HospitalInspections.org

Based on observations, review of documentation, and staff interview, the Critical Access Hospital (CAH) anesthesia staff failed to ensure proper storage of anesthesia drugs as specified by the manufacturer's recommendations. (Anesthesia) The CAH Surgery administrative staff reported approximately 11 surgical cases a month that required use of the identified medications.

Failure to ensure proper temperature controls of pharmaceuticals could potentially cause pharmaceuticals to lose potency, thus not providing desired effect to patients.

Findings included:

1. Tour of the operating room (OR) on 8/31/11 at 12:35 PM revealed the following anesthesia drugs stored in two of two anesthesia carts in the OR area:

Staff L's anesthesia cart:
- 3 of 3 unopened Succinylcholine Chloride Inj. 10 ml Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 2 of 2 unopened Rocuronium Bromide Inj. Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 1 of 1 unopened Atracurium Besylate Inj. 5 ml single dose vial which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.

Staff M's anesthesia cart:
- 2 of 3 unopened and 1 of 3 opened Succinylcholine Chloride Inj. 10 ml Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 3 of 4 unopened and 1 of 4 opened Rocuronium Bromide Inj. Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 1 of 2 unopened and 1 of 2 opened Atracurium Besylate Inj. 5 ml single dose vial which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.

2. Succinylcholine Chloride Inj. manufacturer's product insert, dated May 2004, stated in part ". . . The multidose vials are stable for up to 14 days at room temperature without significant loss of potency. . . ."

3. Rocuronium Bromide Inj. manufacturer's product insert stated in part ". . . Rocuronium Bromide Injection should be stored in a refrigerator, 2-8 degrees C (36-46 degrees F). DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25 degrees C/77 degrees F), use Rocuronium Bromide Injection within 60 days. Use opened vials of Rocuronium Bromide Injection within 30 days. . . ."

4. Atracurium Besylate Inj. manufacturer's product insert, dated May 2004, stated in part ". . . Atracurium Besylate Injection should be refrigerated at 2 - 8 degrees C (36 - 46 degrees F) to preserve potency. DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25 degrees C/77 degrees F), use Atracurium Besylate Injection within 14 days even if rerefrigerated. . . ."

5. Review of Anesthesia policies/procedures revealed the lack of a policy/procedure for storage of anesthesia drugs.

6. During an interview on 8/31/11 at 12:35 PM, Staff L acknowledged the Succinylcholine, Rocuronium, and Atracurium Besylate vials lacked evidence of a date when removed from the refrigerator. Staff L acknowledged the lack of a policy/procedure for storage of anesthesia drugs.

Based on observations, review of documentation, and staff interview, the Critical Access Hospital (CAH) anesthesia staff failed to ensure the development and implementation of policies/procedures to address the proper storage of anesthesia drugs as specified by the manufacturer's recommendations. (Anesthesia) The CAH Surgery administrative staff reported approximately 11 surgical cases a month that required use of the identified medications.

Failure to ensure the development and implementation of policies/procedures to address the proper temperature controls of pharmaceuticals could potentially cause the improper storage of pharmaceuticals and for them to lose potency, thus not providing desired effect to patients.

Findings included:

1. Tour of the operating room (OR) on 8/31/11 at 12:35 PM revealed the following anesthesia drugs stored in two of two anesthesia carts in the OR area:

Staff L's anesthesia cart:
- 3 of 3 unopened Succinylcholine Chloride Inj. 10 ml Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 2 of 2 unopened Rocuronium Bromide Inj. Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 1 of 1 unopened Atracurium Besylate Inj. 5 ml single dose vial which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.

Staff M's anesthesia cart:
- 2 of 3 unopened and 1 of 3 opened Succinylcholine Chloride Inj. 10 ml Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 3 of 4 unopened and 1 of 4 opened Rocuronium Bromide Inj. Multidose Vials which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.
- 1 of 2 unopened and 1 of 2 opened Atracurium Besylate Inj. 5 ml single dose vial which lacked evidence of a date the vials were removed from the refrigerator and stored at room temperature.

2. Succinylcholine Chloride Inj. manufacturer's product insert, dated May 2004, stated in part ". . . The multidose vials are stable for up to 14 days at room temperature without significant loss of potency. . . ."

3. Rocuronium Bromide Inj. manufacturer's product insert stated in part ". . . Rocuronium Bromide Injection should be stored in a refrigerator, 2-8 degrees C (36-46 degrees F). DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25 degrees C/77 degrees F), use Rocuronium Bromide Injection within 60 days. Use opened vials of Rocuronium Bromide Injection within 30 days. . . ."

4. Atracurium Besylate Inj. manufacturer's product insert, dated May 2004, stated in part ". . . Atracurium Besylate Injection should be refrigerated at 2 - 8 degrees C (36 - 46 degrees F) to preserve potency. DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25 degrees C/77 degrees F), use Atracurium Besylate Injection within 14 days even if rerefrigerated. . . ."

5. Review of Anesthesia policies/procedures revealed the lack of a policy/procedure for storage of anesthesia drugs.

6. During an interview on 8/31/11 at 12:35 PM, Staff L acknowledged the Succinylcholine, Rocuronium, and Atracurium Besylate vials lacked evidence of a date when removed from the refrigerator. Staff L acknowledged the lack of a policy/procedure for storage of anesthesia drugs.






19125


Based on review of documents and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure development, implementation and annual review of written policies and procedures that addressed the provision of Sleep Study services and Enterostamal (ET) services provided by the network hospital for patients admitted to Ellsworth Municipal Hospital.

The CAH administrative staff reported Sleep Study inpatient census of approximately 86 patients yearly and ET inpatient census of approximately 38 patients yearly.

Written policies and procedures provide guidance and consistency among staff and serves as a resource for staff in the provision of care. Failure to maintain policies and procedures for staff reference failed to provide staff with guidance for the expected practices and performances in the provision of patient care. The lack of policies and procedures in the provision of patient care could potentially result in the patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm, illness, or even patient death.

Findings include:

1. Review of the CAH Board of Directors Meeting Minutes lacked documentation for reviewing and approving sleep study policies and procedures since 6/4/1997. During an interview on 8/31/11 at 11:05 AM, the Director of Nursing (DON) stated, "We've never had policies review by our hospital since sleep study services originated in 2002."

2. Review of the CAH Board of Directors Meeting Minutes lacked documentation for reviewing and approving ET policies and procedures since 4/21/2002. During an interview on 8/31/11 at 11:05 AM, the DON stated, "We've never had policies review by our hospital since ET services originated in 1997."

3. Review of the CAH Quality Improvement Meeting Minutes, January 2011 to 8/24/2011 revealed active participation from the sleep study department and ET department in the overall quality improvement program.

4. On 8/31/11 Staff Q, Director of Quality, provided a list of contracted Services at Ellsworth Municipal Hospital, pertinent to patient care services. Review of the contracted services list revealed 2 of 5 contracted services (Sleep study and ET) lacked documentation of annual review of policies and procedures.

5. During an interview on 8/31/11 at 8:50 AM, DON stated the CAH policy and procedure manual included "protocols" for sleep study and ET services and since both services are "an extension of our network hospital [Mercy North Iowa] and are provided by North Iowa staff, we can access their [Mercy North Iowa] policies on the intranet." The DON acknowledged policies on the intranet would not be approved by the Ellsworth Municipal Hospital CAH committee, Medical Staff or the Board of Trustees.

6. On 8/31/11 the DON provided copies of policies from Mercy Medical Center - North Iowa, contingent to sleep study services. The DON documented, "The following polices and procedures are utilized by sleep lab staff contracted from Mercy NI (North Iowa). These are not a part of our policy and procedure manual or approved by the CAH committee."

7. On 8/31/11 the DON provided copies of policies from Mercy Medical Center - North Iowa, contingent to ET services. The DON documented, "The following is the guidelines used by the ET nurse contracted through Mercy NI [North Iowa]. They are found on the Mercy NI Intranet page under resources - patient care resources - skin care. These are not a part of our policy and procedure manual approved by the CAH committee."

8. Review of document titled "Annual Program Evaluation" dated 2/23/11 revealed in part, "...The hospital performs an annual evaluation of its total CAH program and services...and determine if the established policies were followed, and if any changes are needed, to plan for those changes...All written policies and services relative to patient care and other services affecting patient health and safety including policies and procedures for all patient care related services...The CAH committee will submit a written report of their findings. A summary of the final report is reviewed annually by the Hospital Board of Trustees."

9. Review of document titled "Critical Access Hospital Provision of Services" dated 2/23/11 revealed in part,"...The Ellsworth Municipal Hospital Board of Trustees is responsible...for determining, implementing and monitoring policies governing the operation of the hospital including all services provided whether or not they are furnished under arrangement or contract. Services are furnished in accordance with appropriate written policies and procedures...and developed by the CAH committee with input and approval of the Board of Trustees...Services provided indirectly...ET Nursing - provide as needed (prn) by a board Certified ET nurse through a contract with Mercy - North Iowa..." The document lacked sleep study services.

5. Tour of the operating room (OR) on 8/31/11 at 12:35 PM revealed the following outdated anesthesia drugs stored in two of two anesthesia carts and one of one refrigerator in the OR area:

Staff L's anesthesia cart:
- 1 of 2 unopened Rocuronium Bromide Inj. Multidose Vials expired 1 May 2011.

Staff M's anesthesia cart:
- 3 of 3 unopened Rocuronium Bromide Inj. Multidose Vials expired 1 May 2001.

OR refrigerator:
- 3 of 3 unopened Rocuronium Bromide Inj. Multidose Vials expired 1 May 2001.

6. Review of Anesthesia policies/procedures revealed the lack of a policy/procedure for storage of anesthesia drugs or who is responsible for checking for outdated drugs in OR.

7. During an interview on 8/31/11 at 12:35 PM, Staff L acknowledged the outdated Rocuronium vials stored in Staff L's and Staff M's anesthesia carts and the OR refrigerator. Staff L acknowledged the lack of a policy/procedure for storage of anesthesia drugs. Staff L also stated Pharmacy staff checked the OR refrigerator for outdated anesthesia drugs.

8. During an interview on 8/31/11 at 1:00 PM, Staff B, Pharmacist, stated the anesthesia staff stocks their own anesthesia carts and Pharmacy is not responsible for checking for outdates in the OR.

9. During an interview on 8/31/11 at 1:25 PM, Staff K, ER/OR Director, stated Pharmacy was responsible for checking outdated drugs in OR and acknowledged the lack of a policy/procedure for who is responsible for checking outdated drugs in OR.











22064


Based on observation and staff interview, the Critical Access Hospital (CAH) staff failed to ensure outdated medications and patient supplies were not available for patient use in 1 of 1 medical/ surgical units, 2 of 3 offsite clinics (Ellsworth Family Medicine Clinic and Iowa Falls Clinic), 1 of 1 Outpatient Surgical Centers and 1 of 1 Operating Rooms (OR). The CAH administrative staff reported a census of 13 inpatients, Ellsworth Clinic- 20 patients a day, Iowa Falls Clinic- 90 patients a day, Outpatient Surgery Center- 20 patients a week and 11 surgeries a month in OR.

Failure to remove outdated medications for patient care areas could potentially result in patients receiving outdated and ineffective medications.

Findings include:

1. Observation during the medical/ surgical environmental tour on 8/29/11 at 10:00 AM revealed the following expired supplies in the nursing supply room:
a. 7- 5% Dextrose 50 ml (milliliter) IV (intravenous) bags of fluid, expiration date 4/1/11
b. 2- 0.9% Sodium Chloride 50 ml IV bads of fluid, expiration date 6/1/11
c. 6- 0.9% Sodium Chloride 50 ml IV bads of fluid, expiration date 8/1/11
d. 1- 16 Fluid ounce Hydrogen Peroxide bottle, expiration date 3/2011

Observation of the crash cart located by the nursing station revealed 2 Provent Arterial Blood sampling kits, expiration date 5/2008.

Observation in the medical/surgical kitchenette revealed 1- 8 ounce Thicken up container, expiration date 7/5/11.

During an interview on 8/29/11 at 10:00 AM, Staff I (Charge Nurse) stated all the supplies and IV fluids were expired and available for patient use.

2. Observation during the Ellsworth Family Medical Clinic environmental tour revealed 1 bottle of Multistix urine test strips, (100 count), with an expiration date 4/2011. Staff documented the bottle opened on 8/9/11.

During an interview on 8/30/11 at 12:50 PM, Staff F (Clinic Manager) stated the test strips had expired.

During an interview on 8/30/11 at 12:50 PM, Staff G (RN) stated the test strips were expired and the nurse dating when the strips were opened should have checked the expiration date on the bottle.

3. Observation during the Iowa Falls Clinic environmental tour on 8/30/11 at 2:00 PM revealed 1 container of Arzol Silver Nitrate Applicators (100 count) expired on 7/2011. The Silver Nitrate Applicators were located in a cupboard in the East Procedure room. The crash cart at th e nurse's station had 1- 1000 ml bag of Lactated Ringers IV fluid expired on 8/1/2011.

During an interview on 8/30/11 at 2:00 PM, Staff J (RN) confirmed all supplies were expired and available for patient use.

4. Observation during the Outpatient Surgical Center tour on 8/30/11 at 2:00 PM revealed 1- 4 oz bottle of Protocol Cytologic Fixature, (used to secure tissue samples to microscope slides), expired 4/2011.

During an interview on 8/30/11 at 2:00 PM, Staff J (RN) confirmed the expiration date on the bottle and available for patient use.

During an interview on 8/31/11 at 10:00 AM Staff C (Chief Nursing Officer) said the CAH did not have a formal policy specifically for checking outdated supplies.




30076


I. Based on policy review, record review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure employees provide pharmaceutical services within their scope of license and follow the CAH policy for drug samples. The health education director reported an average of 9 diabetes education patients counseled monthly. The sample drug log revealed an average of 6 drug samples dispensed monthly.

Failure to provide adequate oversight of drug sample dispensing could potentially lead to a patient receiving the wrong drug and/or wrong dose which could result in hypoglycemia and lead to seizure, loss of consciousness and death or hyperglycemia and lead to damage to nerves, vessels and organs, dehydration and coma.
Findings include:

Review of a pharmacy CAH policy titled "Drug Samples", with an approval date of 2/23/11, stated in part "... 1. ... Physician shall dispense the samples and provide counseling on administration, dosage, side effects, etc".

During an interview on 8/29/11 at 1:00 PM, Staff A, Health Education Director, reported she provided insulin pen and vial samples to diabetes education patients and counseled the patient on its use, as directed by a physician order. Staff A further reported maintenance of a log of samples dispensed and made the log available for surveyor review.

Review of documents titled "Sample Receipt Drug Record" revealed Staff A dispensed the following insulin samples:

17 Lantus SoloStar pens
10 Humalog Kwik pens
8 Humalog vials
5 Levemir Flex pens
6 Novolog 70/30 mix Flex pens
1 70/30 mix vials

II. Based on policy review, record review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure pharmaceutical records contain sufficient detail to follow the flow from entry into the CAH through dispensation.

Review of a pharmacy CAH policy titled "Drug Samples", with an approval date of 2/23/11, stated in part "... 2. The Ellsworth Municipal Hospital and clinics shall have accountability records for the receipt and disbursement of "samples". ... Information included on the accountability record shall include: the date of receipt/dispensing, from/to whom received/dispensed, medication name and strength, lot number and signature of person receiving/dispensing the samples".

Review of documents titled "Sample Drug Receipt Record" revealed lack of documentation for the following:

The date a sample drug dispensed for 13 of 17 Lantus SoloStar pens, 10 of 10 Humalog Kwik pens, 2 of 5 Levemir Flex pens, 6 of 6 Novolog 70/30 mix Flex pens and 1 of 1 70/30 mix vials.

The patients name for 11 of 17 Lantus SoloStar pens, 10 of 10 Humalog Kwik Pens, 5 of 5 Levemir Flex Pens and 3 of 6 Novolog 70/30 Mix Flex Pens

During an interview on 8/29/11 at 1:00 PM, Staff A confirmed some of the log entries lacked the sample dispensation date and/or the patient's name. Staff A reported he/she omitted the patient's name due to concern about confidentiality. Staff A acknowledged the entries logged with only the patient's initials resulted in the inability to recall the entire name of all the patients.

During an interview on 8/30/11 at 7:15 AM, Staff B, Pharmacist, reported he/she provided no oversight to the dispensing of the insulin samples to diabetes education patients. Staff B confirmed knowledge that Staff A stored and dispensed samples but lacked knowledge of the process Staff A followed.

During an interview on 8/30/11 at 7:30 AM, Staff A reported a lack of knowledge regarding the CAH sample drug policy. Staff A further reported he/she had expressed concerns to Staff C, Chief Nursing Officer, regarding the dispensation of insulin samples.

During an interview on 8/30/11 at 8:45 AM, Staff B confirmed a lack of knowledge regarding the details of the CAH sample drug policy. Staff B reported Staff A had expressed concerns regarding his/her role in dispensing the insulin samples.

Based on observations, policy/procedure review and staff interviews, the Critical Access Hospital (CAH) failed to maintain x-ray emitting equipment in 1 of 1 Offsite clinics, (Ackley Clinic), to ensure the safety of personnel operating the equipment. (Radiology). The clinic staff reported an average of 25 x-rays completed every month.

Failure to maintain x-ray emitting equipment could potentially cause harm if over exposure occurs.

Findings include:

Observations during tour of the Radiology Department, (Ackley Clinic), on 8/30/11 at 10:25 AM, revealed the x-ray emitting equipment control cord in the Radiographic Room could extend outside the safety barrier for the personnel operating the equipment.

During an interview on 8/30/11 at 10:25 AM, Staff H Registered Nurse and x-ray technologist confirmed the x-ray emitting equipment control cord in the Radiographic Room could extend outside the safety barrier for the personnel operating the equipment. Staff perform general extremity and chest x-rays.

Review of the CAH policy titled Radiation Safety Rules, dated 4/2010, revealed in part "... Radiology personnel shall be in the control booth or outside the radiation room during all routine radiographic examinations.

Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) laboratory staff failed to secure patient's urine drug toxicology information in the laboratory department against unauthorized access. The CAH laboratory staff reported approximately 445 urine drug screens yearly.

Based on observation, review of policy and procedures, staff interview, the CAH failed to secure patient medical records from unauthorized users in 1 of 3 offsite clinic areas (Ackley Clinic). The Ackley clinic staff reported approximately 250 patients a week.

Failure to secure patient's medical record information against unauthorized access could result in identify theft or unauthorized disclosure of personal medical information.

Findings include:

I. During an interview on 8/30/11 at 9:25 AM, Staff P, the Laboratory Director stated anyone who entered the laboratory could access patient information located in a cabinet in the phlebotomy room. According to Staff P laboratory staff failed to monitor the phlebotomy room at all times.

Tour of the laboratory department on 8/30/11 from 8:25 AM to 10:25 AM revealed 1 drawer in a cabinet in the phlebotomy room that contained urine drug toxicology screens. Review of the urine drug toxicology screens revealed information including but not limited to patient's name, date of birth, social security number, and urine toxicology information. During an interview, at the time of the observation, Staff P stated the drawer contained "thousands" of old and current (Pre-employment and Department of Transportation [DOT] urine toxicology screening procedures. Staff P reported laboratory staff began storing the urine toxicology screens in the cabinet approximately 5 years ago "because we ran out of room in the lab". Staff P stated, "I suppose we should be locking it, I don't know if we even have a key."

During a follow up interview on 8/30/11 at 2:05 PM, Staff P stated laboratory staff secured the urine toxicology screening procedure "elsewhere" and discovered the key "at the bottom of the drawer."


22064


II. Observation during tour of the Ackley Clinic on 8/30/11 at 10:25 AM revealed approximately 10,000 patient medical records located on open shelves in the billing office. Staff could not secure the shelving that contained the medical records. The medical records included the following patient information: date of birth, social security number, diagnosis, tests and treatments.

During an interview on 8/30/11 at 10:25 AM, Staff I (Billing Specialist), stated housekeeping staff clean the billing office, unsupervised, after closing the clinic for the day. Staff I acknowledged housekeeping staff would have access to information in the patient medical records.

Review of the CAH policy titled, Health Record Access, dated 1/2011 revealed in part "... Access to the paper-based health record is to be restricted to only those individuals who have a need to know and who provide a valid ID badge and/or appropriate documentation to access the information."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 10 of 22 medical staff members selected for review received external peer review from an equivalent peer. The CAH administrative staff identified 102 members of the medical staff.

Failure to ensure all medical staff members received external peer review from a true peer could potentially expose patients to inappropriate medical care.

Findings include:

1. Review of credential files on 8/30/11 from 2:10 PM to 4:30 PM revealed:

a. General Surgeon A's credential file lacked documented evidence of external peer review by a surgeon.

b. Psychiatrist B's credential file lacked documented evidence of external peer review by a psychiatrist.

c. Ophthalmologist C's credential file lacked documented evidence of external peer review by a ophthalmologist.

d. Ear/Nose/Throat (ENT) surgeon's credential file lacked documented evidence of external peer review by a ENT surgeon.

e. Pathologist E's credential file lacked documented evidence of external peer review by a pathologist.

f. Obstetrician F's credential file lacked documented evidence of external peer review by an obstetrician.

g. Urologist G's credential file lacked documented evidence of external peer review by a urologist.

h. Radiologist H's credential file lacked documented evidence of external peer review by a radiologist.

i. Radiologist I's credential file lacked documented evidence of external peer review by a radiologist.

j. Radiologist J's credential file lacked documented evidence of external peer review by a radiologist.

2. Review of documentation presented to the surveyor on 8/31/11, from Staff Q, the Director of Quality Assurance revealed in part;..."[ Practitioner K] conducts our annual peer review. I (Director of Quality Assurance) feel he possess the skill set to review our charts at Ellsworth Municipal Hospital....[Practitioner K] is a family practice physician from Mitchell County, Osage, Iowa. He has a wide array of privileges at Mitchell County. Attached is his continuing education...[Practitioner K] is also a member of the Mitchell County Board of Health...[Practitioner K] special interest is in Geriatric Medicine." Additionally, Staff Q presented a document titled "Practitioner K's - Privileges in Family Medicine," dated July 1, 2011 - June 30, 2013. Review of Practitioner K's privileges revealed Practitioner K was not credentialed to perform surgical procedures including but not limited to general surgery, ophthalmology surgery, ENT surgery and lacked privileges for Pathological procedures/interpretation, Obstetrical procedures, Urology procedures and Radiological/Teleradiological procedures/interpretation.

3. Review of the policy "External Peer Review", reviewed 2/11, revealed in part, "All active medical staff and contracted medical staff that provide care/services to patients at Ellsworth Municipal Hospital will participate in an External Peer Chart Review."

4. Review of "Medical Staff Bylaws of Ellsworth Municipal Hospital" dated 9/2010, revealed in part,..."It is the intention of these Bylaws to define the term peer review...the following shall be express conditions on the application for, or the holding or exercise of, membership or privileges at the Hospital. Each applicant and each member hereby expressly:...Authorizes representative of the Hospital and Medical Staff to solicit, review, and act upon information bearing upon...the practitioner's professional ability, qualifications and conduct...and agrees to execute authorizations and releases to facilitate obtaining such information from third parties at the request of the Hospital."

5. During an interview on 8/30/11 at 2:10 PM, Staff Q stated that they sent medical records to another CAH hospital. The outside CAH had the medical records reviewed by a family practice physician. The outside CAH did not have a general surgeon, psychiatrist, ophthalmologist, ENT surgeon, pathologist, obstetrician, urologist, or radiologist review the medical records of patients that received care from General Surgeon A, Psychiatrist B, Ophthalmologist C, ENT surgeon D, Pathologist E, Obstetrician F, Urologist G, and Radiologist H, I, and J. Staff Q stated, "The physician assigned to complete external peer reviews, is a Family Practice physician with a speciality in geriatric medicine. We understood if the physician felt comfortable they could review any kind of physician speciality."

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure that each swing bed patient is informed fully of his/her rights as required by the regulation. The administrative staff stated a daily average census of 4 skilled patients and a current census of 7 skilled patients.

Failure to present and explain to the skilled patients and/or legal representative all of their rights in a language that he or she could understand could potentially place a patient at risk for a lack of understanding of his/her rights. The patient and/or legal representative's lack of information of patient's rights could potentially put the patient at risk of the inability to exercise his/her rights as a citizen of the US (example voting), and to know they are to be free from coercion, discrimination and reprisal from the facility.

Findings include:

1. Review of the "Your Rights and Responsibilities as a Patient - Swing Bed", a document presented to swing bed patients upon admission containing patient rights for swing bed patients, failed to address the patient's rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.

2. Review of the policy/procedure titled "Your Rights and Responsibilities as a Patient - Swing Bed" failed to address the patient's rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.

3. During an interview on 8/29/11 at 4:25 PM, Staff C, Chief Nursing Officer, stated the nursing staff informed the patients of their rights at the time of admission. The swing bed admission package given to the Swing Bed patients contained 1 patient rights documents. Staff C acknowledged the information given to swing bed patients regarding their rights and the policy/procedure failed to address the patient's rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.