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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all outdated supplies are removed from the code cart in the Emergency Department (ED). This failed practice has the potential to affect all patients treated in the ED. The CAH reported 1,347 ED patients seen in fiscal year 2023.

Findings are:

A. ED tour conducted (12/4/24 at 9:28 AM) revealed outdated supplies in ED CODE cart that included the following:
- 10 french stylet with soft distal tip expired 10/17/24;
- 10 french stylet with soft distal tip expired 10/11/23; and
- Angiocath 16-gauge 5.25 inch expired 3/2018.

B. Interview (12/4/24 at 9:28 AM) with RN-G during the ED tour revealed that the department did not have a policy to monitor outdates in nursing care areas only a sign off sheet with all areas that nursing is responsible for monitoring. Nurses are responsible for checking for outdates in the ED for items not located in the pyxis. RN-G agreed that items were outdated. Surveyor requested a copy of the sign off sheet that nursing uses for checking areas for outdates prior to exit. The form was not provided before the exit conference.

Based on staff observations, medical record review, review of facility policies, staff interview and review of the National Library of Medicine reference, the Critical Access Hospital (CAH) failed to label intravenous (IV) antibiotics with the administration rate directions per facility policy and standards of practice for 1 (Patient 36) of 1 sampled patient. This failed practice had the potential to affect all patients of the CAH receiving IV antibiotics. The CAH reported an inpatient census of 248 patients and 713 surgical patients for the fiscal year ending 2023.

Findings are:

A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew "about 10 ml" and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient's name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication.

B. Record review of Patient 36's admission history and physical revealed that the patient, age 78, admitted on 11/13/20204 for IV antibiotics, physical and occupational therapy after a right total hip arthroplasty clean out, with a wound VAC in place due to infection after the surgery. IV antibiotics to continue to 12/12/2024 per Infectious Disease physician. Review of Patient 36's physicians order dated 11/13/2024 revealed an order for Cefazolin (Ancef) 2 grams, IV push every 8 hours with a stop date of 12/13/2024 for Bone and/or joint infection, lacking administration directions on the order.Review of Patient 36's Medication Administration Records (MAR) for the month of November and December revealed under the Cefazolin order, lacked administration directions located on any of the days the medication was administered, no measurement of the external length of the PICC or arm circumference or dressing change documented since 11/22/2024.

C. Interview (12/2/24 at 2:10 PM) with RN-L confirmed that the administration instructions were not on the physician's order, nor was it on the label for the medications. RN-L verbalized that the nursing staff go by the "IV Shortage Administration Guide" that the pharmacy provided that is hanging on the wall in the medication room. RN-L also verbalized that nursing does the handwritten label due to the label printer not printing correctly. RN-L confirmed that the pharmacist enters the orders into the electronic record and that the administration instructions were not on the order or MAR.

D. Interview with the Director of Nursing (DON) (12/2/24 at 2:20 PM) confirmed that the administration rate should be on the MAR and/or in the orders, and confirmed it was not on either the MAR or the orders. Interview with the DON (12/5/2024 at 11:20 AM) confirmed that the nursing staff reconstitute all IV antibiotics.

E. Interview with the Pharmacist-I (12/4/2024 at 8:35 AM) confirmed that "we don't typically put the administration rate into Cerner (the electronic charting system) because there is no way to enter that for an IV push medication". Pharmacist-I went on to state the "library in the system has drugs available in the system and that piggyback medications have administration directions". Pharmacist-I did say they could put it under comments, and it would show up on the MAR, and confirmed that their workload is not too heavy that they could enter the administration directions under comments.

F. Observation (12/4/2024 at 8:40 AM) revealed Pharmacist-J editing the Cefazolin order for Patient 36 and the infusion rate being entered under comments, made an adjustment in Cerner and then Pharmacist-J printed a label. The label was legible, and the infusion rate appeared on the label. Pharmacist-J was unaware of the label printing problem for the nurses.

G. Review of pharmacy facility policy titled Labeling Standards (last revision date of 7/2022) stated under procedure: "IV admixture labels shall include at a minimum: ....name and amount of the basic solution, dose, time/date due, and infusion rate ........".

H. Review of the undated IV Shortage Administration Guide posted on the medication room wall revealed the following: "Cefazolin 0.5g, 1g, 1.5g in 10 ml SWFI 3-5 minutes." All medications on this list were in alphabetically order and single line spacing. There were 7 medications that began with a C all in a row and 3 with similar names together, increasing the risk for medication errors.

I. Review of the National Library for Medicine, under Nursing Advanced Skills: Chapter 2, Administer IV push medications: "Additionally, it is important to consider the specific time frame for drug administration. Many IV medications must be infused over a period of time and cannot be pushed into the venous system rapidly due to potential adverse hemodynamic effects. Medications administered by direct IV route are commonly given very slowly per guidelines outlined in a drug reference guide. Nurses must routinely consult drug reference guides when administering IV push medications to check medication and fluid compatibilities and to ensure that medications are given at the correct rate to prevent complications".

Based on staff observations, medical record review, review of facility policies and staff interview, the Critical Access Hospital (CAH) failed to assess for patency of a Peripherally Inserted Central Catheter (PICC) (a central intravenous (IV) catheter that is inserted peripherally through the arm to administer IV medications) prior to administration of medications, the facility also failed to complete measurements to ensure proper placement (significant complications could occur if medication were to be administered in the wrong location) and document PICC dressing changes per facility policy for 1 (Patient 36) of 1 sampled patient. This failed practice had the potential to affect all patients of the CAH receiving IV medications per a PICC line. The CAH reported an inpatient census of 248 patients and 713 surgical patients for the fiscal year ending 2023.

Findings are:

A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew "about 10 ml" and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient's name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication.

B. Review of Patient 36's physicians order dated 11/13/2024 revealed an order for Cefazolin (Ancef) 2 grams, IV push every 8 hours with a stop date of 12/13/2024 for Bone and/or joint infection. No administration directions found on the order. Review of Patient 36's Medication Administration records for the month of November and December revealed under the Cefazolin order, no administration directions located on any of the days the medication was administered. Patient 36's medical record lacked measurement of the external length of the PICC or arm circumference or dressing change since last documented on 11/22/2024.

C. Review of the facility policy titled Intravenous Access (last revised 3/17/2024) revealed the following under the Medication and Solution Administration section:
"#1.Verify provider order for solution, volume, medication, route, rate, dose, frequency, and duration.
#10. Aspirate for appositive blood return from vascular access device (VAD) to confirm patency."

-Under Table 1 that determines dressing changes, type and frequency, and cap change stated; "The dressing should be changed weekly with cap change and should be flushed with 10 ml normal saline before each use."

D. Interview with the Director of Nursing (DON) (12/2/24 at 2:20 PM) confirmed that the administration rate should be on the Medication Administration Record (MAR) and it was not. The DON also confirmed that the medical record for Patient 36 did not show a dressing change or assessment since 11/22/2024. The DON confirmed that the IV Administration policy indicated weekly dressing change and measurement, and to aspirate blood to check for patency prior to each use.

E. Interview with the Director of Nursing (DON) (12/4/2024 at 8:20 AM) revealed that the facility did not have a medication management policy but that the DON typed one up the previous day to take to the Policy Review Committee, but it was not active yet.

F. Interview with RN-K (12/4/2024 at 8:47 AM) confirmed that hand hygiene was not completed during the IV medication reconstitution and that the nursing staff "typically only aspirate for blood return on the PICC lines once a day, it was done earlier that day".

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure that outdated patient care supplies were removed from the patient care areas in the surgical services department. This failed practice has the potential to affect all patients receiving care in the surgical services department. The CAH reported 713 scopes/surgical procedures during the 2023 fiscal year.

Findings are:

A. Observations during the surgical services tour (12/4/24 at 2:00PM) revealed outdated supplies at the following 4 locations in the surgical services department:
- Procedure room anesthesia cart: Extension set 32inch - 2 expired 4/1/22, 1 expired 5/1/24;
- Scrub sink: Povidone-Iodine EZ Scrub (a soap scrub used by staff prior to surgery) 8 expired 11/24;
- Operating Room (OR) Room: Remover lotion - 4 expired 9/2/2022, 3 expired 7/21/21 Mastisol liquid adhesive - 1 expired 7/23, 2 expired 11/24; and
- Code Cart: Lubricating Jelly Packets 4 expired 6/24 Stylet with Soft Distal Tip 10 french 1 expired 10/17/24.

B. Interview (12/4/24 at 2:00PM) with RN-M revealed that each nurse has an area in the OR that they are responsible for checking for outdates. RM-M agreed that items were outdated. Requested a policy for monitoring of outdated supplies for the Surgical Services Department. RN-M stated that they did not have a policy for outdated supplies.

Based on staff observations, medical record review, review of facility policies, staff interview, review of the United States Pharmacopeia 797 reference, and Emergency Department tour, the Critical Access Hospital (CAH) nursing staff failed to reconstitute intravenous (IV) antibiotics in an aseptic manner to prevent cross contamination and the spread of health care associated illness for 1 patient (Patient 36) of 1 sampled patient. The CAH also failed to ensre that patient care supplies and facility cleaning supplies are stored seperately. This failed practice had the potential to affect all patients of the CAH receiving IV antibiotics and emergency services. The CAH reported an inpatient census of 248 patients and 713 surgical patients and 1,347 ED patients for the fiscal year ending 2023.


Findings are:

A. Medication administration observation (12/2/2024 at 1:46 PM) revealed Register Nurse (RN) -L training RN-K to prepare, reconstitute and administer Cefazolin, an IV antibiotic, for Patient 36. RN-K entered the medication room without performing any hand hygiene and reviewed the order for Patient 36 in the Pyxis machine (an automated locked dispensing system to obtain medications). RN-K then obtained 2 vials of the antibiotic Cefazolin 2 grams (g) and 1 twenty milliliter (ml) vial of sterile water from the Pyxis machine. RN-K took the vials to a prep counter and sat them down to the side, applied gloves and took a Sani Wipe (a disinfectant wipe to create an antiseptic surface) and wiped the prep counter. RN-K then removed gloves, obtained a 20 ml syringe out of a multi-use box of syringes and a needle. RN-K applied gloves without completing hand hygeine and opened the 20 ml syringe and needle. RN-K then opened all vials and wiped the tops with alcohol for 5 seconds each. RN-K attached the needle to the 20 ml syringe, placed into the 20 ml vial of sterile water and withdrew "about 10 ml" and then injected the 10 ml of sterile water into one vial of Cefazolin 1 g. RN-K rotated the vial to mix the contents, withdrew the needle and placed the needle into the 20 ml vial of sterile water and withdrew 10 ml of sterile water and placed the needle into the 2nd vial of Cefazolin 1g and injected the water. RN-K rotated the vial to mix contents and withdrew the mixture into the 20 ml syringe. RN-K then placed the needle with syringe into the first vial of Cefazolin and withdrew the contents of the vial. The total amount in the 20 ml syringe was 19 ml. RN-L had written a label that had the patient's name and Cefazolin 2g written on it. No administration instructions. RN-K removed gloves, obtained a tubing set from the storage unit, gathered the 20 ml syringe of medication and the 2 empty Cefazolin vials. RN-L put on a glove and took the empty vial of sterile water out of the trash where it had been discarded and handed the soiled vial to RN-K. RN-K took all vials and syringe out of the medication room. RN-K and RN-L both used hand sanitizer prior to entering the patient room. RN-K applied gloves, pulled up the order in the computer at the patient bedside and took the scanning device off the wall and scanned the patient wrist band and the vials of solutions, including the soiled vial from the trash can. With the same soiled gloves on, RN-K then placed the 20 ml syringe of Cefazolin, package of tubing set and alcohol wipes on the windowsill that was not wiped off and contained patient personal items. RN-K then opened the package of tubing and primed the tubing with the antibiotic solution from the 20 ml syringe. RN-K placed the 20 ml syringe into the IV pump and wiped the patients Peripherally Inserted Central Catheter (PICC) (a central intravenous catheter that is inserted peripherally through the arm to administer IV medications) for 5 seconds. RN-K then attached a 10 ml syringe with normal saline and flushed the PICC line without aspirating for blood return. RN-K then attached the tubing from the 20 ml syringe with the IV antibiotics and set the pump at 8 minutes to infuse the medication.

B. Review of Patient 36's admission history and physical revealed that the patient, age 78, admitted on 11/13/2024 for IV antibiotics, physical and occupational therapy after a right total hip arthroplasty clean out, with a wound VAC in place due to infection after the surgery. IV antibiotics to continue through 12/12/2024 per the Infectious Disease physician.

C. Interview with RN-K (12/4/2024 at 8:47 AM) confirmed that hand hygiene was not completed during the IV medication reconstitution and that the nursing staff "typically only aspirate for blood return on the PICC lines once a day, it was done earlier this morning".

D. Interview with the Director of Nursing (DON) (12/4/2024 at 8:20 AM) revealed that the facility did not have a medication management policy but that the DON typed one up the previous day to take to the Policy Review Committee, but it was not active yet. The DON confirmed that RN-K and RN-L should have completed hand hygiene per IV administration policy for medication reconstitution.

E. Interview with Pharmacist-J (12/4/2024 at 8:45 AM) revealed that the pharmacy did complete training last summer with the nurses on aseptic techniques for reconstituting medications but might have missed the new RN. Pharmacist-J then presented a copy of the Immediate-Use Compounding Competency Assessment form utilized for the training.

F. Review of the Immediate-Use Compounding Competency Assessment form (undated) received from the pharmacy on 12/4/2024 revealed the following:
"*Hand Hygiene: removed all jewelry on hands and wrists to prevent contamination. Perform hand washing with soap and water and dry with clean, dry paper towel. Appy alcohol-based hand sanitizer to hands and allow to air dry.
*Garbing: Apply gloves and disinfect by applying alcohol or disinfecting agent onto gloves and allow to air dry."

G. Review of United States Pharmacopeia (USP) (which is a set of standards for the quality of medicines and medical devices) 797, 1.3 Immediate -Use Compound Sterile Preparation (CSP) stated "#1. Aseptic techniques, processes, and procedures are followed, and written standards of practice are in place to minimize the potential for contact with nonsterile surfaces, introduction of particulate matter or biological fluids, and mix-ups with other conventionally manufactured products for CSPs."

F. ED tour (12/4/24 at 9:28 AM) RN-G opened a locked cupboard in the clean area. Cupboard contained a bottle of instrument pre cleanser, a bottle of enzymatic cleaner on the same shelf as patient care supplies of hydrogen peroxide and hibiclens (a solution used to prevent skin infections). RN-G stated that they didn't think they could store cleaning products under the sink and that they needed to be in a lock cupboard.

Based on policy and procedure review, review of facility Live on Nebraska agreement/dashboard and staff interview, the Critical Access Hospital CAH failed to ensure a defiinition of imminent death and criteria to determine imminent death was included in their Organ and Tissue Donation Policy. This failed practice had the potential to miss a potential donor while organs are still viable. The CAH reported 248 inpatient admissions and 1,347 ED patients for the fiscal year 2023.

Findings are:

A. Review of the facility policy titled Organ and Tissue Donation (Last Revision 3/25/2022), revealed the policy lacked a definition of imminent death and criteria to determine imminent death to include specific triggers for notification of Live on Nebraska.

B. Review of the Live on Nebraska Donor Institution Agreement revealed that the agreement was signed by the CAH on 12/24/2019. The agreement incudes a "Summary of Donor Institution Agreement Proposed Changes" which includes clarified language to better define when a patient would be considered an imminent death and when that patient should be called in for an organ evaluation. The agreement also includes definitions required for facility policy in Article I.
-Review of facility Live on Nebraska provided dashboards (1/1/24 -9/30/24) revealed that the facility has had 0 organ donors.

D. Interview (12/4/24 at 10:56 AM) with RN-G stated that the CAH does not keep patients on a ventilator so the CAH would not need to worry about imminent death. Clarified with RN-G that CAH does have a ventilator in the ED. RN-G agreed that they do have a ventilator in the ED. RN-G also stated that they "only use the ventilator if they are waiting an extended time for transport."

Based on medical record review, review of policy and procedure and staff interviews, the Critical Access Hospital (CAH) failed to ensure that 3 of 3 swing bed patients (Parients 32, 34, and 35) reviewed had a comprehensive assessment completed after 14 days and 5 of 5 swing bed patients (Patients 32, 33, 34, 35, and 36) reviewed lacked a recapitulation of stay completed at discharge. This failed practice has the potential to affect all swing bed patients at the CAH. The CAH reported 44 swing bed patients for the fiscal year 2023.

Findings are:

A. Review of Patient 32's medical record (12/5/24 at 9:45 AM) revealed patient was admitted to swing bed care on 8/23/24 at 9:09 AM for weakness, fracture of right fibula and Parkinson's. Discharged on 9/7/24 at 1:45PM. The patient had a 15 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay.
- Review of Patient 33's medical record (12/5/24 at 10:00 AM) revealed patient was admitted to swing be on 9/18/24 at 12:01 PM for Chronic Obstructive Pulmonary Disease (COPD) (a disease that causes difficulty breathing because lungs do not work correctly) exacerbation. Discharged on 9/24/24 at 3:34PM. The patient had a 6 day stay. The medical record lacked a recapitulation of stay.
- Review of Patient 34's medical record (12/5/24 at 10:15 AM) revealed patient was admitted to swing bed on 8/22/224 at 1:11 PM for anemia and hypotension (low blood pressure). Discharged on 9/6/24 at 3:20PM. The patient had a 15 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay.
- Review of Patient 35's medical record (12/5/24 at 10:30 AM) revealed patient was admitted to swing bed on 10/8/24 at 12:35 PM for congestive heart failure (CHF) exacerbation and declining status. Discharged on 10/24/24 at 10:45AM. The patient had a 16 day stay. The medical record lacked a comprehensive assessment and a recapitulation of stay.
- Review of Patient 36's medical record (12/5/24 at 10:50 AM) revealed patient was admitted to swing bed on 10/25/24 at 7:25 PM for right hip pain. Transferred to Acute Care Facility on 10/30/24 at 9:10AM. The patient had a 5 day stay. The medical record lacked a recapitulation of stay.

B. Review of facility policy titled Comprehensive Swing Bed Assessment ( Last revision 8/24/21) revealed "The comprehensive assessment will be completed within 14 days of admission to swing bed, utilizing the initial interview for the swing bed patient type."
-Review of facility policy titled Swing Bed Program (Last revision 8/24/21) revealed "A Recapitulation of the Patients Stay - This form is to be completed by the Social Worker and the RN on duty." and "Swing Bed Summary of Patients Stay - This form is to be completed and signed only by the RN on duty. These forms are to be completed within five (5) working days after dismissal of patient."

C. Interview (12/5/24 at 9:45AM) with RN-G and Social Work-N (SW-N) revealed while conducting record reviews during the mock survey, the facility had completed a couple of months ago, that there was difficulty locating the comprehensive assessments and the recapitulations on the swing bed records reviewed. RN-G was able to locate the comprehensive assessment form in the electronic medical record for staff to complete as well as the recapitulation form. RN-G and SW-N both confirmed that for the above (Patients 32, 34 and 35) medical records were lacking the comprehensive assessment after day 14 of swing bed stay. RN-G and SW-N also confirmed that for the above (Patients 32, 33, 34, 35, and 36) medical records were lacking the recapitulation of stay after discharged.