HospitalInspections.org

Based on medical record review, policy and procedure review and staff interview, the facility failed to ensure that all patients were asked whether or not they had an Advance Directive. on six (6) of six (6) medical records reviewed.

Findings Include:

Review of two (2) in-patient records, one (1) procedure record, one (1) surgical record and two (2) discharge records revealed no documented evidence that these patients were asked whether or not they had an Advance Directive.

During an interview on 07/12/16 at 12:15 p.m. the Acute Care Unit Director was asked who was responsible for asking the patients whether or not they have an Advance Directive. She stated, "We do not ask. They do that on the Swing Bed Unit." At 12:30 p.m. the Acute Care Unit Director came back and added: "They are supposed to do that in Admitting."

During an interview on 07/12/16 at 1:45 p.m. the Admissions Coordinator stated, "This is on the Nurses' Screen to ask."

Review of the facility's "Advance Directive" policy (effective date 12/01/03 and revised date 08/01/12) revealed: "Procedure: An inquiry will be made by the Admitting Staff during the admissions process of the patient or if the patient is incapacitated, to the patient's significant other, as to whether or not the patient has completed an advance directive.
Admitting personnel will document in the medical record whether the patient has completed an advance directive and that information concerning advance directives has been given to the patient/significant other during the admission process."

Based on observation, temperature log review, staff interview, and policy review, the facility failed to maintain the paraffin bath in a safe operating condition.

Findings Include:

Observation on 07/12/16 at 1:00 p.m. revealed the facility's paraffin bath was plugged in, was hot to the touch and full of solution.

Review of the facility's temperature logs revealed no documented evidence of any temperature checks for the paraffin bath from 1/10/2016 to 7/11/2016.

During an interview on 07/12/16 at 1:30 p.m. the Physical Therapist stated, "We do not do temperature checks on the paraffin bath because we hardly use it. It is more than likely plugged in because of the surveyors being here today."

Review of the facility's "Therabath Service Manual" rev (revised) 2/21/05 revealed: "... Checking the Temperature of the Bath... 2. Place an accurate thermometer in the bath... 3. After inserting the thermometer, wait approximately 30 minutes for the temperature of the bath to stabilize.... 4. Record the temperature reading when the pilot light comes on, and also record the highest temperature of the bath during one entire heating and cooling cycle (approximately 10-15 minutes.). The temperature should read between 124-139 degrees F (Fahrenheit)..., the absolute operating range."

Based on activity calendar review, staff interview, and policy review, the facility failed to provide an ongoing program of activities for patients.

Findings Include:

An interview with the Activity Director on 07/12/16 at 1:50 p.m. revealed that no employee is assigned to be responsible for activities on weekends and activity calendars are not posted in the facility.

Review of activity calendars revealed that no documented evidence that activities were planned for weekends, times of activities were not documented and only one (1) activity was planned on Wednesdays.

The facility's "Participation in Activities for Swing Bed" policy (revised 8/01/12) revealed: "Activities are offered daily to all patients. These activities take place within the skilled facility. An activity calendar is posted by the Activities/Recreational Therapist upon admission to Swing bed, in the patient's room. Activities are held each A.M. / P.M. in the activities/dining room, or in the patient's room."