HospitalInspections.org

Based on medical record review, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment within 14 calendar days after admission for 4 of 4 swing bed patients (Patients 32, 33, 34 and 36) and a discharge summary that included a recapitulation of the patients stay for 4 of 4 swing bed patients (Patients 33, 34, 35 and 36). This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 2023 was 187.

Findings are:

A. Review of Patient 32's medical record (4/10/25 at 12:30PM) revealed a swing bed admission of 3/24/25 - currently remains swing bed patient for a vertebral fracture (a bone that makes up the spine has a break). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission

-- Review of Patient 33's medical record (4/10/25 at 12:45PM) revealed a swing bed admission of 2/21/25 - 3/10/25 for a gastrointestinal bleed (any bleeding that originates within the digestive tract, encompassing a wide range of potential causes and symptoms). Review of the entire medical record revealed a lack of evidence a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay.

- Review of Patient 34's medical record (4/10/25 at 1:05PM) revealed a swing bed admission of 11/22/24 - 12/16/24 for osteomyelitis (a bone infection). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay.

- Review of Patient 35's medical record (4/10/25 at 1:30PM) revealed a swing bed admission of 12/2/24 - 12/14/24 for a bowel obstruction (occurs when food or liquid can't move through the intestines due to a blockage). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay.

- Review of Patient 36's medical record (4/10/25 at 2:06PM) revealed a swing bed admission of 12/10/24 - 12/26/24 for gangrene (a serious medical condition characterized by the death of tissue, typically due to a lack of blood supply or a serious bacterial infection). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay.

B. Review of facility policy Scope Of Services Level Of Care Provided in Skilled Care Swing Beds, last approved 4/2023 revealed, all swing bed patients will have a discharge summary that includes the following information: Summary (recapitulation) of the patients stay. A final summary of the patient status at the time of discharge is available to authorized persons and agencies with the consent of the patient or their legal representative. A post discharge plan of care that is developed with the participation of the patient and his or her family, which will assist the patient to adjust to his or her living environment. The policy lacks information regarding a comprehensive assessment being completed within 14 days of admission to swing bed.

C. Interview (4/10/2025 at 2:30 PM) with Director of Nursing (DON) confirmed the medical records lacked evidence of the comprehensive assessment and a discharge summary with a recapitulation of the patients stay
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Based on observations and interviews, the Critical Access Hospital (CAH) failed to ensure that outdated supplies were removed for use in Operating Room 1 Anesthesia cart, Operating Room 2 Anesthesia cart, the anesthesia work room and surgical supply room. This failed practice has the potential to affect all patients receiving care in the surgical services department. The CAH reported 353 surgical cases during the 2023 fiscal year. This resulted in the Condition of Participation for Surgical Services not being met.

Findings are:

A. Observations during the surgical department tour (4/9/2025 from 12:30 PM to 2:30 PM) with Surgical Manager RN (Registered Nurse) revealed in Operating Room 1 the anesthesia cart to have the following expired and/or opened items available patient for use:

-3 BD (Becton, Dickinson and Company) Whitacre (type of needle) 25 gauge needles (a needle used to deliver medications in the spinal space) expired on 2/21;
-1 BD Whitacre 25 gauge needle expired on 2/29/24;
-6 BD Whitacre 25 gauge needles expired on 7/31/24;
-2 Touhy (type of needle) epidural 18 gauge needles (a needle to deliver medications in the spinal space) expired on 4/20/20;
-1 Touhy epidural 18 gauge needle expired on 8/31/24;
-2 Pencan pencil point (type of needle) 24-gauge spinal needles (a needle to deliver medications in the spinal space) expired on 5/31/23;
-1 Pencan pencil point 24 gauge spinal needle expired on 5/18/23;
-1 Endotracheal tube (a breathing tube inserted in the windpipe to help provide oxygen) expired on 9/20;
-2 Endotracheal tubes expired on 4/25/22;
-6 Endotracheal tubes expired on 1/1/23;
-2 Endotracheal tubes expired on 2/25/24;
-1 Endotracheal tube expired on 3/5/23, seal broken with open packaging;
-1 Endotracheal tube expired on 2/4/24, seal broken with open packaging; and
-1 Endotracheal tube, seal broken with open packaging.

B. Observations during the surgical department tour (4/9/2025 from 12:30 PM to 2:30 PM) with Surgical Manager Registered Nurse (RN) revealed in Operating Room 2 the anesthesia cart to have the following expired and/or opened items available patient for use:

-4 Pencan pencil point 24 gauge spinal needles expired on 5/31/23;
-2 Touhy epidural 18 gauge needles expired on 4/30/20;
-1 Touhy epidural 18 gauge needle expired on 2/21;
-2 Tuohy epidural 18 gauge needles expired on 4/30/20;
-1 Tuohy epidural 18 gauge needle expired on 6/30/24; and
-1 Endotracheal tube expired on 2/4/24, seal broken with opened packaging.


C. Observations during the tour of the surgical supply room (4/9/2025 from 12:30 PM to 2:30 PM) revealed expired supplies available for patient use:

- 25 packages sterile cast padding (used to protect the skin beneath a cast) expired on 3/28/25.

D. Observations during the tour of the Anesthesia work room (4/9/2025 from 12:30 PM to 2:30 PM) revealed expired supply available for patient use:

-Mastisol adhesive liquid medical adhesive (used for to secure dressings) expired on 2/23.


E. Interview with Surgical Manager RN (4/9/2025 at 1:00PM) confirmed the above expired and opened packages were available for patient use in the anesthesia cart in Operating Room 1. Also stated "nursing is not responsible for these carts; these are anesthesia's responsibility."

-Interview with Surgical Manager RN (4/9/2025 at 1:15PM) confirmed the above expired and opened packages were available for patient use in the anesthesia cart in Operating Room 2.

-Interview with Surgical Manager RN (4/9/2025 at 1:40 PM) confirmed the above box of sterile cast padding packages were expired and available for patient use.

-Interview with CRNA-A (Certified Nurse Anesthetist) (4/9/2025 at 2:00PM) confirmed the above expired supply in the anesthesia work room was available for patient use.