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Based on review of facility policy, observation and staff interview (EMP), it was determined the facility failed to ensure emergency cart checks were performed and documented as per facility policy.

Findings include:

Review on March 24, 2015, of the facility policy "Shift Equipment Checks," last reviewed March 2014, revealed "Policy: It is the policy of Memorial Hospital to ascertain by documentation that all equipment, medications, and supplies are in their appropriate place and functioning properly. It is the RN's responsibility on each shift to determine that all assigned listed items are checked at the beginning of their tour of duty, assuring them that all is where it should be and in operative order. ... Procedure/Protocol Adult and Pediatric Crash Cart: Top of cart is checked for electrodes, defibrillator paper and pads. ... After crash cart is resupplied a new lock is applied and remains locked until next use or next monthly check. ... Defibrillator: Tested according to manufacturer's directions. Paddles are to be kept clean. Crisis sheet clipboard attached to cart. The defibrillator is checked every shift, plugged into an outlet and unplugged. ... Evaluation/Documentation: Documentation will be found on the signature page of each shift check. ..."

Review of sheet identified by EMP1 as the "Shift Check Sheet," no review date, revealed a space for the date, shift, cart lock number and signature.

Interview with EMP1 at approximately 11:00 AM on March 25, 2015, confirmed the "Shift Check Sheet" was the documentation form used to document the crash cart checks completed every shift.

Observation at 11:00 AM on March 24, 2015, of the Cardiology Pulmonary Testing area revealed an emergency crash cart. Further observation revealed no "Shift Check Sheet," documenting the dates, time and signature of the person checking the crash cart. A clipboard on the cart contained a "Crash Cart Data Collection Tool" dated January 5, 2014.

Interview with EMP 10 at 11:00 AM on March 24, 2015, confirmed there was no "Shift Check Sheet" on the crash cart. EMP10 revealed the "Crash Cart Data Collection Tool" was completed by the pharmacy.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure ceiling vents were clean in patient care areas; failed to ensure outside door area was free of spider webs, dirt, and dust; and failed to ensure preventive maintenance checks were completed.

Findings include:

1) Review on March 23, 2015, of the facility's "Cleaning Procedures for Housekeeping Personnel" policy, last reviewed and revised January 24, 2013, revealed "Policy: Room Cleaning 10-Step Cleaning Process It's the policy of Memorial Hospital that all units follow these directions when cleaning patient rooms (Acute care), in Skilled Nursing and Personal Care Home. Procedure: The procedures for the 10 step cleaning process are to be performed in this order where possible and should be localized to site to ensure maximum performance. ... 3. Begin High Dusting a. Begin with high dusting above eye level, ensuring that extreme care is taken with air ducts and sprinkler heads in resident room and restroom. b. Continue with high dusting, ensuring that the top of picture frames, light fixtures, and televisions are addressed. 1. Never high dust over a resident. 2. If a resident is in their room, thoroughly high dust after the resident has been discharged or leaves the room for an activity. ..."

Observation on March 23, 2015, of patient rooms 105, 106, 114, 117 and 119 on the medical surgical patient care unit revealed ceiling air ducts positioned above each patient bed. Further observation revealed gray colored dust on each of these air ducts. The gray dust extended approximately 24 inches around the air duct.

Interview with EMP1, EMP4 and EMP8 on March 23, 2015, at approximately 2:00 PM confirmed the gray colored dust extending approximately 24 inches around the air ducts in patient rooms 105, 106, 114, 117 and 119.

Review on March 23, 2015, of the facility's "Air Filter Policy," last revised April 2008, revealed "It is the policy of Memorial Hospital Inc. to change the air filters in all air handling units, when the resistance to air flow increases to two times the resistance when the filters are installed. Air resistance is measured on manometers installed in each unit, and are read daily and recorded on the rounds sheet. Air filters in the vents are checked quarterly as part of the preventive maintenance program and cleaned as necessary."

A request was made of EMP5 for the logs reflecting the changing of the air filters and the preventive maintenance program check list. None was provided.

2) Review on March 23, 2015, of the facility's "Safety Program," last reviewed March 2014, revealed "... Objective: The objective of the Safety Program is to assure that the staffing, equipping, operating, and maintenance of the Hospital will adequately conform to safe practices and conditions as outlined by the JCAHO, applicable state and federal regulations in order that the facility is functionally safe and sanitary for patients, hospital staff, and visitors. This will be accomplished through the development of safe practice guidelines, promotion of general safety awareness in all employees, detection of unsafe practices or conditions, and appropriate correction of the situations. ..."

Observation tour on March 24, 2015, of the facility's outpatient physical therapy entrance revealed four lights with a thick accumulation of spider webs, dirt and dust covering these lights.

Interview with EMP1 on March 24, 2015, at approximately 9:15 AM confirmed the outpatient physical therapy entrance lights with a thick accumulation of spider webs, dirt and dust covering these lights.

3) Interview on March 24, 2015, at approximately 9:30 AM with EMP11 revealed the facility has no policy and procedure for completing and reporting preventive maintenance.

Review on March 24, 2015 at approximately 9:15 AM of the routine preventive maintenance (PM) for equipment revealed the following: In April 2014, there was no documentation of PMs for six air handlers. In November of 2014 in Same Day Surgery, there was no documentation of PMs for the medical gas alarms and the ultraviolet (UV) lights. In the Critical Care Unit, there was no documentation of PMs for the medical gas alarms, door alarms, and UV lights. In the Emergency Room, there was no documentation of PMs for the medical gas alarms, housekeeping vacuum, and UV lights. In Radiology, there was no documentation of PMs for the medical gas alarms and UV lights. In the Medical-Surgical Unit, there was no documentation of PMs for the medical gas alarms and the UV lights. On the roof top equipment, there was no documentation of PMs on the exhaust fans in 33 areas. In Dietary, there was no documentation of PMs for five doors, the walk-in cooler, the walk-in freezer, the oven, two slicers, two fryers, two plate warmers, the hot food cart, two steam tables, the dishwasher, the booster heater, and two exhaust fans. In the Laboratory, there was no documentation of PMs for the morgue cooler, the blood bank cooler and freezer. In Pharmacy, there was no documentation of PMs for the exit door alarm, a cooler, a freezer, and the narcotic door alarm. In Purchasing, there was no documentation of PMs on the door alarm, the offices and two store rooms.

Interview on March 24, 2015 at approximately 9:30 AM with EMP3, EMP11, and EMP12 confirmed the preventive maintenance schedules for April 2014 and November 2014 were not completed.

Based on review of facility documents, medical records (MR), observation and staff interview (EMP), it was determined the facility failed to ensure intravenous (IV) bags and tubing were used for only one patient; the facility failed to address the recurrence of drain flies on the medical surgical patient care unit and throughout the facility; the facility failed to maintain a sanitary environment in the Dietary Department; the facility failed to maintain a sanitary environment in the Laboratory Department; the facility failed to ensure laboratory staff secure their laboratory coats in a way to prevent contamination of clothing; the facility failed to ensure the glucose testing meter was cleaned after each patient use; and the facility failed to ensure multidose vials were marked with the date opened.

Findings include:

1) Review on March 24, 2015, of facility policy "Injection of IV Contrast with the Med Rad Injector," last reviewed September 26, 2014, revealed "Policy: It is the policy of Memorial Hospital that before the use of the Med Rad Injector the CT [computerized tomography] or MRI [magnetic resonance imaging] Tech be trained on the use and purpose of the injector's buttons. Purpose: To obtain safe operations of the Med Rad Injector. ... Procedure/Protocol: 1. Review the IV contrast questionnaire with the patient. 2. Pick the correct protocol on the Med Rad Injector and the correct amount of contrast. 3. Draw up the contrast. 4. Hook up the Med Rad syringe to the IV site. 5. When ready for the contrast, start injecting by pushing the yellow button. 6. When study is finished unhook the injector and throw the syringe into the red bag. Patient Outcomes: Proper utilization of the Med Rad Injector to optimize the study and to minimize patient's risk."
Further review of this policy did not reveal directions on how to flush the Med Rad Injector with the normal saline flush solution.
Observation at 10:30 AM on March 24, 2015, in the CT room revealed a 250 cc (cubic centimeter) bag of NaCL (normal saline) hanging on an IV pole next to the Med Rad Injector. The IV bag was spiked with tubing hanging from the port on the bag. The IV bag was labeled with the date March 24, 2015.
Interview with EMP9 at 10:30 AM on March 24, 2015, revealed the IV bag of NaCl was used to fill the flush syringe in the Med Rad Injector for a patient examination performed earlier in the morning. EMP9 stated the IV bag was used to fill the Med Rad Injector syringe for patients scheduled to receive contrast later in the day. EMP9 stated the connector was cleansed with alcohol prior to connecting it to the Med Rad Injector. EMP9 stated the IV bag was good for 24 hours after it was spiked. EMP9 confirmed the IV bags were discarded each day. Further interview with EMP9 confirmed the NaCL bag and tubing were used for multiple patients.

2) Review on March 23, 2015, of the facility's "Safety Program," last reviewed March 2014, revealed "... Objective: The objective of the Safety Program is to assure that the staffing, equipping, operating, and maintenance of the Hospital will adequately conform to safe practices and conditions as outlined by the JCAHO, applicable state and federal regulations in order that the facility is functionally safe and sanitary for patients, hospital staff and visitors. This will be accomplished through the development of safe practice guidelines, promotion of general safety awareness in all employees, detection of unsafe practices or conditions, and appropriate correction of the situations. ..."

Review on March 23, 2015, of the "Director of Environmental Services" job description, no review date, revealed "Character of Position Under the guidance of the Regional Director of Operations (RDO), the Director is responsible for the overall management of the Environmental Services Department. ... Accountabilities of the Director: ... 4. Maintain an environment that is in sanitary, attractive and in orderly condition. 5. Plan, organize, direct, coordinate and supervise functions and activities of the department ... 7. Maintains the department in an 'inspection ready' state at all times, assuring the department operates within federal, state, and local regulations. ..."

Observation tour on March 23, 2015, of patient room 102 revealed approximately 30 dead and two flying insects on the window sill next to the patient bed and one flying insect in the patient bathroom.

Interview with the facility's pest control company on March 23, 2015, at approximately 11:45 AM revealed these insects were drain flies, and they appear when water is not run down the sink and shower drains.

Interview with EMP5 on March 23, 2015, at approximately 11:50 AM revealed these drain flies were identified beginning July 2014 in the closed obstetrical unit, medical surgical patient rooms 118 and 120, in the Medical Record Department and in the Outpatient Therapy Department.

Interview with EMP6 and EMP7 on March 24, 2015, at approximately 10:00 AM revealed these insects were an ongoing problem. Further interview with EMP6 and EMP7 revealed housekeeping staff were told to run water down the sink and shower drains in patient rooms on a periodic basis. Continued interview with EMP6 and EMP7 revealed no schedule was developed to determine the frequency or amount of water needed.

Interview with EMP1 on March 25, 2015, at approximately 10:00 AM revealed the facility's pest control company treated medical surgical patient rooms 102, 116, 117, 118, 119 and 120 on March 24, 2015, for drain flies.

3) A request was made of EMP5 for the Dietary Department cleaning schedule. No schedule was provided.

Review on March 24, 2015, of the facility's "Dietary Department" job description, last revised February 2011, revealed "Stock / Cleaning Work Schedule Thursday 1 Day a Week Position [pound sign] 11 7:00 A.M. - 3:30 P.M. Thursday ... Mop floors in all areas to include walk-in refrigerator/freezer ..."

Review on March 24, 2015, of the facility's "Area and Equipment Cleaning" policy, last revised January 2014, revealed "Policies: Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department. The procedures are written to cover all necessary safety precautions. ... Procedures: Assistant Director Develops a reference manual on cleaning areas and equipment in the Food and Nutrition Services/Dining Services Department. Trains associates on cleaning procedures and use of reference manual; training is documented. Manual is kept where it is accessible by all associates. Assigns daily cleaning responsibilities in each position workflow. ..."

Observation tour on March 24, 2015, of the facility's Dietary Department revealed a thick accumulation of dried food and dust debris on the side of the convection oven and steam table. This dried food and dust debris when scrapped together measured approximately four quarters in size.

Interview with EMP1, EMP5 and EMP15 on March 24, 2015, at approximately 10:45 AM confirmed the thick accumulation of dried food and dust debris on the side of the convection oven and steam table. Further interview confirmed this dried food and dust debris when scrapped together measured approximately four quarters in size.

Observation tour on March 24, 2015, of the facility's hot warmer cart revealed a thick accumulation of dried food and dust debris on the tray slides. Further observation of the tray slides in the hot warmer cart revealed the accumulation of dried food and dust debris was too thick to measure.

Interview with EMP1, EMP5 and EMP15 on March 24, 2015, at approximately 11:15 AM confirmed the thick accumulation of dried food and dust debris on the tray slides and this accumulation was too thick to measure.

Observation tour on March 24, 2015, of the Dietary Department walk in refrigerator and walk in freezer revealed an accumulation of dried food, debris and dust under all the food storage racks. Further observation revealed this accumulation of dried food, debris and dust measured approximately the size of a lemon in the walk in refrigerator when swept together and the size of half a grapefruit in the walk in freezer when swept together.

Interview with EMP5 and EMP15 on March 24, 2015, at approximately 11:25 AM confirmed the accumulation of dried food, debris and dust under all the food storage racks. Further interview with EMP15 confirmed this accumulation of dried food, debris and dust measured approximately the size of a lemon in the walk in refrigerator when swept together and the size of half a grapefruit in the walk in freezer when swept together.

4) Review on March 24, 2015, of the facility's "Policy for Laboratory Environment" policy, last reviewed November 7, 2007, revealed "Purpose: To manage the personal safety of the laboratory/hospital staff and visitors and to establish a clean working environment in the laboratory. It is the intent of Memorial Hospital to keep the laboratory in a clean environment. The housekeeping and laboratory staff will be responsible persons to establish this goal. 1. Laboratory Cleanliness ... c. The laboratory staff will maintain the cleanliness of all of the refrigerators in the laboratory with the aid of the housekeeping staff if needed. The refrigerators will be cleaned with a decontamination solution (Bleach or Dispatch) at least once per quarter. The following months will be the assigned months to clean the refrigerators: November, February, May and August. The cleaning will be done by the 10the [sic] day of the assigned month. ..."

Review on March 24, 2015, of the facility's monthly Countertop Cleaning Chart revealed the following refrigerators and freezer listed: Blue Frig [refrigerator], Brown Frig, Micro [microbiology] Frig, Coag [coagulation] Frig, Blood Frig, Blood Frig, Plasma Frzr [freezer], Chem Rgt [Chemistry Reagent] Frig, Plasma Thaw, Quest Frig and Micro Incb's [incubators].

Observation on March 24, 2015, of the microbiology, plasma, brown, chemistry reagent, and chemistry refrigerators revealed an accumulation of dirt, dust and debris measuring approximately two half dollars in size. Observation of the chemistry freezer revealed an accumulation of dirt, dust and debris. Further observation revealed this dirt, dust and debris measured approximately one half dollar in size when scrapped together.

Review on March 24, 2015, of the laboratory cleaning chart from January 1, 2014 to March 24, 2015, revealed laboratory staff last cleaned the Brown refrigerator on May 10, 2014, the Plasma refrigerator on July 3, 2014, and the Chemistry Reagent refrigerator on October 31, 2014. Further review revealed no documentation laboratory staff cleaned the microbiology refrigerator, the chemistry refrigerator and the chemistry freezer from January 1, 2014 to March 24, 2015.

Interview with EMP1 and EMP18 on March 24, 2015, at approximately 10:45 AM confirmed the microbiology, plasma, brown, chemistry reagent, chemistry refrigerators with an accumulation of dirt, dust and debris measuring approximately two half dollars in size and the chemistry freezer with an accumulation of dirt, dust and debris measuring approximately one half dollar in size when scrapped together. EMP18 confirmed laboratory staff last cleaned the Brown refrigerator on May 10, 2014, the Plasma refrigerator on July 3, 2014, and the Chemistry Reagent refrigerator on October 31, 2014, and there was no documentation laboratory staff cleaned the microbiology refrigerator, the chemistry refrigerator and the chemistry freezer from January 1, 2014 to March 24, 2015.

5) Review on March 24, 2015, of the facility's "Laboratory PPE and Lab Coat Policy," last approved December 7, 2011, revealed "Purpose: To protect healthcare workers (Laboratory Personnell [sic]) from transmission of infectious diseases. Principle: Laboratory workers shall use personal protective equipment such as lab coats or clinic jackets in occupational exposure situations. Personal protective equipment will be considered 'appropriate' only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work cloths, street cloths, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. ... Procedure/Protocol ... 2. Laboratory coats must be buttoned, as to protect the employee's street clothes from blood and/or body fluid exposure and to protect any areas of exposed skin. ..."

Observation tour of the facility's laboratory on March 24, 2015, revealed EMP16 and EMP17 working with blood and body fluid specimens. Further observation revealed these employee's laboratory coats were not buttoned to prevent their clothes from exposure to blood and body fluids.

Interview with EMP1 and EMP18 on March 24, 2015, at approximately 9:45 AM confirmed EMP16 and EMP17 were working with blood and body fluid specimens, and these employee's laboratory coats were not buttoned to prevent their clothes from exposure to blood and body fluids.

6) Review on March 25, 2015 of the facility policy "Whole Blood Glucose Testing with Nova Stat Strip," last revised March 2014, revealed "Policy: It is the policy of Memorial Hospital to monitor Blood Glucose testing with the Nova Stat Strip monitor following manufactures instructions. ...Procedure/Protocol Blood Glucose Testing ... K. Clean Meter after each use with germicidal disposable wipes ...."

Observation on March 25, 2015, at 9:45 AM, revealed EMP14 used the blood glucose meter on MR55. EMP14 did not clean the blood glucose meter after using it on MR55.

Interview on March 25, 2015 at 9:45 AM, with EMP14 confirmed the blood glucose meter was not cleaned after being used on MR55. Further interview revealed EMP14 did not clean the blood glucose meter after each use. EMP14 cleaned the blood glucose meter only when dirty.

Interview on March 25, 2015 at 9:45 AM, with EMP2 confirmed EMP14 did not clean the blood glucose meter after used on MR55. Further interview confirmed the blood glucose meter was to be cleaned after each patient use.

7) Review on March 23, 2015 of the facility policy "Multiple Dose Vial Expiration Dating," last revised January 2015, revealed "Policy: It is the policy of Memorial Hospital that multiple dose vials will be eliminated whenever possible. ... Procedure/Protocol ... Where multiple dose vial is only form available: a. When nurse opens vial she will record date opened on vial. ..."

Observation on March 23, 2015, at 1:35 PM, revealed an open vial of Albuterol Sulfate 20cc. (a bronchodilator that relaxes muscles in the airways). There was no date on the vial noting when it was opened.

Interview on March 23, 2015, at 1:35 PM, with EMP19 confirmed the open vial of Albuterol Sulfate 20cc., and there was no open date on the vial. Further interview confirmed the vial was to be dated when opened.

Interview on March 23, 2015, at 1:35 PM, with EMP2 confirmed the open vial of Albuterol Sulfate 20cc., and there was no open date on the vial. Further interview confirmed the vial was to be dated when opened.

Based on review of facility documents, medical records (MR) and staff interviews (EMP), it was determined the facility failed to ensure surgical consent forms were completely filled out for four of seven medical records reviewed (MR53, MR54, MR55 and MR56).

Findings include:

Review on March 25, 2015, of the facility policy "Informed Consent," last reviewed December 2014, revealed "... Purpose: To establish guidelines to obtain an informed consent from a patient for treatments, certain defined diagnostic procedures and all surgical procedures. Procedure ... 2. The consent form will be signed by the patient, POA [power of attorney] or in the case of a minor, the parent or legal guardian and/or next of kin. ... Key Points ... 2. If completed at the hospital it will be done either at the time of the pre-operative hospital visit or on the day of surgery. The consent will be obtained by the operating practitioner. ... Procedure ...7. Consent forms will be filled out appropriately. Key Points ... Proper procedure Correct spelling Legible Initial and last name of operating practitioner No abbreviations Signed by the patient, parent, guardian, POA or next of kin with date and time Witnessed Surgeons signature with date and time."

Review on March 25, 2015, at 11:50 AM of MR53 revealed the patient underwent excision of a ganglion of right upper foot on March 25, 2015. Review of the surgical consent for MR53 revealed no date and time after the patient's signature.

Review on March 25, 2015, at 11:50 AM of MR54 revealed the patient underwent a colonoscopy on March 25, 2015. Review of the surgical consent for MR54 revealed no date and time after the patient's signature.

Review on March 25, 2015, at 11:50 AM, of MR55 revealed the patient underwent repair of an incisional hernia with mesh on March 25, 2015. Review of the surgical consent for MR55 revealed no date and time after the patient's signature.

Review on March 25, 2015, at 11:50 AM, of MR56 revealed the patient underwent a left knee arthroscopy on January 27, 2015. Review of the surgical consent for MR56 revealed no date and time after the patient's signature.

Interview on March 25, 2014, at 11:50 AM, with EMP2 and EMP13, confirmed the surgical consents were not dated or timed after the patient signature on MR53, MR54, MR55 and MR56.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to complete a swing bed admission activity assessment to determine patient activity preference and failed to document the activities on the activity calendar that were offered to four of six swing bed patients (MR39, MR40, MR43 and MR44).

Findings include:

Review on March 26, 2015, of the facility's "Medical Surgical Unit/Swing Bed Activities Program" policy, last reviewed September 2014, revealed "Policy: It is the policy of Memorial Hospital's Swing Bed Program that each patient admitted for swing bed status would be offered an activities program. The program is directed by an Occupational Therapist. Purpose: The activities program will offer daily events to include leisure activities such as support, games, cards, music, etc. designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each swing bed patient. Equipment Activities to include games, books, drinks, crossword puzzles, word search, newspaper and access to a computer. Procedure/Protocol Programs are schedule on a monthly basis by the Activities Coordinator. Each swing bed patient will be assessed by the OT [Occupational Therapist] or Activities Coordinator within 72 hours of admission. Swing bed team welcomes families to visit frequently and bring books, games and hobbies their loved one enjoys. Activities are incorporated into the care plan. The swing bed patient will be presented with the opportunity for involvement in the available activities as outlines on the calendar by the nurse's aide. Nurse's aides will document patient's activity participation in the patient's medical record. Evaluation/Documentation: Initial Evaluation Form for Activities. Patient Outcomes: Checklist of activities each swing bed patient participated in and/or were offered."

1) Review on March 26, 2015, of the facility's Activities Program for March 13 - 26, 2015, revealed the facility offered daily events of snacks, puzzles, card games, family time, crafts and group lunch.

Review of MR39 on March 26, 2015, revealed the facility admitted the patient to swing bed status on March 13, 2015. Further review revealed no documentation the facility completed a swing bed admission activity assessment on MR39 to determine the patient's activity preferences. Continued review of MR39 revealed facility documentation the patient watched television daily during the swing bed stay. There was no documentation the facility offered daily activity events to MR39 as indicated on the facility's activity calendar.

2) A request was made of EMP4 and EMP8 on March 26, 2015, for the facility's swing bed activity calendars for February and March 2014. No activity calendars were provided.

Review of MR40 on March 26, 2015, revealed the patient was a swing bed patient from February 7, 2014 to March 12, 2014. Further review revealed no documentation the facility completed a swing bed admission activity assessment on MR40 to determine the patient's activity preferences. Continued review of MR40 revealed facility documentation the patient watched television daily during the swing bed stay. There was no documentation the facility offered any daily activity events to MR40 while a swing bed patient.

3) Review on March 26, 2015, of the facility's Activities Program for December 12 - 31, 2014, revealed the facility offered daily events of games, snacks, puzzles, card games, family time, crafts, a Christmas gathering, baking, one-to-one time, bring in the new year party, tea time and group lunch.

Review of MR43 on March 26, 2015, revealed the facility admitted the patient to swing bed status from December 15 - 31, 2014. Further review revealed no documentation the facility completed a swing bed admission activity assessment on MR43 to determine the patient's activity preferences. Continued review of MR43 revealed facility documentation the patient watched television daily during the swing bed stay. There was no documentation the facility offered any daily activity events of snacks, puzzles, card games, family time, crafts and group lunch to MR43 as indicated on the facility's activity calendar.

4) A request was made of EMP4 and EMP8 on March 26, 2015, for the facility's swing bed activity calendar for August 2014. No activity calendar was provided.

Review of MR44 on March 26, 2015, revealed the facility admitted the patient to swing bed status from August 21 to 28, 2014. Further review revealed no documentation the facility completed a swing bed admission activity assessment on MR44 to determine the patient's activity preferences. Continued review of MR44 revealed facility documentation the patient watched television daily during the swing bed stay. There was no documentation the facility offered any daily activity events to MR44 while a swing bed patient.

Interview with EMP4 and EMP8 on March 26, 2015, at approximately 2:00 PM confirmed the facility did not complete a swing bed admission activity assessment on MR39, MR40, MR43 and MR44 to determine these patients' activity preferences. Further interview with EMP4 and EMP8 confirmed the facility did not document what activities were offered to MR39, MR40, MR43 and MR44 from the activity calendar while they were swing bed patients.