HospitalInspections.org

Based on observation, interview and review of documents from the life safety validation survey performed July 14, 2015 through July 15, 2015, Aspirus Medford Hospital was found to be not in compliance. The hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 12 of the 12 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-12: Class of Construction
K-18: Corridor openings were not smoke tight;
K-27: Openings in Smoke Compartment were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers
K-38: Delayed locking devices
K-56: Sprinkler system was not installed per NFPA 13

Please refer to the specific K-tags for additional details.

Based on tour of the facility with facility staff between July 14th through July 15th, 2015; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effect of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients in 12 of the 12 smoke compartments. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

Findings Include:
K-12: Class of Construction
K-18: Corridor openings were not smoke tight;
K-27: Openings in Smoke Compartment were not smoke tight.
K-29: Hazardous areas were not enclosed with hourly rated fire barriers;
K-38: Delayed locking devices
K-56: Sprinkler system was not installed per NFPA 13;

Please refer to the specific K-tags for additional details

Based on observation, interview, and record review the facility failed to ensure MDV medications being treated as single dose vials are only used for 1 patient in 1 of 1 observation (OR anesthesia cart), and outpatient therapy staff dispose of expired ointment in 1 of 2 wound care treatment rooms observed (Room #195). This can potentially effect all patients receiving surgery and outpatient therapy.



Findings include:

Per interview with Surgery Dir C on 7/13/15 at 11:20 AM, Dir C stated MDV are treated as single dose vials in the OR and should not be used for more than one Pt.

On 7/13/14 at 1:55 PM the anesthesia cart had two open MDV of lidocaine (numbing agent) and one open MDV of Neostigmine (to reverse blocking agents). This is confirmed in interview with CRNA D at time of discovery, who was unaware MDV vials cannot be used for multiple Pts in the OR.




34337



Facility policy "Expiration of Non-Dated Creams & Ointments" dated 1/2015 states: "The ointment, cream or solution must be disposed within 12 months of the "open date" on the container."

During an observation of the outpatient therapy department on 7/13/2015 at 11:05 AM, wound care treatment room #195 contained an open tube of Therahoney wound ointment. The tube was undated with a manufacturer's expiration date of 6/2015.

Dir U stated at the time of the observation that all ointments and creams "should be labeled when opened and are good for 12 months" and the tube "shouldn't be in here."

Based on observation, record review and interview staff failed to do the following; store food and beverages per policy in 1 of 1 kitchen observed and 2 of 6 patient care areas observed (RT, Med/Surg) and ensure sanitation solutions are mixed at appropriate concentrations in 1 of 1 kitchens observed; perform hand hygiene, maintain a sanitary environment, and handle patient supplies,equipment, and medication in an aseptic manner as per policy in 5 of 5 staff observations (ST G, PA H, MD I, RN J, CRNA E). This could potentially effect all patients receiving treatment at this facility.


Findings include:


Per review on 7/14/15 at 10:45 AM of facility P&P titled Hand Hygiene, #INF-013-01, dated 8/14, it states alcohol -based hand rub will be used "C. After contact with a patient's intact skin.... After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; G. Before and after removing gloves..."

Per review on 7/14/15 at 10:45 AM of facility P&P titled Intravenous Therapy, #017-532-01, dated 2/15, it states under 1.A. "Gather materials and wash your hands, don gloves...

Per review on 7/14/15 at 3:30 PM of facility P&P titled Asepsis, #160-015-01, dated 8/14 states under #6 "...areas of the gown that must be considered unsterile are the...back."

Per interview with QA T on 7/14/15 at 4:15 PM there is no P&P that specifies cleaning a vial septum upon opening or if MDV before inserting a needle.


SURGERY:

The following examples are observed in the Pre-Post Operative area and OR on 7/13/15 between 11:20 AM and 2:42 PM:

At 12:07 PM Pre-operative RN F prepared Pt #1 for a knee arthroscopy. RN F entered data into the computer, proceeded to mark Pt #1's left knee, touched Pt #1's left lower leg, removed the cap from a vial of lidocaine (numbing agent) and drew up the medication for an IV start. RN F did not perform hand hygiene between tasks.

At 12:15 PM RN F assessed Pt #1's arms for IV placement, touched both arms of Pt #1, proceeded to perform an antiseptic wash to the site without wearing gloves and did not perform hand hygiene. RN F proceeded to don gloves without hand hygiene, wiped off the remaining antiseptic wash from the IV site with gauze, palpated the IV site, injected lidocaine without recleaning the site, palpated the site and inserted the IV catheter without recleaning the site. RN F removed the gloves, donned new gloves without performing hand hygiene, and secured the IV tubing.

At 12:51 PM in the OR, CRNA E, while wearing gloves, handled the trash bin and moved it next to the head of Pt #1, CRNA E proceeded to inject sedation medication in Pt #1's IV line, inserted a laryngeal mask (breathing tube allow an open airway during anesthesia), removed gloves and donned new gloves without performing hand hygiene between tasks.

At 1:05 PM MD I cleaned Pt #1's left knee with alcohol soaked gauze. MD I removed the container that held the gauze from the trash bin near the computer, deposited the used alcohol gauze in the container and placed the container on the table next to the antiseptic skin preparation.

At 1:13 PM RN J removed the container with gauze from the table, tossed it into the trash, donned sterile gloves and applied antiseptic solution Pt #1's knee without performing hand hygiene.

At 1:15 PM CRNA E changed gloves without performing hand hygiene, used an alcohol wipe to clean and open a vial of medication, and used the same alcohol wipe the IV port to administer the medication via the port.

At 1:20 PM with the instrument table is within 16 inches of staff, ST G, PA H and MD I turned their backs to the table.

Per interview on 7/13/15 at 4:00 PM with Dir C, the above observations were disclosed, Dir C agreed hand hygiene should be done between tasks, IV sites should be cleaned after palpation, items should not be removed from the trash, and staff should not turn their backs to the instrument table.


29972


DIETARY:

Facility policy "Dishwashing (Three-Compartment Sink for Manual Washing, Rinsing & Sanitizing)" dated 10/2014 states: "If chemical sanitizing is used, the sanitizer must be mixed at the proper concentration. (Check at regular intervals with a test kit)."

Facility policy "Sanitation" dated 10/2014 states in part: "All working surfaces are cleansed thoroughly and sanitized after each use."

Facility policy "Food Storage and Date Marking" dated 1/2015 states: "A date will be placed on the item when it is opened and the manufacturer's expiration will be honored...All food in refrigerators will be labeled and dated with the opened date and use by date and the name of the product...Freezer Storage: A date will be placed on the item when it is opened." The policy includes the following guidelines for refrigerated food storage: "Bacon: 5 days (cooked); Cheese: 1 month; Canned fruit juices: 5 days (opened); Nuts, shelled: 6 months." Dry food storage: "Rice, white: 2 years; Rice, brown: 6 months; Pasta: 1 year; Cake mixes: 6-9 months; Sauce and gravy mixes: 6-12 months; Syrups: 1 year; Spices, ground: 6 months; Herb/spice blends: 12 months." Freezer storage: "Doughnuts: 6 months; Cake, baked, frosted: 6 months; Breads, Bagels: 6 months."

During observations in the kitchen on 7/13/2015 at 12:55 PM the refrigerator contained the following open, unlabeled and undated items: chopped garlic; shredded coconut; nuts; syrup; shredded mozzarella cheese; sliced cheeses; cooked bacon. The kitchen freezer contained unlabeled, undated doughnuts; prepared cupcakes; prepared shakes and bagels. Large unlabeled, undated containers of cake mix and sugar were in the baker's corner of the kitchen. The dry storage area contained open and undated packages of rice and pasta. The shelf above the stove housed open, undated spice containers.

On 7/13/2015 at 1:10 PM, a "Sanitation Bucket Recording" log was observed near the kitchen's 3-compartment sink. The log stated: "Sanitation bucket is tested once per day." The most recent recording on the log was dated 3/22/2015.

Dir N stated during an interview at the time of the observation that the sanitizer "should be checked daily" to ensure proper sanitation in the kitchen.

On 7/13/15 at 1:20 PM while touring Med Surgical floor "Nourishment" room 2033, identified the following items in the refrigerator: 6 plastic containers containing orange jello with no label or date, 46 ounce container of opened Grape Juice dated 6/4/2015, and a 46 ounce container of opened orange juice with no date.

Per interview with RN B at the time of observation, RN B stated juice should be labeled with open date and discarded within 5 days after opening.


During observation of the RT unit on 7/13/2015 at 2:20 PM, the Pulmonary Function Test room #239 contained 7 juice boxes with a manufacturer's expiration date of 5/2015.

Dir N stated at the time of the kitchen observations that open food items "should be labeled and dated." During an interview on 7/13/2015 at 1:25 PM, Dir N stated dietary staff is responsible for maintaining food and beverages on the patient units.







34337

Based on record review and interview staff failed to develop a comprehensive care plan including interventions and measurable goals for 12 of 20 MR's reviewed (Pt 1,2,3,4,5,6,7,10,11,16,17,21).


Findings include:

Per review on 7/14/15 at 4:15 PM of Facility policy "Multidisciplinary Care Plan" dated 10/2014 states: "A multidisciplinary care plan shall be developed...based on identified needs...from all appropriate disciplines...Realistic goals, with specific time limits for attainment, will be established for each patient with the methods, approaches and services for delivering the needed care...When the goals are put into effect, and when they are met/not met, this shall be documented in the progress notes...with an explanation of how/why the goals were/were not met."

Pt #1's MR review revealed the Pre-operative CP started on 7/13/15 for a knee surgery states as problems "Preprocedure Anxiety" and "Preprocedure Readiness". The MR indicates the goals were met. There is no documentation of goals, including Pt #1's goals, and interventions.

Pt #2's MR review revealed the Pre-operative CP started on 4/23/15 for a colonoscopy and hernia repair states as problems "Preprocedure Anxiety" and "Preprocedure Readiness". The MR indicates the goals were met. There is no documentation of goals, including Pt #2's goals, and interventions.

Pt #3's MR review revealed the Pre-operative CP started on 6/19/15 for a port placement (to administer medications) state as problems "Preprocedure Anxiety" and "Preprocedure Readiness". The MR indicates the goals were met. There is no documentation of goals, including Pt #3's goals, and interventions.

The findings for Pt's 1-3 MR's were reviewed and confirmed on 7/14/15 between 2:00 PM and 3:00 PM with RN S who agreed in interview during the MR review, who stated the information goes away after discharge.

Pt #4's MR review revealed the CP started on 7/13/15 at 9:58 AM, indicates Pt #4, a Post Partum Pt, has the following problem: "Risk for Injury" with a goal as "Maternal Status: Postpartum". Under Goal Details there is a definition "Extent to which maternal wellbeing (sic) is within normal limits from delivery of placenta to completion of involution (uterus returning towards non-pregancy size). There are Indicators listed as "Blood pressure, Uterine fundal height, Lochia amount (bleeding), Comfort" The NOC (Nursing Outcomes Classification) is rated at 2 (Substantial deviation from normal range) with a target of 4 (Mild deviation from normal range). The CP does not include Pt #4's goals, does not include measurable goals, and has no specific interventions.

Pt #5's MR review revealed the CP stated on 1/6/15 (no available date) for Pt #5, a Post Partum Pt, the problem as "Risk for Injury" with a goal as "Maternal Status: Postpartum". There is a NOC rating of 3. The CP note on 1/7/15 at 11:19 PM reflected no change to the NOC rating of 3. And the discharge CP note dated 1/8/15 at 8:54 AM has no mention of a NOC rating and states "Goal Met." The CP does not include Pt #4's goals, does not include measurable goals, has no specific interventions.

Pt #6's MR review revealed the CP started on 7/13/15 at 10:30 AM, indicates Pt #6, a Newborn, has the problem as "Readiness for Enhanced Organized Infant Behavior" with goal one as "Newborn Adaptation", the Goal Details state "Definition: Adaptive response to the extrauterine environment by a physiologically mature newborn during the first 28 days" The Indicators are "Feeding tolerance, Interaction with caregiver, Thermoregulation, Skin color. The NOC rating is 3 with a target of 5 "No deviation of from normal range". There are no measurable goals, there are no time limits, there are no specific interventions.

Pt #7's MR review revealed the CP started on 1/6/15 (no available date) indicates Pt #7, a Newborn, has the problem as "Readiness for Enhanced Organized Infant Behavior" with goal one as "Newborn Adaptation". The CP note dated 1/6/15 at 7:34 PM indicates the NOC rating as 3. The discharge CP note dated 1/8/15 at 12:43 PM has no mention of the NOC rating and states "Goal Met". There are no measurable goals, there are no time limits, there are no specific interventions.

The findings for Pt's 4-7 MR's were discussed and confirmed in interview with Dir M on 7/14/15 during the MR reviews between 12:00 PM and 1:15 PM, who was unable to state how the listed goals were measurable.




34337


Pt. #10 received inpatient services from 4/8/2015 through 4/15/2015 for cough and shortness of breath. Pt. #10's care plan includes a problem of Impaired Gas Exchange initiated on 4/8/2015 with a goal of "Respiratory Status: Gas Exchange" based on the following indicators: Cognitive status; Oxygen saturation; Dyspnea at rest. Pt. #10's goal rating on 4/8/2015 is documented as "3-Moderately Compromised" with a goal rating of "4-Mildly Compromised." There are no interventions/methods included in Pt. #10's plan of care. Care plan progress notes dated 4/8/2015 through 4/14/2015 rate the patient's outcome at a "3" rating. The care plan progress note dated 4/15/2015 states: "Outcome: Goal Met." Documentation does not address indicators or explanation of how the goal was met.

Pt. #11 received inpatient services from 6/8/2015 through 6/10/2015 for heart failure and pneumonia. Pt. #11's care plan includes a problem of Decreased Cardiac Output with a goal of Circulation Status and a target goal rating of "4-Mildly Compromised" up from initial rating of "2-Substantially Compromised" as indicated by Systolic and Diastolic blood pressure. Goal interventions include Medication Administration; Vital Signs Monitoring; Oxygen Therapy. The care plan progress notes document Pt. #11's outcome rating as 2 on 6/8/2015 at 12:39 PM; 3 on 6/8/2015 at 11:16 PM; 2 on 6/9/2015 at 9:58 AM and "goal met" on 6/10/2015 at 8:09 AM. The care plan does not document how the goal was met.

Pt. #21 was admitted to the facility on 7/12/2015 with hypoxia. Care plan problems initiated include Deficient Fluid Volume with a goal of hydration "4-Mild" and Impaired Gas Exchange with a goal of gas exchange "4-Mildly Compromised." Progress toward hydration is indicated through skin turgor; moist mucous membranes; 24 hour intake and output balance and weight loss. There are no methods or interventions documented. Interventions listed under Impaired Gas Exchange include Oxygen Therapy and Vital Signs Monitoring.

During an interview with RN R on 7/14/2015 at 3:35 PM, RN R stated the goal ratings are a "matter of opinion using clinical judgement" and that there was no objective criteria to use in rating a patient's current goal status. RN R stated goal "indicators are built in [to the EHR] and there is no room for individualization." Interventions "auto-populate into the care plan as ordered" but not all care plan goals have interventions.






29972


Review of Pt 16's MR revealed Pt 16 was admitted to inpatient unit from ED on 4/10/15 with a chief complaint of diarrhea, vomiting, and weakness. Per Pt 16's H&P dated 4/10/15, "Assessment/Plan" stated the following issues; Ileus (obstruction of the intestine), dehydration, leg weakness; "Planning NPO (no food by mouth) status, bowel rest, IV hydration." Review of Pt 16's CP shows only a CP initiated for "Activity Intolerance", no evidence of staff developing an individualized CP addressing Pt 16's specific nursing care needs for dehydration related to diarrhea, vomiting, and NPO status.

Review of Pt 17's MR revealed Pt 17 was admitted to inpatient unit from ED on 4/14/15 with a chief complaint of loss of consciousness at work and loss of bowel function. Per Pt 17's H&P dated 4/14/15, Pt 17 developed a sudden onset of extreme weakness and passed out in the bathroom at work. Pt 17's H&P "Assessment/Plan" states the following issues: Acute upper GI bleed, Acute blood-loss anemia secondary to diagnosis, acute symptomatic orthostatic hypotension, acute syncope, Cerebral Palsy. Review of Pt 17's CP shows only CP for "Deficient Fluid Volume" initiated, no evidence of nursing staff developing an individualized CP related to Pt 17's risk for falls.

Based on record review and interview staff failed to provide accurate instructions to patients upon discharge for 5 of 12 discharged patients (#9, #11, #12, #13, #16).

Findings include:

Facility policy "Discharge Planning (Home) -- Hospital" dated 3/2015 states: "Nursing staff are to complete the After Visit Summary (AVS) prior to/at the time of discharge. This document provides an overview of the patient's medical condition and functional level at the time of discharge. It may also contain referrals, discharge instructions, follow-up appointments...The AVS is printed and given to the patient on discharge. The nurse discusses the information on the AVS with the patient on discharge."

Facility policy "Patient Safety: Medication Reconciliation" dated 3/2015 states: "Medication reconciliation is required...at discharge...The physician will review the Medication Reconciliation and indicate whether each home medication should be continued after discharge. The provider will order any new medications..."

Pt. #9 was discharged to home from the facility on 4/2/2015 with a diagnosis of pyelonephritis (kidney infection) and bacteremia (blood infection). Pt. #9's discharge summary states "start taking these medications: hydrocodone-acetaminophen 5-325 mg per tablet 1-2 tablets by mouth every 4 hours as needed for pain; ciprofloxacin 500 mg tablet take 1 tablet by mouth twice daily for 7 days; metronidazole 500 mg tablet take 1 tablet by mouth 3 times daily for 7 days." Pt. #9's AVS states "start taking these medications: hydrocodone-acetaminophen 5-325 mg per tablet." The medication list on the AVS does not include ciproflaxacin or metronidazole.

Pt. #11 was discharged to home from the facility on 6/10/2015 with a diagnosis of pneumonia. Pt. #11's discharge summary states "start taking these medications: doxycycline 100 mg tablet; guaifenesin 600 mg tablet." The AVS medication list given to the patient at discharge does not include doxycycline or guaifenesin. The discharge summary states "continue these medications: furosemide, metoprolol, polyethylene glycol powder, potassium chloride, warfarin." The AVS medication list states "stop taking these medications: furosemide, metoprolol, polyethylene glycol powder, potassium chloride, warfarin."

Pt. #12 was discharged to home from the facility on 6/11/2015 for physical deconditioning. Pt. #12's discharge summary includes nitroglycerin. Pt. #12's AVS medication list instructs the patient to stop taking nitroglycerin. The discharge summary documents Pt. #12's discharge diet as "carbohydrate controlled", AVS instructions lists diet as "regular."

Pt. #13 was discharged to home from the facility on 6/27/2015 after inpatient rehabilitation. Pt. #13's discharge summary includes carvedilol daily. The AVS medication list instructs the patient to stop carvedilol. The discharge summary documents Pt. #13's discharge diet as "low sodium", AVS instructions lists diet as "regular."

The above findings were confirmed with Dir O on 7/14/2015 beginning at 10:00 am during MR review. Dir O stated the AVS serves as the patient discharge instructions and "should" reflect the providers orders. Dir O was unable to explain the discrepancies between the provider's discharge summary and the patient's discharge instructions.



29972


Review of Pt 16's MR reveals Pt 16 admitted to inpatient unit 4/10/15 through 4/13/15 with a diagnosis of Ileus (intestinal obstruction), diarrhea, vomiting, and dehydration. Pt 16's MR's shows no documentation of discharge instructions in EHR. Per interview with RN B at the time of MR review on 7/14/15 beginning at 3:00 PM, RN B stated there are no discharge instructions in EHR for Pt 16.

Based on observation, record review and interview the facility failed to ensure verbal confirmation and written documentation reflect the ABSP is dry prior to draping in 1 of 1 surgical observation (Pt #1). The facility failed to ensure proper attire is worn in the OR in 6 of 6 staff observed (E, G, H, I, J and K). The facility failed to ensure instruments are cleaned per manufacturer's recommendation, in 1 of 1 staff observed cleaning instruments (K). The facility failed to ensure a comprehensive APA that includes Cardiopulmonary status, Level of consciousness, follow-up, observations and complications, in 4 of 4 surgical MR's reviewed (1, 2, 3 and 5) out of a total 20 MR's reviewed. This could potentially effect all patients receiving surgery at this facility. See tag C322.

Findings include:

Review on 7/13/15 at 2:00 PM of manufacturer's instructions (posted on the wall above the decontamination sink) from ECOLAB on manual cleaning it states under #4 "Cleaning should be done under the surface of the water."

Per interview with Surgery Dir C on 7/13/15 at 11:20 AM, the facility follows AORN Recommendations in the surgery area, and staff are to verbalize the ABSP is to be dry prior to applying drapes. In follow up interview on 7/14/15 at 4:45 PM, Dir C provided a copy of the "Time Out" used pre-surgery does not include stating and documenting the ABSP is dry prior to draping." Dir C was unaware they should document the ABSP is dry prior to draping.

Per review on 7/14/15 at 4:15 PM of facility P&P titled Attire in the Operating Room, #160-060-01, dated 8/14, it states under 1.I. "Non-scrubbed personnel should wear long sleeved jackets..."

Per review on 7/15/15 at 11:00 AM of AORN 2015 Edition Guidelines for Perioperative setting it states under Patient Skin Antisepsis IV.g.2 states "Adequate time should be allowed for the flammable skin antiseptic to dry completely and for any fumes to dissipate before surgical drapes are applied or a potential ignition source is used " Under Environment of Care, Part 1, II.b. "A fire risk assessment should be completed and communicated to the entire perioperative team before beginning a surgical procedure...II.b.1 The fire risk assessment should identify fuels that are present, ignition sources that are present..." And under Aseptic Practice Surgical Attire I.c. "When in the restricted area, all nonscrubbed personnel should completely cover their arms with a long sleeved scrub top or jacket...Recommendation III "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears and facial hair."

Per observation on 7/13/15 at 1:13 PM RN J prepped Pt #1's left knee for arthoscopic surgery using an ABSP Duraprep. At 1:17 PM PA H began to apply draping. Neither RN J or PA H stated to the surgical team the ABSP was dry prior to applying drapes. Review of Pt #1's MR revealed on the Site Preparation screen "Leg prepped with alcohol by (MD I) prior to local injection. Alcohol dry and prepped with Duraprep (ABSP) by RN." There is no documentation the Duraprep is dry prior to draping. This was confirmed in interview and MR review with RN B on 7/14/15 at 4:00 PM. RN B stated in interview RN B was unaware of the need to document ABSP is dry prior to draping.

During observation of Pt #1's knee arthoscopy on 7/13/15, between 12:50 PM and 1:50 PM the following staff had on bonnets and/or skull caps that did not cover all of their hair or ears, CRNA E, ST G, PA H, MD I, and ST K. CRNA E did not have on a jacket.

Per observation of ST G cleaning instruments on 7/14/15 at 2:05 PM, ST G held the instruments above the water line when scrubbing with a brush, rather than following manufacturer's instructions of holding below the water line.

Based on record review and interview the facility failed to ensure a comprehensive APA that includes Cardiopulmonary status, Level of consciousness, follow-up , observations and complications, in 4 of 5 MR's requiring an APA (1, 2, 3 and 5) out of a total 20 MR's reviewed.

Findings include:

Pt #1's MR review revealed Pt #1 had knee arthroscopy on 7/13/15. The APA completed on 7/13/15 at 4:07 PM by CRNA E, states the following: Respiratory: Yes; Cardiovascular: Yes; Mentation: Yes; Pain: Yes; Nausea/Vomiting: No; Hydration: Yes and Temperature: Yes. An additional note states "Compazine (anti nausea medication) IV for nausea". There are no vital signs indicating temperature, cardio and respiratory function, no indication of what Pt #1's mental status is, no indication of Pt #1's pain level and action taken, no indication of level of hydration, and the note contradicts documentation of no nausea.

Pt #2's MR review revealed Pt #2 had a colonoscopy and hernia repair on 4/23/15. There is no APA in the MR to indicate Pt #2 made a full recovery from anesthesia.

Pt #3's MR review revealed Pt #3 had a port inserted surgically for medication administration on 6/19/15. The APA completed on 6/19/15 at 1:36 PM by CRNA D states the following: Respiratory: Yes; Cardiovascular: Yes; Mentation: Yes; Pain: Yes; Nausea/Vomiting: Yes; Hydration: Yes and Temperature: Yes. An additional note states "No complications noted." There are no vital signs indicating temperature, cardiac and respiratory function, no indication of what Pt #1's mental status is, no indication of Pt #1's pain level and action taken, the note contradicts documentation of Pt #3 having nausea, and no indication of level of hydration.

The above MR's and findings were reviewed and confirmed in interview on 7/14/15 between 2:00 PM and 3:00 PM with RN S who agreed in interview during the MR review, the documentation should be complete and accurate.

Pt #5's MR review revealed Pt #5 had a Dialation and Curettage to remove retained placenta after delivering a baby on 1/6/15. The APA completed on 1/6/15 at 9:06 AM by CRNA L states the following: Respiratory: Yes; Cardiovascular: Yes; Mentation: Yes; Pain: Yes; Nausea/Vomiting: Yes; Hydration: Yes and Temperature: Yes. An additional note states "No complications noted." There are no vital signs indicating temperature, cardiac and respiratory function, no indication of what Pt #1's mental status is, no indication of Pt #1's pain level and action taken. There is a note that states "Pt reports only minimal back soreness at epidural insertion site." This finding was confirmed in interview with Dir M at time of MR review on 7/14/14 at 12:40 PM, who was unaware of the requirements for APA note.

Based on record review and interview, facility staff failed to provide a comprehensive activities program for 2 of 2 swing bed patients (Pt. #12, #13).

Findings include:

Facility policy: "Recreational Therapy Program" dated 10/2014 states: "The recreational therapy program shall be an integral part of the patient's plan of care...Documentation of programming and patient participation shall include attendance records and progress notes."

Pt. #12 received inpatient swing bed services from 5/20/2015 through 6/11/2015 for generalized muscular weakness. A recreational therapy assessment dated 5/22/2015 includes a recreational therapy goal of "Functional Leisure Skills: Increase Socialization/Emotional Skills" using the following methods: "Structured leisure activities participation; Independent leisure activities participation; Community reintegration." A recreational therapy progress note dated 6/10/2015 documents: "Met with patient, had declined attending music on 6/5/2015, said was not able to at this time, visited 1-1 in room, family has been visiting. Patient to discharge 6/11/2015." Pt. #12's MR does not include any further documentation of methods used of patient progress toward goal.

Pt. #13 received inpatient swing bed services from 6/14/2015 through 6/27/2015 for rehabilitation status post fall. A recreational therapy assessment dated 6/17/2015 includes a recreational therapy goal of "To demonstrate leisure independence and personal enjoyment through participation in appropriate leisure opportunities." Methods identified to aid patient in meeting goals: "Attend Catholic Mass and music programs prescribed weekly. Independent leisure activities participation." Pt. #13's MR does not include progress notes or documentation of Pt. #13's participation in recreational activities or progress toward goal.

During an interview on 7/14/2015 at 1:55 PM, Dir U stated staff maintain a "flowsheet" for swing bed patients to document activity participation but Pt. #12 and Pt. #13 did not have an activity flowsheet because Pt. #12 and Pt. #13 "preferred not to be involved."

Based on record review and interview, facility staff failed to develop a comprehensive care plan including interventions and measurable goals for 2 of 2 swing bed patients (Pt. #12 , #13).

Findings:

Facility policy "Recreational Therapy Program" dated 10/2014 states: "...activities program shall be an integral part of the patient's plan of care."

Facility policy "Multidisciplinary Care Plan" dated 10/2014 states: "A multidisciplinary care plan shall be developed...based on identified needs...from all appropriate disciplines...Realistic goals, with specific time limits for attainment, will be established for each patient with the methods, approaches and services for delivering the needed care...When the goals are put into effect, and when they are met/not met, this shall be documented in the progress notes...with an explanation of how/why the goals were/were not met."

Pt. #12's MR includes a care plan problem for Activity Intolerance initiated on 5/20/2015. The goal is for the patient to achieve Activity Tolerance. The care plan does not include a measurable goal, nor does the care plan identify any interventions/methods to aid Pt. #12 in achieving the goal. There is no documentation of the activities/recreational therapies included in Pt. #12's plan of care.

Pt. #13's MR includes a care plan problem for Activity Intolerance initiated on 6/14/2015. The goal is for the patient to achieve an Activity Tolerance rating of "4-Mildly Compromised" an improvement over a rating of "2-Substantially Compromised" at initiation. Indicators for the rating scale include pulse rate with activity, respiratory rate with activity and ease of breathing with activity. Care plan progress notes do not include documentation of the patient's progress toward goals using the indicators listed. The care plan does not include interventions/methods designed to aid Pt. #13 in achieving the goal. There is no documentation of the activities/recreational therapies included in Pt. #13's plan of care.

The above findings were confirmed with CM O at the time of the review. During an interview with RN R on 7/14/2015 at 3:35 PM, RN R stated the goal ratings are a "matter of opinion using clinical judgement" and that there was no objective criteria to use in rating a patient's current goal status. RN R stated goal "indicators are built in [to the EHR] and there is no room for individualization." Interventions "auto-populate into the care plan as ordered" but not all care plan goals have interventions.