HospitalInspections.org

Based on record review, interview and review of the hospital policy and procedures it was determined that the hospital failed to have documented evidence that emergency room patients recieved their patient rights.

Findings include:

Review of the hospital policy and procedure titled "Patient Rights and Responsibilities" dated "8/2010" revealed the following:
- "A copy of the policy found in the Patient Handbook is provided to each patient upon admission to the Medical Center. The rights and responsibilities will be briefly reviewed by Admitting/Emergency Registration personnel at the time of admission. ...
- Written confirmation of receipt of handbook and a brief explanation is obtained by having the patient sign an acknowledgment on the General Consent form."

Review of the hospital "Emergency Department" consent on 12/3/10 revealed no documented evidence that emergency room patients were informed of the patient's rights in advance of receiving emergency room treatment and services.

During interview with Staff E (Emergency Room Director) on 12/3/10 at approximately 10:45 a.m. after Staff E reviewed the hospital "Emergency Department" consent listed above, Staff E confirmed that there is no documented evidence on the emergency room patient record to show that these patients are informed of their rights in advance of receiving emergency room treatment and services.

Staff E indicated that the patients sign a hospital document at the time of admission to the hospital regarding patient rights and that there is no documented evidence of these rights for emergency room patients.

Based on observation and interview the hospital failed to ensure that medical records are stored, in the building on the hospital grounds that is separated from the hospital, in a manner that protects the records from fire and/or water damage.

Findings include:

On 12/1/10 the storage building on the hospital grounds separated from the hospital building was toured/observed with Staff G, Director of Medical Records and Staff M, the Operational Manager of the Medical Records Department. Staff G confirmed during an interview while observing the stored medical records that the records are stored in cardboard boxes on the movable record storage shelves.

Interview with Staff N, Director of Maintenance on 12/3/10 revealed that this storage building has no fire safety sprinkling system. These medical records stored in cardboard boxes on the movable shelves in this building would not be protected from fire damage during a fire or from water damage if the building were to have an overhead leak.

Based on observation and interview the facility failed to ensure that confidential patient information was only accessible to authorized personnel in the ICU (Intensive Care Unit).

Findings include:

During tour observations on 11/30/10 in the ICU it was identified that additional monitors were hung in the hallway high on the walls and facing downward. These monitors were displaying the cardiac rhythms of the patients being monitored in the unit at that time. Observation at this time also identified that each patient who was being monitored had their full name displayed on the monitor identifying which rhythm belonged to which patient and confirming that they were a patient in the hospital. Interview at this time with Staff C (Chief Nursing Officer) and Staff D (Clinical Coordinator) identified that the names were listed like that for easier patient recognition and confirmed that those listed were the patients being monitored. It was also confirmed that the monitors were situated in areas that any visitor to the ICU had visual access to.

Based on observation and interview the hospital failed to ensure that unauthorized individuals cannot gain access to or alter patient records.

Findings include:

On 12/1/10 the storage building on the hospital grounds separated from the hospital building was toured/observed with Staff G, Director of Medical Records and Staff M, the Operational Manager of the Medical Records Department. Observations revealed that the storage building is locked and that patient medical records are stored in cardboard boxes on movable open sided shelves.

Observation of the storage and interview with Staff G and Staff M revealed the patient medical records are stored on the same open sided shelves with records from other hospital departments - hospital business records, medical records transferred from doctors office practices that are not hospital records, old behavior health charts, pharmacy records, radiology records, central supply records, human resources records and medical staff office records.

Observations of the stored hospital patient medical records in this building shows that they are not stored separately and securely from all the other types of records to prevent assess by unauthorized individuals who go to the building to access other types of records.

Based on record review, interview and review of the hospital Medical Staff General Rules and Regulations it was determined that the hospital failed to ensure that the medical record entries for 6 emergency room transfer patients and 4 inpatients were complete, dated, timed and signed. (Patient identifiers are #34, #35, #36, #37, #38, #39, #58, #60, #61 and #62.)

Findings include:

Review of the hospital Medical Staff General Rules and Regulations revealed the following:
- "Clinical Entries:
All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated. Authentication means to establish authorship by written signature, identifiable initials or electronic signature or rubber stamp."

Patient #34.
Record review on 12/3/10 of the emergency room record for Patient #34 dated "10/18/10" revealed that Patient #34 was transferred to another hospital in critical condition. Further review of the emergency room record revealed no documented evidence of a completed "TRANSFER CERTIFICATION" form to show that Patient #34 was transferred to another hospital on 10/18/10.

Patient #35.
Record review on 12/3/10 of the emergency room record for Patient #35 dated "10/16/10" revealed that Patient #35 was transferred to another hospital in stable condition. Further review of the emergency room record revealed no documented evidence of a completed "TRANSFER CERTIFICATION" form to show that Patient #35 was transferred to another hospital on 10/16/10.

Patient #36.
Record review on 12/3/10 of the emergency room record for Patient #36 dated "9/20/10" revealed that the "TRANSFER CERTIFICATION" form to show that Patient #36 was transferred to another hospital was not completed with the "Name of Ambulance Service, Attendant's Signature, Date, Name of Receiving Personnel, Signature of Nursing Staff and Date."

Patient #37.
Record review on 12/3/10 of the emergency room record for Patient #37 dated "11/01/10" revealed that the"TRANSFER CERTIFICATION" form to show that Patient #37 was transferred to another hospital was not completed with the "Name of Receiving Personnel, Signature of Nursing Staff and Date."

Patient #38.
Record review on 12/3/10 of the emergency room record for Patient #38 dated "10/12/10" revealed that the "TRANSFER CERTIFICATION" form to show that Patient #38 was transferred to another hospital was not completed with "Date & Time" of patient signature, "Name of Receiving Personnel, Signature of Nursing Staff and Date."

Patient #39.
Record review on 12/3/10 of the emergency room record for Patient #39 dated "10/17/10" revealed that Patient #39 was transferred to another hospital in critical condition. Further review of the emergency room record revealed no documented evidence of a completed "TRANSFER CERTIFICATION" form to show that Patient #39 was transferred to another facility on "10/18/10".

During interview with Staff E (Emergency Room Director) on 12/3/10 at approximately 1:45 p.m. after Staff E reviewed the above listed findings, Staff E confirmed that the hospital emergency room transfer forms for Patients #34, #35, #36, #37, #38 and #39 were not complete.



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Patient #58.
Review of this patient's discharge medical record shows that the patient was in the hospital from 7/29/09 to 8/7/09 for acute care and surgery. Review of progress notes dated 8/1, 8/2, 8/3 and 8/6 shows that the year is missing from the date and the progress note is not timed when it was written. Review of a Surgery Post Op (Operative) Notes (Date and Time) form filed in the medical record for the 7/29/10 to 8/7/10 acute care stay and bladder surgery shows that the MD (Medical Doctor) who signed the Surgery Post Op Notes form did not date it when it was signed.


Patient #60.
Review of this patient's discharge medical record shows that the patient was in the hospital from 4/28/08 to 5/2/08 for surgery for the diagnosis of recurrent diverticulitis. Review of the "Admission Nursing Assessment/Pre-op SSU/Holding Area and Anesthesia Consult Record" shows that the hospital staff did not enter the date and the time on the top of the first page of the multi-page form. Review of an MD telephone order dated 5/1/08 which begins, "percocet 1-2 tabs po (by mouth) prn (as needed) pain Q (every) 4 (symbol for hour) ... ," shows that the nurse who received and wrote the telephone order did not record the time that the telephone order was obtained and written.

Patient #61.
Review of this patient's medical record shows that patient was in the hospital from 11/28/06 to 12/15/06. Review of Physician's Orders written on a Pediatric Order Sheet shows that the physician dated the orders 11/28/06 but did not include the time on the order sheet when the orders were written. Review of MD progress notes shows that two progress notes written on 11/30/06, one a Peds (Pediatric) note and one an Ophthalmology Consult note, are not timed by the MDs who wrote the notes. Review of three Peds (Pediatric) Progress Notes dated 12/2/06, 12/9/06 and 12/15/06 shows that these notes have no time entered when the progress notes were written.

Patient #62.
Review of this patient's discharge medical record shows that the patient was in the hospital from 11/7/10 to 11/13/10 for a gastro-intestinal bleed and liver failure. Review of a Physician's Orders sheet with a telephone order dated 11/9/10 shows that the nurse who received the telephone order for the patient's diet did not enter the time on the order sheet when the order was received.

Based on record review and interview the hospital failed to ensure that all MD (Medical Doctor) telephone orders were signed by the MDs within 48 hours of the telephone order being received and recorded by nursing staff members. (Patient identifiers are #54 and #55.)

Findings include:

Patient #54.
Review of this patient's medical record on 12/3/10 shows that the patient's MDs gave telephone orders on 11/19/10 at 1435, on 11/20/10 at 0510, on 11/21/10 at 1758, on 11/23/10 at 1847, on 11/23/10 at 1932 and 11/28/10 at 0018 that were not signed by the MD as of 12/3/10 a.m.

Staff L, RN (Registered Nurse) Clinical Information Nurse and Staff H, RN Director of Medical Surgical Units were present during the review of the patient's medical record and when asked stated that these above telephone orders had not been signed by the MD's.

Patient #55.
Review of this patient's medical record on 12/3/10 shows that the patient's MDs gave telephone orders on 11/26/10 at 1619, on 11/26/10 at 1620, on 11/26/10 at 1918 and on 11/27/10 at 2130 that were not signed by the MDs as of 12/3/10.

Staff L and Staff H were present during the review of the patient's medical record and when asked stated that these above telephone orders had not been signed by the MDs.

Based on record review, interview and review of the hospital policy and procedures it was determined that the hospital failed to ensure that consent for emergency room treatment was completed for 3 of 10 emergency room patients. (Patient identifiers are #32, #35 and #40.)

Findings include:

Review of the hospital policy and procedure titled "Informed Consent" with a review date of "12/09" revealed the following:
-"Policy:
- Except in emergency situations, every patient will sign a consent form for all admissions and for all surgical procedures that require anesthesia. ....

- Types of Consents
- A. The admissions registrar is responsible for obtaining and witnessing the patient's signature on the general consent form, the abbreviated treatment consent for the Emergency Care Center and the outpatient consent to treatment forms."

Emergency room record review of Patient #32 on 12/3/10 identified that the "Emergency Department, Consent To Treatment" form revealed no documented evidence that this consent was witnessed or dated for emergency treatment on 11/25/10.

Emergency room record review on 12/3/10 identified that the "Emergency Department, Consent To Treatment" form in the record was not completed, dated or signed for the services and treatment Patient #35 received in the emergency room on 10/16/10.

Record review on 12/3/10 of the emergency room record for Patient #40 dated "12/03/2010" revealed that the hospital "Emergency Department" consent was not completed, dated or signed.

During interview with Staff E (Emergency Room Director) on 12/3/10 at approximately 1:45 p.m. after Staff E reviewed the above listed findings, Staff E confirmed that the hospital emergency room consents for Patient's #32, #35 and #40 were not completed, dated or signed.

Based on interview and review, of the hospital's report of incomplete medical records entitled, "Delinquent Charts Status Report", dated/timed 11/30/10 11:53 A.M., the hospital failed to ensure that all patients' medical records were completed within 30 days of the patients' discharges from the hospital. Based on review of discharged patient medical records during the survey shows that the following patient discharged medical records were incomplete beyond 30 days after discharge. (Patient identifiers are #58, #60 and #61.)

Findings include:

The hospital provided the survey team with a Delinquent Charts Status Report that is dated 11/30/10 on the first day of the validation survey. Review of this report and interview with Staff G, Director of Medical Records during the survey revealed that as of 11/30/10 the first day of the survey there were 12 providers who had incomplete medical records. The total number of medical records incomplete beyond 30 day from the patients' discharges is 85.

Patient #58.
Review of this patient's discharge medical record shows that the patient was in the hospital from 7/29/09 to 8/7/09 for acute care and surgery. Review of progress notes dated 8/1, 8/2, 8/3 and 8/6 shows that the year is missing from the date and the progress note is not timed when it was written. Review of a Surgery Post Op (Operative) Notes (Date and Time) form filed in the medical record for the 7/29/10 to 8/7/10 acute care stay and bladder surgery shows that the MD (Medical Doctor) who signed the Surgery Post Op Notes form did not date it when it was signed.

Patient #60.
Review of this patient's discharge medical record shows that the patient was in the hospital from 4/28/08 to 5/2/08 for surgery for the diagnosis of recurrent diverticulitis. Review of the "Admission Nursing Assessment/Pre-op SSU/Holding Area and Anesthesia Consult Record" shows that the hospital staff did not enter the date and the time on the top of the first page of the multi-page form. Review of an MD telephone order dated 5/1/08 which begins, "percocet 1-2 tabs po (by mouth) prn (as needed) pain Q (every) 4 (symbol for hour) ... ," shows that the nurse who received and wrote the telephone order did not record the time that the telephone order was obtained and written.

Patient #61.
Review of this patient's medical record shows that patient was in the hospital from 11/28/06 to 12/15/06. Review of Physician's Orders written on a Pediatric Order Sheet shows that the physician dated the orders 11/28/06 but did not include the time on the order sheet when the orders were written. Review of MD progress notes shows that two progress notes written on 11/30/06, one a Peds (Pediatric) note and one an Ophthalmology Consult note, are not timed by the MDs who wrote the notes. Review of three Peds (Pediatric) Progress Notes dated 12/2/06, 12/9/06 and 12/15/06 shows that these notes have no time entered when the progress notes were written.

Based on observation and interview during the initial tour of the kitchen on 11/30/10 with Staff F (Director of Nutritional Services) it was found that the facility failed to maintain two pieces of kitchen equipment, and failed to provide for proper hand washing technique.

Findings include:

During the initial tour of the kitchen with Staff F it was observed by this surveyor and shown to Staff F that two different pieces of equipment had what appeared to be food/food by-product built up on them. Staff F stated when interviewed that both items were ready to be used. The two items observed were the meat slicer and a manual can opener. Once observed and identified, Staff F took the items out of service until cleaned. Also during the initial tour of the kitchen on 11/30/10 with Staff F it was observed that hand washing dispensers were placed throughout the kitchen and dish room. Staff F was asked if the kitchen staff uses these dispensers and what type of agent was inside the dispensers. Staff F stated that the dispensers had a foam agent that does not require water. Based on interview and observation the facility failed to provide for proper hand washing technique (soap regular or anti-microbial, hot water, and disposable towels and /or heat/air drying methods) while working in the kitchen area.

Based on tour of the surgical suites on 12/1/10 with Staff A (Director of Surgical Services) and Staff B (Nurse Educator of Surgical Services) it was observed that the facility failed to maintain an environment that assures the patient's well-being and safety.

Findings include:

During tour of the surgical suites with Staff A and Staff B it was observed and shown to both Staff that two of the operating room ceilings had lights that were broken and had large accumulations of dust particles in the areas where the pieces were missing. Operating room 1 had three light covers that were broken and operating room 3 had 1 light cover which was broken.

ANSI [Approved American National Standard]/ASHRAE/ASHE [American Society for Healthcare Engineering] Standard 170-2008 Ventilation of Health Care Facilities. Page 11. 7.4 Surgery Rooms. 7.4.1 Class B and C Operating Rooms. "Operating rooms shall be maintained at a positive pressure with respect to all adjoining spaces at all times. A pressure differential shall be maintained at a value of at least =0.01 in. wc (2.5Pa)."

ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Chapter 7 Health Care Facilities. Specific Design Criteria Surgery and Critical Care. 7.5 The following conditions are recommended for operating, catheterization, cystoscopic, and fracture rooms:

*Air pressure should be kept positive with respect to any adjoining rooms by supplying excess air.

*A differential-pressure-indication device should be installed to permit air pressure readings in the rooms. Thorough sealing of all wall, ceiling, and floor penetrations, and tight-fitting doors are essential to maintaining readable pressure.


Based on tour of the surgical suites on 12/1/10 with Staff A (Director of Surgical Services) and Staff B (Nurse Educator of Surgical Services) it was observed that the facility failed to monitor the pressurization of the five surgical suites.

Findings include:

During tour on 12/1/10 of the surgical suites it was observed and shown to Staff A and Staff B that the surgical suites failed to have visual air pressurization monitoring devices to show the appropriate level of air pressurization from the surgical suite to the sterile core.

Based on observation and interview the facility failed to ensure the infection control officer had developed a system of identifying potential infection control issues in the kitchen area, in the surgical suite area, and in the implementation of policy and procedure in accordance with manufacturer's instruction for the use of disinfectant materials.

Findings include:

During the initial tour of the kitchen on 11/30/10 with Staff F it was observed that hand washing dispensers were placed throughout the kitchen and dish room. Staff F was asked if the kitchen staff uses these dispensers and what type of agent was inside the dispensers. Staff F stated that the dispensers had a foam agent that does not require water. Based on interview and observation the facility failed to ensure that waterless hand disinfectants were not used in food preparation areas.

During 12/1/10 tour of the surgical suites with Staff A and Staff B it was observed and shown to both Staff that two of the operating rooms ceiling lights were broken with large accumulations of dust particles in the areas where the pieces were missing. Operating room 1 had three light covers that were broken and operating room 3 had 1 light cover which was broken

AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non- perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suites on 12/1/10 with Staff A (Director of Surgical Services) it was observed that the facility failed to maintain an environment that provides ceiling materials that meet industry standards.

Findings include:

During tour of the surgical suite on 12/1/10 it was observed and shown to Staff A that the ceiling tiles located in the semi-restricted corridors between operating rooms 1 and 2 and in the semi-restricted corridor between operating rooms 3, 4, and 5 of the facility failed to be clipped down, also there were several tiles where the protective covering was ripped and torn.


AIA 3.9 Gastrointestinal Endoscopy Facilities
5.2.2.1 Floors. Floor finishes shall be appropriate for the areas in which they are located and shall be as follows:

(3) Floor finishes in areas such as procedure rooms and the decontamination room shall be scrubbable, capable of withstanding chemical cleaning and monolithic with an integral base.

Based on observation during tour of the Endoscopy suite on 12/1/10 with Staff A (Director of Surgical Services) it was found that the facility failed to have the proper floor covering.

Findings include:

During tour of the Endoscopy suite on 12/1/10 it was observed and shown to Staff A that all four procedure rooms and decontamination room failed to have the proper floor covering. None of the areas have monolithic floors with an integral base.

Review of organization's policy revealed the disinfectant Virex is used to disinfect surfaces in the operating room between surgical cases. Facility practice is that Virex is sprayed onto surface and left for one minute then wiped off. Manufacturer's recommendations state the product Virex should be left on the surface for 10 minutes prior to wiping off.

Interview on 12/1/10 of Staff B, Nurse Educator Surgical Services, confirmed the product Virex was sprayed on the surface to be cleaned and left 1 minute prior to wiping off.

AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities 2.1 General Hospitals 8.2 General Standards for Details and Finishes 8.2.3.4 Ceilings

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, non- perforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane into the semirestricted environment. Perforated, tegular, serrated, or highly textured tiles shall not be used.

Based on tour of the surgical suites on 12/1/10 with Staff A (Director of Surgical Services) it was observed that the facility failed to maintain an environment that provides ceiling materials that meet industry standards.

Findings include:


During tour of the surgical suite on 12/1/10 it was observed and shown to Staff A that the ceiling tiles located in the semi-restricted corridors between operating rooms 1 and 2 and in the semi-restricted corridor between operating rooms 3, 4, and 5 of the facility failed to be clipped down, also there were several tiles where the protective covering was ripped and torn.


AIA 3.9 Gastrointestinal Endoscopy Facilities
5.2.2.1 Floors. Floor finishes shall be appropriate for the areas in which they are located and shall be as follows:

(3) Floor finishes in areas such as procedure rooms and the decontamination room shall be scrubbable, capable of withstanding chemical cleaning and monolithic with an integral base.

Based on observation during tour of the Endoscopy suite on 12/1/10 with Staff A (Director of Surgical Services) it was found that the facility failed to have the proper floor covering.

Findings include:

During tour of the Endoscopy suite on 12/1/10 it was observed and shown to Staff A that all four procedure rooms and decontamination room failed to have the proper floor covering. None of the areas have monolithic floors with an integral base.


NFPA 101, 2000 edition *Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width.

"(A) It is not the intent that the required corridor width be maintained clear and unobstructed at all times. Projections into the required width are permitted by the exception to 7.3.2...it is recognized that wheeled items in use (such as food service carts, housekeeping carts, gurneys, beds and similar items) and wheeled crash carts not in use (because they need to be immediately accessible during a clinical emergency) are encountered in health care occupancy corridors. The health care occupancy's fire plan and training program should address the relocation of these items during a fire. Note that 'not in use' is not the same as 'in storage.'..."

Based on tour of the surgical suites on 12/1/10 with Staff A (Director of Surgical Services) and Staff B (Nurse Educator of Surgical Services) it was observed that the facility failed to maintain the sterile core free of obstruction.

Findings include:

During tour of the surgical suite's sterile core with Staff A and Staff B it was observed that the area failed to be free and clear of obstructions along with permanent fixtures. When touring the core it was observed that several permanent fixtures were located within this area along with multiple wheeled carts which are:

1) Refrigerator
2) Pyxis (medication dispensing device)
3) Two wall mounted storage cabinets
4) Multiple racks of storage materials
5) Multiple racks of storage materials on wheels, with such an amount of equipment the staff would not be able to relocate these items during a fire making them "in storage".

Based on policy review and interview the facility failed to utilize the disinfectant Virex according to manufacturer's recommendations.

Finding include:

Review of organization's policy revealed the disinfectant Virex is used to disinfect surfaces in the operating room between surgical cases. Facility practice is that Virex is sprayed onto surface and left for one minute then wiped off. Manufacturer's recommendations state the product Virex should be left on the surface for 10 minutes prior to wiping off.

Interview on 12/1/10 of Staff B, Nurse Educator Surgical Services, confirmed the product Virex was sprayed on the surface to be cleaned and left 1 minute prior to wiping off.

Based on record review and interview the facility failed to ensure a post-anesthesia evaluation was completed and documented no later than 48 hours after surgery on 2 outpatient surgical records in a standard survey sample of 12 surgical patients' charts. (Patient identifiers are #10 and #11.)

Findings include:

Review on 12/1/10 of Patient #10 and Patient #11's surgical records for procedures performed on 9/3/10 and 9/15/10 respectively revealed the day surgery outpatient post-anesthesia evaluation was not documented by anesthesia in the patients medical record. Interview of Staff A, Director of Surgical Services, confirmed the outpatient post anesthesia evaluation documentation was not in the patients medical record.

Based on interviews the hospital failed to ensure that the Swing Bed Program has a designated activities professional for the Swing Bed Activities Program. Based on record reviews and interviews the hospital failed to ensure that there is an ongoing program of activities to meet the interests and the physical, mental and psychosocial well-being of each patient. This is identified for 4 of 4 Swing Bed Program patients reviewed. (Patient identifiers are #49, #50, #51 and #52.)

Findings include:

On 11/30/10 at 11:10 a.m., during the initial tour of medical surgical units where swing bed services are provided to patients, an interview was conducted with Staff D,RN(Registered Nurse) Director of Critical Care Services who is responsible for overseeing the Swing Bed Program. Staff D was asked who the designated activities professional is and Staff D stated that there is no formally designated activities professional and that activities are a part of the nursing department.

On 12/3/10 Staff H, RN Director of Medical Surgical Services was interviewed about the activities program for Swing Bed Program patients. Staff H stated activities services come thru OT (Occupational Therapy) when they do their assessments. Staff H continued to explain that OT and PT (Physical Therepy) staff meet with the nursing staff to plan the daily schedule for physical care services for patients not patients' leisure time services and that the support staff from OT and PT help patients with physical care - showers and work with patients in the gym. Staff H said that Staff J, OT, and Staff K, PTA (Physical Therapy Assistant) provide these daily scheduled physical care services.

Staff H said a Therapeutic Recreation Specialist (TRS) consult can be requested but that it seldom is ordered because the length of stay of the swing bed patients is short. Staff L, RN, stated the TRS is used to provide TRS - evaluations and treatments on the rehabilitation unit. Staff H stated that the Swing Bed Program activities service is primarily driven by nursing. The nurses have magazines, puzzles and music to provide to the swing bed patients.

Swing Bed Patient #51.
On 12/3/10 during interviews about the Swing Bed Program activities services, Staff D, RN, said that the hospital had a swing bed patient (#51) during the year who was provided activities services. Review of the patient's form Swing Bed Admission Orders - Physician's Orders dated 7/3/10 shows that the MD checked the following consults: Dietary, Social Work, OT and PT. Review of this form shows that there is a box for the MD to check Recreational Therapy which is not checked and that there is no box/entry for Activities Services. Review of the medical record for the Swing Bed Program stay starting 7/3/10 shows that there is no activities program assessment by the OT at any time during the swing bed stay.

Review of this patient's medical record showed that the patient started receiving swing bed services on 7/3/10 and was discharged from the Swing Bed Hospital stay to a nursing facility on 10/7/10. Review of the medical record shows that on 8/31/10 the MD (Medical Doctor) gave a telephone order for the patient to receive a Recreation Therapy consult. Staff J, the Theraputic Recreation Specialist's evaluation dated 9/2/10 stated the patient had limited leisure interests and socialization, that when the patient is out of the hospital at home, the patient only leaves the house to go to the hospital and that the patient would benefit from Therapeutic Recreation interventions to increase activity level, endurance and quality of life. The TRS plan was to meet with the patient 2-3 times a week on a one-to-one basis.

Review of this patient's evaluation and progress notes shows that the TRS evaluation was completed on 9/2/10 and that follow-up recreation/activity service visits were made; 1. on 9/10/10 - 8 days after the evaluation, 2. on 9/20/10 - 10 days after the first treatment visit, 3. on 10/1/10 - 11 days after the second treatment visit, 4. on 10/4/10 - 3 days later and 5. on 10/7/10 the day of the patient's discharge - 3 days after the 10/4/10 visit.

This patient did not have an activities evaluation from 7/3/10 the day of status change from acute care to Swing Bed Program care until 9/2/10 and the TRS did not provide recreation/activity services after the 9/2/10 evaluation on the 2-3 times a week schedule planned for in the TRS evaluation.

Swing Bed Patient #52.
This active Swing Bed Program patient's medical record was reviewed on 11/30/10. Record review shows that the patient was acute care from 11/12/10 to 11/18/10 and review of the history and physical shows the patient was treated for pneumonia and a urinary tract infection. The record shows that on 11/18/10 the patient changed to a swing bed status for MD ordered Physical Therapy and Occupational Therapy services. Review of the medical record shows that this patient had no activity evaluation/assessment documentation and no documentation to show that there were activity services implemented for the patient during the Swing Bed Program stay.

This patient's medical record was reviewed again on 12/3/10 with Staff L, RN, and Staff L did not find any activity assessment or Therapeutic Recreation Specialist evaluation or treatment visit progress notes to show that the patient received activity services.

Swing Bed Patient #49.
This patient's discharge Swing Bed Program medical record review on 12/1/10 shows that the patient was in a Swing Bed Program status from 10/6/10 to 10/20/10. The record review shows that there is no activity assessment documented in the medical record by an OT or by an activity professional. Review of the nursing narrative notes from 10/6/10 to 10/20/10 shows no documentation of activity services being implemented for this patient by the nursing staff.

Rereview of the medical record on 12/3/10 with Staff L, RN for an evaluation completed by the TRS showed there was no activities evaluation done by the TRS for this patient.

Swing Bed Patient #50.
This patient's discharge Swing Bed Program medical record review on 12/1/10 shows that the patient was in a Swing Bed Program status from 9/24/10 to 10/3/10. The record review shows that there is no activity assessment documented in the medical record by an OT or by an activity professional.

Rereview of the medical record on 12/3/10 with Staff L, RN, for an evaluation completed by the TRS shows there was no activities evaluation done by the TRS for this patient.