HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to make only 25 inpatient beds available for use exclusive of the beds used for observational patients and obstetrical patients in labor or recovery after delivery of newborn infants.

Failure to identify beds to be used for inpatients creates the risk that the facility will exceed its capacity for patient care, which may result in poor patient outcomes due to inadequate care or poor resource allocation.

Findings included:

1. On 07/16/20 at 9:30 AM, Surveyor #3, accompanied by the hospital's Chief Nursing Officer (Staff Member #301), conducted a physical bed count to determine how many acute care patient beds were available for patient use in the hospital. The surveyor observed that the hospital had 27 beds set up for patient use: 13 in the medical-surgical unit, 6 in the intensive care unit, 2 in the in the obstetrical/nursery unit, and 6 in the observational/swing bed area.

2. On 07/16/20 at 10:30 AM, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the physical bed count just completed. Staff #301 stated that the hospital never exceeds their 25 inpatient bed limit. One of the beds in the intensive care unit is only used if a negative air pressure isolation is required. Similarly, one of the beds in the observation/swing bed area is only used if a behavioral health "safe" room is required. She acknowledged the rooms were setup except for bed linens being placed. Staff #301 stated the hospital's procedure was to "take down" another bed if those rooms are used.
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Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that hospital staff developed and implemented comprehensive care plans for long-term care ("swing bed") patients in accordance with the resident's comprehensive assessment for 2 of 5 records reviewed (Patient #301, #302) (Item #1), and provide evidence that an interdisciplinary team (which included the nursing staff) reviewed and revised the comprehensive care plan after each weekly update meeting for 2 of 5 records reviewed (Patient #303, #304) (Item #2).

Failure to develop and implement a comprehensive plan of care based on an assessment of the long-term care resident's needs risks deterioration of the resident's health and can result in inconsistent, delayed treatment, or adverse healthcare outcomes.

Findings included:

Item #1 - Comprehensive Care Plans

1. Document review of the hospital's policy and procedure titled "Care of Swing Bed Patient," no policy number, no approval date, showed that the plan of care for each Swing Bed patient will be individualized to each individual by a team comprised of a Hospitalist, Social Worker, Utilization Review, Physical Therapist, Activity Therapist, Dietician, Pharmacist and Director/Manager of Inpatient Services (or nursing designee). The care plan is the backbone of all care provided in the program and represents the patient's ongoing progress in relation to the physician's goals for treatment and each disciplines plan of care. The care plan must include measurable objectives and timetables to meet the patient's medical, nursing, rehabilitation, mental and psychosocial needs that are identified in the comprehensive assessment.

2. On 07/22/20 from 9:30 AM through 2:30 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) reviewed the medical records for five patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed the following:

a. Patient #301 was a 79 year-old patient who had been admitted to the hospital's swing bed program on 12/05/19 for physical deconditioning after suffering a fall resulting in a hip fracture. The patient's medical records showed the patient had multiple medical problems including diabetes, peripheral neuropathy, hypertension, and foot drop. According to the patient's discharge summary note dated 12/13/19, the patient had required an adjustment of his diabetic management to include insulin administration but had decline to continue this at home. Review of the patient's care plan showed the patient's diabetes had not been identified as a problem.

b. Patient #302 was 80 year-old patient who had been admitted to the hospital's swing bed program on 11/04/19 for rehabilitation following surgical repair of a hip fracture. The patient's medical records showed the patient had multiple medical problems including insulin dependent diabetes, hypertension, and chronic kidney disease. According to the patient's history and physical, the patient had uncontrolled diabetes during his inpatient hospitalization as a result of an incorrect medication reconciliation upon admission. The discharge summary note dated 11/09/19 showed that the patient was restarted on two injectable insulins during their Swing Bed admission, was placed on a carbohydrate controlled diet, and was seen by the hospital dietician regarding knowledge of the diabetic diet. Review of the patient's care plan showed that the patient's diabetes had not been identified as a problem.

3. On 07/22/20 between 1:00 PM and 2:30 PM during an interview with Surveyor #3, the Chief Nursing Officer (Staff #301) confirmed the hospital's care planning policy and procedure had not been followed for Patients #301 and #302.

Item #2 - Interdisciplinary Team Comprehensive Care Plan Reviews

1. Document review of the hospital's policy and procedure titled "Care of Swing Bed Patient," no policy number, no approval date, showed that the care and documentation of the patient will be evaluated on admission and every Wednesday thereafter to evaluate eligibility for discharge or transfer. The care plan is the backbone of all care provided in the program and represents the patient's ongoing progress in relation to the physician's goals for treatment and each disciplines' plan of care.

Document review of the hospital medical record titled, "Interdisciplinary Team Record," showed that the form is used to document which hospital services attended the meeting and their respective individual discipline's concerns for the patient, goals for the patient, and plan for the patient.

2. On 07/22/20 from 9:30 AM through 2:30 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) reviewed the medical records for five patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed the following:

a. Patient #303 was admitted to the hospital's swing bed program on 03/04/20 and discharged on 03/20/20. A review of the hospital document titled, "Interdisciplinary Team Record" dated 03/18/20 showed the Wednesday Swing Bed meeting for the patient was attended by Physical Therapy, Occupational Therapy, and the attending Hospitalist with their concerns, goals, and plan. The surveyor could find no evidence that Nursing Services documented their attendance or concerns, goals, or plans during this comprehensive care plan update review.

b. Patient #304, was admitted to the hospital's swing bed program 03/20/20 and discharged on 04/05/20. A review of the hospital document titled, "Interdisciplinary Team Record" dated 03/25/20 showed the Wednesday Swing Bed meeting for the patient was attended by Physical Therapy, Occupational Therapy, Pharmacy, and the attending Hospitalist with their concerns, goals, and plan. The surveyor could find no evidence that Nursing Services documented their attendance or concerns, goals, or plans during this comprehensive care plan update review. Similar findings (no nursing services documentation) were found on the "Interdisciplinary Team Record" dated 04/01/20.

3. On 07/22/20 between 1:00 PM and 2:30 PM, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the weekly Wednesday Swing Bed meeting. Staff #301 stated that this meeting is led by the nursing staff but they had failed to document their attendance or concerns on the "Interdisciplinary Team Record as required.