team. This assessment may begin prior to admission, but in no event later than at the time of the inital nursing assessment. All disciplines are involved in the assessment and planning for after discharge healthcare needs of the patient and/or family. The purpose of discharge planning is to identify a patient's unique needs for continuing physical, emotional, housekeeping, transportation, social and other needs and to arrange services to meet those needs.
Each discipline assesses needs for after care as part of their ongoing assessment and reassessment process. It is the responsibility of each discipline assessing discharge planning needs to document associated assessment findings within the medical record.



Patient #2
Review of Patient #2's medical record revealed the patient had been admitted to swing bed status on 2/14/18 and was discharged on 2/23/18. Further review revealed the patient had been admitted for inpatient rehabilitation status post a failed bilateral hip replacement.

Additional review of Patient #2's electronic medical record, navigated by S2ADON, revealed no documented evidence of ongoing discharge planning/discharge plans.

In an interview on 4/24/18 at 9:40 a.m. with S2ADON, he confirmed there was no documented evidence of ongoing discharge planning/discharge plans in Patient #2's electronic medical record.


Patient #3
Review of Patient #3's electronic medical record, navigated by S2ADON, revealed the patient was admitted to swing bed status on 2/3/18 for physical therapy due to deconditioning and for continued intravenous antibiotics for treatment of an E. coli urinary tract infection. Further review revealed the patient was discharged on 2/9/18.

Additional review of Patient #3's electronic medical record, navigated by S2ADON, revealed no documented evidence of ongoing discharge planning/discharge plans.

In an interview on 4/24/18 at 9:55 a.m. with S2ADON, he confirmed there was no documented evidence of ongoing discharge planning/discharge plans in Patient #3's electronic medical record.


Patient #4
Review of Patient #4's medical record revealed the patient had been admitted to swing bed status on 1/30/18 and was discharged on 2/2/18. Further review revealed the patient had been admitted for continued intravenous antibiotics and supplemental oxygen. .

Additional review of Patient #4's electronic medical record, navigated by S2ADON, revealed no documented evidence of ongoing discharge planning/discharge plans.

In an interview on 4/24/18 at 10:05 a.m. with S2ADON, he confirmed there was no documented evidence of ongoing discharge planning/discharge plans in Patient #4's electronic medical record.


Patient #5
Review of Patient #5's medical record revealed the patient had been admitted to swing bed status on 1/19/18. Further review revealed the patient had been admitted for physical therapy for reconditioning due to general weakness and debility status post influenza infection. .

Additional review of Patient #5's electronic medical record, navigated by S2ADON, revealed no documented evidence of ongoing discharge planning/discharge plans.

In an interview on 4/24/18 at 10:20 a.m. with S2ADON, he confirmed there was no documented evidence of ongoing discharge planning/discharge plans in Patient #5's electronic medical record. S2ADON reported there were multidisciplinary team meetings held to discuss each patient and documentation of the multidisciplinary team meetings was requested at that time. S2ADON reported there was no documentation maintained of the actions being taken/plans made during the meeting. S2ADON said it was mainly documentation that a meeting had been held.

Based on record review and interview, the hospital failed to ensure its surgical services policies were developed and followed in accordance with acceptable standards of practice based on nationally recognized guidelines for terminal cleaning of the operating rooms (OR). Findings:

Review of the hospital's policy titled Surgery Suite Cleaning Policy Reference #1000 effective 03/01/2018 revealed in part: ORs should be cleaned:
Before the first case of the day, using lint free cloth moistened with disinfectant and;
In between cases, linen, trash, and infectious waste removal. Wiping OR overhead light reflectors and OR mattress and equipment with a cleaner/disinfectant.
Room turnover: Cleaning done by OR staff between each case.
Terminal clean: Monthly deep cleaning done by OR staff.
Room turnover procedures include: removal of instruments, basins, trays, trash, linen; cleaning of equipment, tables, mattress, bed frame, remaining surfaces, cardiac/EKG cables, mop floor.
Terminal room cleaning procedures include: the scrub room, halls and utility room, store rooms and instrument processing areas; sink shelves and surrounding surfaces, scrub sink area.
Further review revealed no documented source regarding the nationally recognized guidelines used to develop the policy for terminal cleaning of the OR.

On 04/24/18 at 9:40 a.m., an interview with S14SurgDir confirmed that the turnover cleaning done between cases included wiping down high-touch surfaces, cords and cables, machines and equipment, and lights; mopping and trash removal. She further confirmed that the cleaning at the end of each day was no different than the cleaning between cases. She stated that terminal cleaning was done once per month on the 16th and/or 17th day of the month and included cleaning of shelves bins, walls and checking for and removing expired supplies.

Review of the AORN 2015 Guidelines for Perioperative Practice Environmental Cleaning Recommendation IV.a., p.16 revealed: Terminal cleaning and disinfection of perioperative areas, including sterile processing areas, should be performed daily when the areas are used and should include cleaning and disinfecting of all exposed surfaces, including wheels and casters, of all items, including: anesthesia carts and equipment, anesthesia machines, patient monitors, OR beds, reusable table straps, OR bed attachments, positioning devices, patient transfer devices, overhead procedure lights, tables and stands, mobile and fixed equipment, storage cabinets, supply carts and furniture, light switches, door handles and push plates, telephones and communications devices, computer accessories, chairs and stools, trash and linen receptacles.

On 04/24/18 at 2:00 p.m., an interview with S1Adm and S5AdmAsst revealed they were not able to identify the resource for the terminal cleaning policy for the OR, but did confirm that the hospital followed Perioperative Standards and Recommended Practices by the Association of perioperative Registered Nurses (AORN).

Based on observation, record review and interview, the hospital failed to ensure radioactive materials were prepared, labeled, used, transported, stored, and disposed of in accordance with acceptable standards of practice as evidenced by: 1) Leaving the Nuclear Medicine Services exam room with the door open and unattended with radioactive materials readily accessible. 2) Failing to develop policies and procedures for the safe storage of radioactive materials and implementing procedures to control access of all radioactive materials.

Findings:

Observation on 4/24/18 at 1:38 p.m. revealed the Nuclear Medication Services room open and unattended by hospital staff. Further observation revealed an inner room with the door open and the contents of the room unsecured and accessible.

On 4/24/18 at 1:45 p.m., this surveyor walked to the nurse's station, asked to speak with the Nuclear Medication Technician, and the nurses stated the technician was currently working in the operating room. Surveyor requested S6RadDir be notified to meet him and she arrived on the second floor to accompany surveyor on tour of Nuclear Medication Services room.

Observation on 4/24/18 at 1:50 p.m. with S6RadDir present revealed the following: the Nuclear Medication Services room was unsecured with the main door open, the inner office was unsecured, and its door was open. Continued observation revealed two rectangular black containers with zipper-topped closures on the desk of the inner office. S6RadDir opened the containers to reveal radioactive materials in both containers.

During an interview on 4/24/18 at 1:53 p.m., S6RadDir acknowledge radioactive materials are a health hazard and the material should be stored in a secure manner.

Review of the hospital's policies and procedures for Nuclear Medication Services provided to the surveyor by S6RadDir and S5AdmAsst failed to reveal policies and procedures for the safe storage and control of access of radioactive materials.

During an interview on 4/25/18 at 12:25 p.m., S6RadDir and S5AdmAsst stated the hospital does not have a policy for the security of radioactive materials at every stage and location of their use within the hospital.

Based on record review and interviw, the hospital failed to address, in the swing bed patient's rights, and to notify swing bed patients, of the right of refusal to work or compensation concerning work performed by the patient while in the hospital for patients admitted to swing bed status for 5 (#1-#5) of 5 discharged swing bed patient records reviewed from a total patient sample of 35.

Findings:

Review of the Patient's Rights document, submitted by the hospital as the current patient rights given to all patients (acute inpatient and swing bed ), revealed no documented evidence that the swing bed patient's right of refusal to work or compensation concerning work performed by the patient while in the hospital was addressed.

Review of discharged swing bed Patients #1- #5's electronic medical records, navigated by S2ADON, revealed no documented evidence of notification of the above referenced right.

In an interview on 4/24/18 at 9:24 a.m. with S2ADON, he confirmed swing bed patients had not been given a list of specific swing bed patient rights when they had been admitted to swing bed status. He also confirmed the right of refusal to work or compensation concerning work performed by the patient while in the hospital on swing bed status had not been addressed on the Patient Rights given to all patients (including swing bed patients) on admission.

Based on record review and interview, the hospital failed to address, in the swingbed patient's rights, and to notify swingbed patients, of the right to send and promptly receive mail that is unopened and to have access to stationery, postage, and writing implements at the patient's own expense for 5 (#1-#5) of 5 discharged swing bed patient records reviewed from a total patient sample of 35.

Findings:

Review of the Patient's Rights document, presented by the hospital as the current patient rights given to all patients (acute inpatient and swing bed), revealed no documented evidence that the swing bed patient's right to send and promptly receive mail that is unopened and to have access to stationery, postage, and writing implements at the patient's own expense was addressed.

Review of discharged swing bed Patients #1- #5's electronic medical records, navigated by S2ADON, revealed no documented evidence of notification of the above referenced right.

In an interview on 4/24/18 at 9:24 a.m. with S2ADON, he confirmed the discharged swing bed patients reviewed (Patient's #1-#5) had not been given a list of specific swing bed patient rights when they had been admitted to swing bed status. He also confirmed the right to send and promptly receive mail that is unopened and to have access to stationery, postage, and writing implements at the patient's own expense had not been addressed on the Patient Rights given to all patients (including swing bed patients) on admission.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights, and to notify swing bed patients, of the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement for 5 (#1-#5) of 5 discharged swing bed patient records reviewed from a total patient sample of 35.

Findings:

Review of the Patient's Rights document, presented by the hospital as the current patient rights given to all patients (acute inpatient and swing bed), revealed no documented evidence that the swing bed patient's right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement was addressed.

Review of discharged swing bed Patients #1- #5's electronic medical records, navigated by S2ADON, revealed no documented evidence of notification of the above referenced right.

In an interview on 4/24/18 at 9:24 a.m. with S2ADON, he confirmed the discharged swing bed patients reviewed (Patient's #1-#5) had not been given a list of specific swing bed patient rights when they had been admitted to swing bed status. He also confirmed the the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.had not been addressed on the Patient Rights given to all patients (including swing bed patients) on admission.

Based on record review and interview, the hospital failed to ensure there was an ongoing program of activities, designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each swing bed patient that was provided by an appointed, qualified activity professional for 4 (#2-#5) of 5 (#1-#5) sampled discharged swing bed patients records reviewed from a total patient sample of 35.

Findings:

Review of the job description titled," Swing Bed Activities Coordinator", revealed in part: Job Summary: To lead swing bed patients in a variety of daily activities in order to enhance and achieve great independence. Job duties: 1. Works with the swingbed patients one on one, surveying the interests and abilities of the patient. 2. Plans and coordinates individual activity programs to meet needs. 3. Conducts initial interview with resident/family by obtaining individual profiles, social history, activity likes and dislikes, update patient activity/socila records accordingly, and answer patient/family questions when possible. 6. Documents patient's involvement and reaction to activity program. 11. Encourages and motivates residents to participate in activity. 13. Document activity rendered on a daily basis, including patient involvement and reaction to activity offered or if patient declines.


Patient #2
Review of Patient #2's medical record revealed the patient had been admitted to swing bed status on 2/14/18 and was discharged on 2/23/18. Further review revealed the patient had been admitted for inpatient rehabilitation status post a failed bilateral hip replacement.

Additional review of Patient #2's electronic medical record, navigated by S2ADON, revealed no documented evidence of a comprehensive activities assessment and no activities plan of care.

In an interview on 4/24/18 at 9:40 a.m. with S2ADON, he confirmed there was no comprehensive activities assessment and no activities plan of care in Patient #2's electronic medical record. He further confirmed the hospital did not currently have an appointed activities director and also confirmed there had been no appointed activities director since 2015.


Patient #3
Review of Patient #3's electronic medical record, navigated by S2ADON, revealed the patient was admitted to swing bed status on 2/3/18 for physical therapy due to deconditioning and for continued intravenous antibiotics for treatment of an E. coli urinary tract infection. Further review revealed the patient was discharged on 2/9/18.

Additional review of Patient #3's electronic medical record, navigated by S2ADON, revealed no documented evidence of a comprehensive activities assessment and no activities plan of care.

In an interview on 4/24/18 at 9:55 a.m. with S2ADON, he confirmed there was no comprehensive activities assessment and no activities plan of care in Patient #3's electronic medical record.


Patient #4
Review of Patient #4's medical record revealed the patient had been admitted to swing bed status on 1/30/18 and was discharged on 2/2/18. Further review revealed the patient had been admitted for continued intravenous antibiotics and supplemental oxygen. .

Additional review of Patient #4's electronic medical record, navigated by S2ADON, revealed no documented evidence of a comprehensive activities assessment and no activities plan of care.

In an interview on 4/24/18 at 10:05 a.m. with S2ADON, he confirmed there was no comprehensive activities assessment and no activities plan of care in Patient #4's electronic medical record.

Patient #5
Review of Patient #5's medical record revealed the patient had been admitted to swing bed status on 1/19/18. Further review revealed the patient had been admitted for physical therapy for reconditioning due to general weakness and debility status post influenza infection. .

Additional review of Patient #5's electronic medical record, navigated by S2ADON, revealed no documented evidence of a comprehensive activities assessment and no activities plan of care.

In an interview on 4/24/18 at 10:20 a.m. with S2ADON, he confirmed there was no comprehensive activities assessment and no activities plan of care in Patient #5's electronic medical record.

Based on record review and interview, the hospital failed to ensure a discharge summary that included a recapitulation of the patient's stay was present on the patient's chart within 30 days of discharge for 2 (#1,#3) of 5 (#1-#5) sampled discharged swing bed patients reviewed from a total patient sample of 35.

Findings:


Patient #1
Review of Patient #1's electronic medical record, navigated by S2ADON, revealed the patient was admitted to swing bed status on 2/16/18 for extended intravenous antibiotics for a Pseudomonas aeruginosa urinary tract infection. Further review revealed the patient expired on 2/20/18.

Further review of Patient #1's electronic medical record on 4/24/18 at 9:30 a.m., navigated by S2ADON, revealed no documented evidence of a discharge summmary, including a recapitulation of the patient's stay. S2ADON confirmed, at the time of the review, that there was no discharge summary in Patient #1's electronic medical record.


Patient #3
Review of Patient #3's electronic medical record, navigated by S2ADON, revealed the patient was admitted to swing bed status on 2/3/18 for physical therapy due to deconditioning and for continued intravenous antibiotics for treatment of an E. coli urinary tract infection. Further review revealed the patient was discharged on 2/9/18.

Further review of Patient #3's electronic medical record on 4/24/18 at 9:50 a.m., navigated by S2ADON, revealed no documented evidence of a discharge summmary, including a recapitulation of the patient's stay. S2ADON confirmed, at the time of the review, that there was no discharge summary in Patient #3's electronic medical record.