The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CASS LAKE INDIAN HEALTH SERVICES HOSPITAL 425 7TH STREET NW CASS LAKE, MN 56633 Nov. 17, 2016
VIOLATION: COMP ASSESSMENT, CARE PLAN & DISCHARGE Tag No: C1620
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and staff interview, the facility failed to ensure an initial comprehensive assessment completed within the first 14 day after admission to the facility for 1 of 2 sampled swing bed patients (P21). The failure to complete and initial comprehensive assessment had the potential to provide inadequate patient care that would affect the patient's physical, mental and psychosocial well-being.

Findings include:

P 21's medical record review revealed an admission on 1/15/16 with diagnosis of an infected diabetic foot ulcer and required long term intravenous (IV) therapy. P 21 was discharged on [DATE], after 21 days as a resident of the facility. Medical record review lacked documented evidence that a comprehensive assessment that included the residents functional capacity to develop a plan of care to provide the appropriate care/services based on the P 21status.

An interview on 11/15/16 at 11:00 a.m. with the Director of Nursing (DON) confirmed that P21's medical record lacked documentation of the initial comprehensive assessment required for the swing bed patients.

The facility had a " Swing Bed - Resident Assessments " policy dated: April 1, 2004 and revised: 8/4/16 that documented: " II/ Policy: All swing bed patients will receive a comprehensive assessment to gain the information necessary to develop a care plan and develop the appropriate care/services based on the resident ' s status. After the initial care plan is developed the patient will receive ongoing assessments for further evaluation of care. "

The policy section " III. Procedure: A. The assessment must include the following: " The assessment process will include: 1. Direct observation and communication with the resident, and 2. Communication with licensed and non-licensed direct care staff members on all shifts. " The policy lacked a time frame for completion of the assessment, only that " All swing bed patients " will have one.
VIOLATION: SPECIAL REQUIREMENTS FOR CAH PROVIDERS LTC Tag No: C1600
Based on staff interview, policy review and medical record review, the Condition of Participation for Swing-Bed was not met because the facility: 1)failed to follow the facility abuse policy that required staff to be trained/educated in the recognition/prevention of patient abuse; 2) failed to appoint a qualified activity director for the swing bed program; 3) failed to complete an initial comprehensive assessment for patients admitted to the swing bed program; and 4) failed to complete a discharge summary that recapitulated the patients swing bed stay.

Findings include:

1. The facility failed to follow the facility abuse policy that required staff to be trained/educated in the prevention of patient abuse. Refer to C0383.

2. The facility failed to appoint a qualified activity director for the facility's swing bed activity program. Refer to C0385.

3. The facility failed to complete an initial comprehensive assessment for patients admitted to the swing bed program. Refer to C0388.

4. The facility had failed to complete a Discharge Summary that recapitulated the swing bed stay. Refer to C0399.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, staff interview, and review of the policies and procedures, the facility failed to follow the policy and "Infection Control (IC) Plan" to ensure the facility developed a system for identifying, reporting, investigating, and controlling infections for 2 patients (P9 and P18) of 22 sampled inpatients. Failure to develop an active infection control program that identified, reported, and investigated to control infections within the facility had the potential to expose all 22 sampled inpatients admitted to the facility.

Findings include:

Review of a closed medical record for Patient (P) 9 revealed an admission date of [DATE] with a diagnosis of acute urinary tract infection (UTI) and was discharged on [DATE]. The physician noted in the "DISCHARGE SUMMARY" under the "HOSPITAL COURSE" that P9 was hospitalized for intravenous (IV) antibiotic therapy for a pseudomonas aeruginosa (a common Gram-negative bacterium that causes disease and is multi drug resistant) UTI. The physician also noted P9 was treated with Meropenem (an ultra-broad-spectrum injectable antibiotic used to treat a wide variety of infections) every 8 hours.

Review of the medical record for P18 revealed an admission date of [DATE] with a diagnosis of cellulitis (a bacterial infection of the inner layers of the skin) of the right arm. Review of the "DISCHARGE SUMMARY" dated 8/16/16 revealed the patient was admitted with swelling, redness, pain, and purulent (caused by pus) drainage and was treated with Bactrim (an antibiotic) as an outpatient prior to the admission. The physician, at admission, noted the patient was started on IV Clindamycin (an antibiotic). The wound culture results grew Methicillin-resistant Staphylococcus aureus (MRSA) (a bacterium that causes infections in different parts of the body resistant to some antibiotics) that was sensitive to the antibiotic Clindamycin. The physician noted P18 left the facility on the evening of 8/16/16 against medical advice (AMA), but agreed to come to "URGENT CARE" the next morning to pick up an antibiotic prescription.

Review of the Infection Control (IC) meeting minutes revealed that between 11/1/15 to 11/1/16 the facility lacked documentation of P9's UTI infection and the antibiotic treatment and the MRSA infection, antibiotic treatment and follow up for P18 after the patient left the facility AMA on 8/16/16. The minutes also lacked documentation of a facility wide surveillance IC program.

Interview on 11/17/16 at 9:15 a.m., confirmed the Director of Nursing (DON) was the facility designee for the IC program. The DON verified the IC minutes lacked documentation and failed to identify, report, and investigate P9's UTI infection and P18's MRSA infection. The DON also confirmed the facility had not had an active IC surveillance program since 11/25/15 which included identification and data reports of patients with infections, staff/patient hand hygiene data, laboratory data, pharmacy data, radiology data, housekeeping/linen data, and food service data reports.

Review of the policy titled, "Infection Control Program: Role and Scope", ICM 00, Effective date: 11/1/03, Revision/Reviewed Date: 7/27/16, provided the following information,
"I. Description of Program, The ...program of Infection Control ...are assigned to a registered Nurse on staff ...II. Goals, The goals of the program are: a. To provide epidemiologic activity consisting of surveillance, risk assessment ...and data management, analysis and presentation. b. To provide direct interventions at the patient, location, and service level where they are needed ...IV. Scope and Complexity of Patient/Customer Needs and Services; Patients of all ages and medical/surgical specialties are included in infection control surveillance activities. Comprehensive isolation policies are utilized which address all common communicable diseases and whose intent is to reduce spread of these conditions ...V. For identification of problems and timely interventions, a review of the microbiology reports is done on a daily basis. IC investigates verbal and written incident reports of potential infection control problems... VI. The spread of infectious agents between patients or between HCW's (health care workers) and patients can result in serious negative outcomes and/or outbreaks ....V11. Effectiveness and Services ...Regular reports to the Executive Team Meeting through the Chief Executive Officer and the Medical Staff serve to communicate infection control progress in area of concern identified within the Service Unit ..."
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on document review, staff interview, and policy and procedure review, the facility failed to meet the Condition of Participation (CoP) for Quality Assurance when they failed to ensure: 1) The Performance Improvement Plan was implemented and actively evaluated for the quality and appropriateness of the diagnosis and treatment furnished and the patients treatment outcomes; 2) The Performance Improvement Plan was implemented and actively evaluated all patient services and other services affecting patient health and safety; 3 The Performance Improvement Plan was implemented and actively evaluate nosocomial infections (hospital acquired infections) and medication therapy; 4. The facility failed to have a contract with an external entity to evaluate the care provided to patients by the facility physicians.

Findings include:

1. The facility failed to ensure the Performance Improvement Plan was implemented and actively evaluated for the quality and appropriateness of the diagnosis and treatment furnished and the patients treatment outcomes. Refer to C0336

2 The facility failed to ensure the Performance Improvement Plan was implemented and actively evaluated all patient services and other services affecting patient health and safety. Refer to CO337

3. The facility failed to ensure the Performance Improvement Plan was implemented and actively evaluate nosocomial infections (hospital acquired infections) and medication therapy. Refer to C0338

4. The facility failed to have a contract with an external entity to evaluate the care provided to patients by the facility physicians. Refer to CO340
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and review of the policies and procedures, the facility failed to ensure the Performance Improvement Plan was implemented and actively evaluated for the quality and appropriateness of the diagnosis and treatment furnished and the treatment outcomes for 2 patients (P) of 22 sampled patients identified with infections (P9 and P18). The failure to evaluate the diagnosis and treatment had the potential to miss opportunities for controlling the spread of diseases/infections and improving patient care for all 22 patients admitted to the facility.

Findings include:

Review of the closed medical record for P9 revealed an admission date of [DATE] with a diagnosis of acute urinary tract infection (UTI) and was discharged on [DATE]. P9 was admitted and treated for a Pseudomonas Aeruginosa (a common Gram-negative bacterium that causes disease and is multi drug resistant) UTI and ordered Meropenem (an ultra-broad-spectrum injectable antibiotic used to treat a wide variety of infections) every 8 hours (an intravenous [IV] antibiotic therapy).

Review of the medical record for P18 revealed an admission date of [DATE] with a diagnosis of cellulitis (a bacterial infection of the inner layers of the skin) of the right arm. Review of the physician's "Discharge Summary" dated 8/16/16 revealed the patient admitted with swelling, redness, pain and purulent (caused by pus) drainage and was treated with Bactrim (an antibiotic) as an outpatient prior to the admission. At admission the patient was ordered IV Clindamycin (an antibiotic) and a wound culture. The wound culture result was Methicillin-resistant Staphylococcus aureus (MRSA-a bacterium that causes infections in different parts of the body resistant to some antibiotics) that was sensitive to the antibiotic Clindamycin. P18 left the facility on the evening of 8/16/16 against medical advice (AMA).

Review of the "Infection Control (IC) Meeting Minutes" revealed between 11/1/15 to 11/1/16 the facility lacked documentation of P9's UTI infection and antibiotic treatment and P18's MRSA infection, antibiotic treatment and follow up after leaving the facility AMA.

Review of the "Executive Team Meetings Minutes" dated from 1/14/16 to 10/30/16 lacked data or an evaluation of P9's and P18's diagnoses and treatment for their identified infections.

During an interview on 11/17/16 at 9:15 a.m., the Director of Nursing (DON) confirmed the facility failed to gather data on the diagnosis and treatment of P9 and P18 and present it to the Executive Meeting as directed in the Performance Improvement Plan. Further interview at this time with the DON verified the facility had not reported any Performance Improvement data to the Executive Team since 11/15.

An interview on 11/16/18 at 1:20 p.m. confirmed the Clinical Manager (CM) was the facility Performance Improvement (PI) designee and was in charge of the program. The CM verified, during this interview, that the PI committee had not reported to the Executive Committee since 11/15. The CM confirmed the "Performance Improvement Plan" dated 1/9/15 was not signed or approved by the required personnel or the Governing Body representative.

Review of the unsigned policy "Performance Improvement Plan, PID-001," Effective date: 1/15/09, Revision: Date 1/9/15, provided the following information;
" ...Responsibility: The leaders-Executive Team and Governing Board set priorities for the Performance Improvement, ...including staff time required to measure, assess and improve the organizations performance ...The ...Coordinator is responsible for the ongoing appraisal of the implementation of the ... Plan, to meet regulatory requirements, and for reporting ...data to Executive Team collected through departmental and organization wide ...activities ... Documentation: All committees, performance Improvement Teams and departments shall maintain records of performance improvement efforts. At minimum the evaluation of effectiveness of actions is documented and presented to the Performance Improvement Department ...6. Rescission: PID-001 This Policy and Procedure was Reviewed and Approved by the Follwing[sic]:1. Performance Improvement ...2. Director of Nursing ...3. Medical Director ...4. Chief Executive Officer ...5. Governing Board Representative ...."
VIOLATION: QUALITY ASSURANCE Tag No: C0337
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, staff interview, and review of the policies and procedures, the facility failed to ensure the Performance Improvement Plan was implemented and actively evaluated for all patient and other services affecting patient health and safety for 2 of 22 patients (P's 9 and 18). The failure to implement the plan and actively evaluate all patients and services affecting patient health and safety had the potential for missed opportunities to improve patient care and ensure patient safety for all 22 patients admitted to the facility.

Findings include:
Review of the closed medical record for P9 revealed an admission date of [DATE] with a diagnosis of acute urinary tract infection (UTI) and identified treatment with antibiotic therapy. There was no documented evidence of a current nursing care plan with interventions for treatment of the UTI within 24 hours of admission.

Review of the closed medical record for P18 revealed an admission date of [DATE] with a diagnosis of cellulitis (a bacterial infection of the inner layers of the skin) of the right arm. The wound culture results identified Methicillin-resistant Staphylococcus aureus (MRSA-a bacterium that causes infections in different parts of the body resistant to some antibiotics) and was treated with IV (intravenous) Clindamycin antibiotic therapy.

Review of the "Executive Team Meetings Minutes" on 11/16/16 at 1:20 p.m. dated from 1/14/16 to 10/30/16 lacked data/reports submitted to the Performance Improvement Program from patient care services that included Laboratory reports of the cultures that identified the infections and the Pharmacy report for antibiotic therapy for P9 and P18.

During an interview, on 11/17/16 at 9:15 a.m., the Director of Nursing (DON) confirmed the facility failed to gather data and report the infections identified and the pharmacy treated with antibiotic therapy for P9 and P18. Further interview, at this time, with the DON verified the facility had not reported any Performance Improvement (PI) data to the Executive Team since a year ago in November, 2015.

An interview on 11/16/16 at 1:20 p.m. confirmed the Clinical Manager (CM) was the facility PI designee and was in charge of the program. The CM verified, during this interview, that the PI committee had not reported to the Executive Committee since a year ago in November, 2015. The CM confirmed the "Performance Improvement Plan" dated 1/9/15 was not signed or approved by the required personnel or the Governing Body representative.

Review on 11/16/16 of the facility's unsigned policy titled "Performance Improvement Plan, PID-001," Effective date: 1/15/09, Revision: Date 1/9/15, provided the following information;
" ...Responsibility: The leaders-Executive Team and Governing Board set priorities for the Performance Improvement, ...including staff time required to measure, assess and improve the organizations performance ...The ...Coordinator is responsible for the ongoing appraisal of the implementation of the ... Plan, to meet regulatory requirements, and for reporting ...data to Executive Team collected through departmental and organization wide ...activities ... Documentation: All committees, performance Improvement Teams and departments shall maintain records of performance improvement efforts. At minimum the evaluation of effectiveness of actions is documented and presented to the Performance Improvement Department ...6. Rescission: PID-001 This Policy and Procedure was Reviewed and Approved by the Follwing[sic]:1. Performance Improvement ...2. Director of Nursing ...3. Medical Director ...4. Chief Executive Officer ...5. Governing Board Representative ...."
VIOLATION: QA - MEDS & INFECTIONS Tag No: C0338
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review, staff interview, and review of the policies and procedures, the facility failed to ensure the Performance Improvement Plan was implemented and actively evaluated nosocomial infections (hospital acquired infections) and medication therapy for 2 patients (P) of 22 sampled patients (P9 and P18). The failure to evaluate nosocomial infections and medication therapy had the potential to miss reporting hospital acquired infections and prevent the potential spread of diseases/infections and improve patient care for all 22 patients admitted to the facility.

Findings include:

Review of the closed medical record for Patient (P) 9 revealed an admission date of [DATE] with a diagnosis of acute urinary tract infection (UTI). P9's infection was identified as Pseudomonas Aeruginosa (a common Gram-negative bacterium that causes disease and is multi drug resistant) UTI and ordered Meropenem (an ultra-broad-spectrum injectable antibiotic used to treat a wide variety of infections) every 8 hours (an intravenous [IV] antibiotic therapy).

Review of the closed medical record for P18 revealed an admission date of [DATE] with a diagnosis of cellulitis (a bacterial infection of the inner layers of the skin) of the right arm. A wound culture was obtained and the laboratory reported the culture result was Methicillin-resistant Staphylococcus aureus (MRSA) (a bacterium that causes infections in different parts of the body resistant to some antibiotics) that was treated with IV Clindamycin (an antibiotic therapy).

Review of the "Infection Control (IC) Meeting Minutes" on 11/16/16 at 2:15 p.m. dated from 11/1/15 to 11/1/16 revealed the facility lacked documentation of nosocomial infections (hospital acquired infections) and medication therapy. The IC program lacked documentation of an investigation and the findings for P9's UTI infection and antibiotic treatment and P18's MRSA infection, antibiotic treatment.

Review of the "Executive Team Meetings Minutes" on 11/16/16 at 1:20 p.m. dated from 1/14/16 to 10/30/16 lacked data, evaluation, investigation, and medication therapy for identified infections for P9 and P18.

During an interview, on 11/17/16 at 9:15 a.m., the Director of Nursing (DON) confirmed the facility failed to evaluate P9's and P18's identified source of infection and medication therapy to rule out the possibility of a nosocomial infection and present the finding to the Executive Meeting as directed in the Performance Improvement Plan. Further interview at this time with the DON verified the facility had not reported any Performance Improvement data to the Executive Team since 11/15.

An interview on 11/16/16 at 1:20 p.m. confirmed the Clinical Manager (CM) was the facility Performance Improvement (PI) designee and was in charge of the program. The CM verified, during this interview, that the PI committee had not reported to the Executive Committee since 11/15. The CM confirmed the "Performance Improvement Plan" dated 1/9/15 was not signed or approved by the required personnel or the Governing Body representative.

Review on 11/16/16 of the unsigned policy "Performance Improvement Plan, PID-001," Effective date: 1/15/09, Revision: Date 1/9/15, provided the following information;
" ...Responsibility: The leaders-Executive Team and Governing Board set priorities for the Performance Improvement, ...including staff time required to measure, assess and improve the organizations performance ...The ...Coordinator is responsible for the ongoing appraisal of the implementation of the ... Plan, to meet regulatory requirements, and for reporting ...data to Executive Team collected through departmental and organization wide ...activities ... Documentation: All committees, performance Improvement Teams and departments shall maintain records of performance improvement efforts. At minimum the evaluation of effectiveness of actions is documented and presented to the Performance Improvement Department ...6. Rescission: PID-001 This Policy and Procedure was Reviewed and Approved by the Follwing[sic]:1. Performance Improvement ...2. Director of Nursing ...3. Medical Director ...4. Chief Executive Officer ...5. Governing Board Representative ...."
VIOLATION: QUALITY ASSURANCE Tag No: C0340
Based on staff interview and facility documentation, the facility failed to ensure there was a contract with an external entity to evaluate the care provided to patients by the facility physicians for 3 of 3 physicians reviewed (MD3, MD4, and MD5). The failure to contract with an external entity to evaluate the patient care the physicians provided had the potential to miss opportunities for improved patient care for 22 admitted patients.

Findings include:

On 11/16 16 at 3:45 p.m. the Clinical Manager provided the contracted "Rural Wisconsin Health Cooperative (RWHC)" dated; 5/31/12 for the facility's professional peer review of the medical staff. Interview at this time with the Clinical Manager verified the facility no longer had a contract to complete the physician peer reviews and confirmed the facility lacked documentation of a peer review for the years that included 2012, 2013, 2014, 2015 and the current year 2016.

An interview on 11/16/16 at 3:45 p.m. with the Health Information Management Director confirmed the facility lacked documentation related to an annual external peer review for the facility physicians.
VIOLATION: PATIENT ACTIVITIES (483.15(F)) Tag No: C0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, record review, and policy review, the facility failed to ensure the Activity program director was qualified and completed a comprehensive assessment/plan of care that included the residents ' interests and physical, mental and psychosocial well-being for 2 of 2 residents in swing beds (P21 and P22).The failure to have a qualified activity director and ensure they completed a comprehensive assessment for residents had the potential to provide inadequate resident care that included their physical, mental and psychosocial well-being.

Findings include:

P 21's medical record review revealed an admission on 1/15/16 with diagnosis of an infected diabetic foot ulcer and was discharged on [DATE], after 21 days as a resident of the facility. The medical record lacked evidence of a comprehensive assessment/plan of care that included P 21's physical, mental and psychosocial well-being.

P22's medical record review revealed an admission on 6/8/16 with a diagnosis of bacteremia (an infection) and thoracic epidural abscess (an infection of the spine). P 22 was in the facility for 20 days and discharged on [DATE].The medical record lacked evidence of a comprehensive assessment/plan of care that included P 22's physical, mental and psycohosocial well-being.

In an interview on 11/15/16 at 11:00 a.m. the Director of Nursing (DON) stated the facility failed to designate a qualified activity person for developing activity programs for swing bed patients.

Review of " Swing Bed - Activity Policy " with an effective date 12/30/03, Revision/Review date of 8/4/16 indicated:
" II. Policy: An ongoing program of activities, designed in accordance with the comprehensive assessment, will be provided for swing bed patients. These activities will meet the interests and the physical, mental, psychosocial well-being of each resident. " The policy further documented at " III. Procedure: A. Patients admitted to swing bed will receive comprehensive Swing Bed Activities Assessment by a qualified professional in accordance with CMS/CAH standards. 1. In a CAH the services may be directed either by a qualified professional meeting the requirements at 483.15(f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy. "
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
HRJZL

Based on observation, record review, and interview, the facility failed to demonstrate compliance with the requirements found at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101 - 2012 edition during the the survey conducted November 14 to 16, 2016. Please refer to the citations at C231.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
HRJZL

Based on observation, record review, and interview, the facility failed to demonstrate compliance with the requirements of the National Fire Protection Association (NFPA) standard 101 - 2012 edition.

Please refer to the K-tags cited during the survey conducted November 14 to 16, 2016.
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0960
Based on staff interview, record review, policy and procedure reviews, Swing Bed program review, Governing body Bylaws, and Medical Staff Bylaws the facility failed to meet the Condition of Participation (CoP) for Organizational Structure when they failed to ensure: 1) the governing body or an individual that assumes full legal responsibility failed to determine, implement and monitor policies governing the total operation and ensure that those policies are administered to provide quality health care in a safe environment; 2) failed to meet the Condition of Participation (CoP) for Quality Assurance when they failed to ensure the Performance Improvement Plan was implemented and actively evaluated for the quality and appropriateness of the diagnosis and treatment furnished and the patients treatment outcomes; evaluated all patient services and other services affecting patient health and safety; evaluated nosocomial infections (hospital acquired infections) and medication therapy; and maintained a contract with an external entity to evaluate the care provided to patients by the facility physicians. 3) failed to meet the Condition of Participation (CoP) for Special Requirements for CAH (Critical Access Hospital) Providers for Long-Term Care Services ("Swing-Beds). "

Findings include:

1) The facility failed to ensure the governing body or an individual that assumes full legal responsibility failed to determine, implement and monitor policies governing the total operation and ensure that those policies are administered to provide quality health care in a safe environment.

2) The facility failed to meet the Condition of Participation (CoP) for Quality Assurance when they failed to ensure the Performance Improvement Plan was implemented and actively evaluated for the quality and appropriateness of the diagnosis and treatment furnished and the patients treatment outcomes; evaluated all patient services and other services affecting patient health and safety; evaluated nosocomial infections (hospital acquired infections) and medication therapy; and maintained a contract with an external entity to evaluate the care provided to patients by the facility physicians. Refer to CoP C0330.

3) The facility failed to meet the Condition of Participation (CoP) for Special Requirements for CAH (Critical Access Hospital) Providers for Long-Term Care Services ("Swing-Beds"). Refer to CoP at C0350.
VIOLATION: GOVERNING BODY OR RESPONSIBLE INDIVIDUAL Tag No: C0962
Based on staff interview, review of the policies, and Governing Body bylaws, the facility failed to ensure there was an effective governing body or an individual that assumes full legal responsibility to determine, implement and monitor policies governing the total operation and ensure that those policies are administered to provide quality health care in a safe environment. The facility's failure to ensure the governing body monitored, reviewed and approved the hospital policies and procedures to provide quality health care in a safe environment had the potential to affect 22 sampled patients (P1 - P22) admitted to the facility.

Findings include:

Review on 11/15/16 of the facility policy and procedure manuals for Pharmacy, Nursing (volumes 1 and 2), Radiology, Inpatient Admissions, and Laboratory revealed the governing body failed to sign or date the facilities policy manuals.

An interview with the clinic manager on 11/14/16 at 10:45 a.m. confirmed the last governing body meeting was held on 12/4/15. The clinic manager verified the facility lacked documentation the governing body met in 2016 to approve, sign, and date the departmental policy manuals.

In an interview on 11/17/16 at 9:00 a.m., the Director of Nursing (DON) confirmed the governing body or designee had failed to sign and date in order to approve the facility's policy and procedure manuals.

Review of the Governing Body Bylaws under, " Section III Regular/Special Meetings of the Governing Board " revealed the board would meet " at least thrice during the calendar year for the purpose of regular and special presentation and consultation. "
VIOLATION: NURSING SERVICES Tag No: C1050
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, and review of the policies and procedures, the facility failed to follow the policy and procedure to ensure a nursing plan of care was developed and kept current for 1 patient (P9) of 22 sampled inpatients. Failure to develop a nursing care plan had the potential for provision of inadequate nursing care with interventions for the 22 patients admitted to the facility.

Findings include:

Review of the closed medical record for P9 revealed an admission date of [DATE] at 12:50 p.m. with a diagnosis of acute urinary tract infection (UTI) and was discharged 2 days later on 3/6/16. Review of the EHR (electronic health record) revealed the Registered Nurse (RN) 11 had completed and electronically signed the admission care plan on 3/6/16 at 6:17 a.m.

During an interview, on 11/15/16 at 11:20 a.m.., RN 12 verified the nursing care plan policy required the plan to be completed within 24 hours of admission. RN12 confirmed P9's care plan was not completed in the EHR until RN11 signed the plan at 6:17 a.m. on 3/6/16. RN12 confirmed when an RN initiated a care plan and failed to electronically sign the plan, no other nurse would be able to view and read the patient's plan of care or the interventions in the EHR system.

Review of "Inpatient Admission Data Information Sheet: NURSING", Effective date; 6/04, Revision/Review Date: 8/1/16, provided the following information:
"I. Purpose ...D. To identify and prioritize the appropriate nursing diagnosis(es) which provide the focus for the development of the patient's plan of care. ...II. Policy: ...B. Initial EHR (electronic health record) using the nurse admission data template. The documentation will be completed: 1) Within 24 hours of admission to the hospital.