HospitalInspections.org

Based on review of facility documents, personnel files (PF), medical records (MR), and staff interview (EMP), it was determined that the facility failed to have a qualified individual serve as an Activities/Volunteer Leader and that the facility failed to provide an ongoing program of activities to meet the needs of nine of nine applicable medical records reviewed (MR3, MR4, MR5, MR6, MR11, MR12, MR13, MR14 and MR27).

Findings include:

A review conducted on February 9, 2010, of Troy Community Hospital job description "Activities/Volunteer Leader" last revised June 2007, revealed: "Main Function: Provides on ongoing program of activities based on the comprehensive assessment designed to meet the interests and the physical, mental and psychosocial well being of each swing bed and long term ventilator patient. ... Education: Must possess, as a minimum, high school diploma or equivalent. Must have healthcare experience. Qualified therapeutic recreational specialist or activities professional who is licensed or registered by the State and is eligible for certification as a therapeutic recreation specialist or activities professional is preferred. Experience: 1) Two years experience in social or recreational program within the last five years, one of which was full time in a patient activities program in health setting or 2) Occupational therapist or occupational therapy assistant or 3) Training program approved by the State is preferred. Essential Functions: ... 2. Designs an ongoing activity program which meets the individual interests, physical, mental and psychosocial needs of each patient. Plan bedside, individual and group activities. ... Develops activities calendar each month that include day, evening and weekend activities that are scheduled for the convenience of the patient and includes patient choices. ..."

1) A review on February 9, 2010, of PF5 revealed that Troy Community Hospital hired PF5 on January 5, 2009 as a nursing assistant. On December 30, 2009, PF5 signed the Troy Community Hospital job description for Activities/Volunteer Leader. Further review of PF5 revealed no documented evidence that PF5 met the education or experience requirements for an Activities/Volunteer Leader as described by the Troy Community Hospital job description.

Interview with EMP1 and EMP2 on February 9, 2010, at 9:45 AM confirmed that the facility hired PF5 as a nursing assistant and that PF5 signed the job description for Activities/Volunteer Leader on December 30, 2009. Further interview with EMP2 confirmed that PF5 did not meet the education and experience qualifications to work as an Activities/Volunteer Leader.
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A review on February 9, 2010, of Troy Community Hospital Activities Department policy "Swing Bed Program" last revised November 2007, revealed: "... Procedure: The intent is to provide an ongoing activities program that is appropriate to meet the interest, physical, mental, and psychosocial well-being of each swing bed patient ... The activities care plan is completed with in seven days of admission and the plan is reviewed and updated at least every 60 days. Outcomes and/or patient responses to activities are documented in the activity progress note. The programs Activity Leader is responsible for the overall development and management of the activities planned for each swing bed patient, the development and distribution of the monthly activities, care plan development and updates, and progress notes. ..."

2) A review on February 9, 2010, of Troy Community Hospital Recreation calendars for November and December 2009 revealed that the activities department scheduled seven events for each month. Further review of Troy Community Hospital Recreation calendars for January and February 2010 revealed that the activities department scheduled nine events for each month. The activities included room visits, current events and finishing touches which included nail painting and curling hair. These activities were only scheduled during the day.

3) A review on February 9, 2010, of MR3 and MR4 revealed that these patients were admitted to swing bed status. Further review of MR3 and MR4 revealed no documented evidence that the facility completed a comprehensive activity assessment.

4) A review on February 9, 2010, revealed that the facility admitted MR12 (PT1) on December 4, 2009, to a swing bed. Further review of MR12 revealed no documented evidence of a comprehensive assessment of activity interests on admission to the swing bed unit and/or development of an activity care plan based on the patient's interests. Additional review revealed no documented evidence of the patient's attendance or participation in any facility activities.

Interview with PT1 on February 9, 2010, at 2:15 PM revealed that the activities scheduled at the facility for the months of December 2009 and January and February 2010 did not interest them. PT1 further stated that the facility did not ask what activity preferences they had and that they spent most of their time in their room.

5) A review on February 9, 2010, revealed that the facility admitted MR13 on December 4, 2009 to a swing bed. The completed activity assessment of interests for MR13 on February 5, 2010, revealed interests to include crafts and reading. Further review of the activity log for MR13 revealed no documented evidence of the patient participating in activities of their interest and/or any facility activity.

6) A review on February 9, 2010, revealed that the facility admitted MR14 (PT2) on January 22, 2010, to a swing bed. The completed activity assessment for MR14 on January 25, 2010, revealed interests to include listening to audio tapes. A review of the activity log for MR14 revealed no documented evidence of participation in facility activities.

Interview with PT2 on February 9, 2010, at 2:35 PM revealed that they spent the day in their room and that they would like to listen to their favorite audio tapes.

Observation of PT2's room on February 9, 2010, at 2:30 PM revealed no audio tapes and/or tape player.

7) A review on February 9, 2010, of MR11 and MR27 revealed they were admitted to swing bed status. Further review of physician orders for MR11 and MR27 revealed an order for the Activity Leader to evaluate activity interests. Additional review of MR11 and MR27 revealed no documented evidence of a completed activity assessment or that these patients attended or participated in any facility activities.

8) A review on February 9, 2010, of MR5 and MR6 revealed that the facility completed an activity assessment of interests for MR5 on December 29, 2009 and MR6 on January 30, 2010. There was no documented evidence that MR5 and MR6 attended or participated in any facility activities from December 2009 thru January 2010.

9) Interview with EMP1 and EMP3 on February 9, 2010, at 3:00 PM confirmed that there was no documentation in MR11, MR12, MR13, MR14, and MR27 indicating completion of an activities evaluation and that these patient attended and/or participated in any facility activities.