HospitalInspections.org

Based on interview and record review, the Critical Access Hospital (CAH) failed to provide a copy, or inform 10 of 20 patients (P3, P5, P6, P9, P10, P11, P12, P13, P14, and P19) of their Bill of Rights at the time of admission.
Findings include:
P3 was admitted to the CAH on 6/30/14. P3 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 10/7/13.
On 7/1/14, at 2:25 p.m. P3 was interviewed and s/he was unable to recall if s/he had been made aware of his/her rights upon admission.
P5 was admitted to the CAH on 7/1/14. P5 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 5/19/14.
On 7/1/14, at 1:10 p.m. P5 was interviewed and s/he was unable to recall if s/he had been made aware of his/her rights upon admission.
P6 was admitted to the CAH on 6/5/14. P6 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 3/24/14.
P9 was admitted to the CAH on 4/25/14. P9 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 1/27/14.
P10 was admitted to the CAH on 5/11/14. P10 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 12/16/13.
P11 was admitted to the CAH on 4/15/14. P11 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 10/30/13.
P12 was admitted to the CAH on 2/17/14. P12 ' s parent had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 8/29/13.
P13 was admitted to the CAH on 5/22/14. P13 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 10/24/13.
P14 was admitted to the CAH on 1/17/14. P14 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 1/1/14.
P19 was admitted to the CAH on 5/17/14. P19 had signed the CENTRACARE HEALTH SYSTEM BILL OF RIGHTS ACKNOWLEDGEMENT FORM MEDICARE CONDITION OF PARTICIPATION form on 10/7/13.
On 7/1/14, at 11:20 a.m. the director of patient services confirmed the Bill of Rights was provided to the patients once a year. This practice had been initiated on 4/7/11.
The CAH's BILL OF RIGHTS - HIPPA AND RESPONSIBILITIES OF PATIENTS policy dated 4/7/11, indicated the Bill of Rights were to be given yearly to every patient.

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure preventive maintenance (PM) was performed on the patient beds. This had the potential to affect all patients who received care at the CAH.
Findings include:
On 7/1/14, at 1:15 p.m. a tour of the nursing unit was completed with the maintenance manager (MM). The patient bed count was completed and the MM verified there were 20 beds currently in the CAH with two additional beds in storage. It was observed that the patient beds lacked a PM sticker. The MM confirmed the CAH had stopped placing PM stickers on the hospital beds and the maintenance department did not routinely conduct PM on the patient beds. The MM was unable to confirm when the last PM had been conducted on the patient beds.
On 7/2/14, at 11:55 a.m. the director of patient services verified the biomedical staff from St. Cloud hospital, who conducted PM on some of the CAH's equipment, had removed the PM stickers from the patient beds. The director stated they had made the recommendation for the CAH maintenance department to develop a PM plan for the patient beds to ensure routine monitoring continued to be completed. The director of patient services was unable to verify when the last PM had been completed on the patient beds.
No policy or manufacture guidelines, with regards to preventive maintenance for the CAH's patient beds, were provided.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure a comprehensive list of services furnished under agreements or arrangements had been maintained. This had the potential to affect all patients who receive services at the CAH.
Findings include:
On 7/1/14 at 9:50 a.m., the administrative secretary provided the CAH's current list of services provided through agreements or arrangements. The CAH's [undated] "Listing of contracts" identified 14 services the CAH had an arrangement or agreement; however the list lacked documentation of the contracted services responsibilities. The administrator and administrative secretary confirmed the list provided did not include a delineation of responsibilities of the agreement services, nor was this an inclusive list. The administrator verified some of the agreement or contracted services which were missing from this list were: American Red Cross (blood services), Sightpath Medical (cataract instrumentation services), Clean Harbors (hazardous waste disposal), St. Cloud Sleep Study and Sinclair (emergency fuel services.)