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.

Based on interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members developed and implemented an individualized, ongoing activity program in accordance with interests identified in the resident's activities assessment for 2 of 3 long-term care ("swing bed") residents reviewed (Patients #1, #2).

Failure to develop and implement an individualized activities plan for long-term care residents risks impairment of physical, mental, and psychosocial well-being.

Findings included:

1. Review of the hospital's policy and procedure titled "Activities and Activity Program, SB," Policy # 95 approved 01/19, showed the hospital would provide for an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of each swing bed resident in accordance with their comprehensive assessment. A variety of activities would be offered to facilitate the resident's physical, social, and mental well-being.

2. Review of the medical records of three swing bed residents currently hospitalized under the hospital's long-term care "swing bed" program showed that a hospital staff member had performed an assessment of each resident's activity interests and developed activity plans. On 11/13/19 at 9:35 AM during an interview with the investigator, a staff nurse caring for Patients #1 and #2 (Staff #3) stated the residents had experienced a significant decline in health status and were currently on end-of-life care. The activity plans for these residents had not been revised to reflect their current needs.

3. On 11/13/19 at 1:50 PM during an interview with the investigator, the hospital's activities program director (Staff #4) stated that the hospital's activities coordinator (Staff #5) worked one day per week. The interview showed there were no structured activities on the days that the coordinator was not present.

4. On 11/14/19 at 8:10 AM during an interview with the investigator, the hospital's activities coordinator (Staff #5) confirmed there were no structured activities on the days she was not present. The coordinator stated she had not been trained to provide activities for residents with significantly limited abilities related to ongoing health problems.