HospitalInspections.org

Based on employee health record review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to implement a system to identify and prevent transmission of infections and communicable diseases to patients, which included routine health screening for CAH volunteers. Problems were identified 2 of 3 volunteers selected for review. The CAH identified 105 active volunteers.

Failure to identify infections and communicable diseases could potentially result in causing harm to patients through exposure and transmission of communicable diseases.

Findings include:

1. Review of the Iowa Administrative Code for the Department of Inspections and Appeals, Chapter 51 titled "Hospitals", last updated 12/10/14, revealed in part ". 51.24(3) Health examinations for all personnel shall be required at the commencement of employment and thereafter at least every four years. The examination shall include, at a minimum, the health status of the employee . . .

2. Review of a CAH policy titled "Tuberculosis Screening", reviewed in 2/13, revealed in part "... All current associates will participate in an every four year health screening which includes screening for TB (tuberculosis) ... "

3. Review of the volunteer health information revealed Staff F and Staff G, Volunteers, revealed the lack of a documented health screen within the last 4 years.

4. During an interview on 3/9/2016, at 10:00 AM, Staff E, Administrative Assistant, reported the volunteers are required to have a TB test and health screening when they start as a volunteer, but the health screening is not repeated every 4 years, as required for employees. Staff E acknowledged the health screenings in the files for Staff F and Staff G contained health screenings from 2009.

Based on observation, policy and document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to secure and protect patient information from unauthorized users in 1 of 1 basement storage areas.

Failure to ensure administrative staff secured patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. Review of a CAH policy titled "Confidentiality and Security of Patient Data", revised 5/2013, revealed in part " ... All information contained in the medical record of a patient, both paper and electronic, will be considered protected health information and is confidential ... "

2. During the CAH environment tour on 3/8/16, at 2:10 PM, observation in the basement storage area revealed a large open room which contained several shelving units of radiology films, cardiology testing records and laboratory records.

3. During an interview on 3/8/16 at 2:10 PM, Staff H, Coordinator of Plant Engineering, reported the Medical Records/Business Office Supervisor, maintenance and environmental services staff had a key to access the basement storage area. Staff J, Lead Radiology Tech, reported the department stored radiology films and cardiology testing records in the storage area and acknowledged the information included patient's personal health information, such as name, date of birth, test results, etc. Staff J confirmed the area contained 10 large file boxes of cardiology information and approximately 7,500 radiology films. Staff K, Contracted Lead Laboratory Tech, reported they stored laboratory requisitions in the storage area and acknowledged the information included patient's personal health information, such as name, date of birth, patient identification numbers (some of which were social security numbers), test results, etc. Staff H and Staff I, Contracted Supervisor of Plant Engineering, confirmed the area stored approximately 157 large file boxes of laboratory records.

During a follow-up interview, on 3/9/16, at 8:00 AM, Staff H reported when he confirmed who had a key to access the basement storage area, he determined most departments have one, which would most likely be accessible to all the department employees and allow them unsupervised access to patient's personal health information.

During an interview on 3/9/16, at 12:20 PM, Staff L, Medical Records/Business Office Supervisor, confirmed the open storage of radiology and laboratory records in the basement provided unsupervised access to patient's personal health information to unauthorized users.

4. Review of a document provided by Staff H, on 3/9/16, revealed a list of departments with a key to access the basement storage area which identified Acute nursing, Administrator, Human Resources, Environmental Services, Laboratory, Maintenance, Mercy Family Pharmacy (retail), Nutrition, Oak Crest Manor spiritual care, Radiology and Rehab.

Based on review of policies/procedures, documents and staff interviews, the Critical Access Hospital (CAH) failed to ensure the periodic evaluation of its total CAH program included the number of patients served and the volume of services provided at the CAH for 10 of 14 services provided. (Nutrition, Physical Therapy, Infusion, Pharmacy, Radiology, Laboratory, Ultrasound, Occupational Therapy, Speech Therapy, and Enterostomal) The CAH staff identified a current census of 3 patients at the start of the survey.

Failure to include the number of patients served and the volume of services provided at the CAH could potentially result in the CAH failing to meet the needs of their patients.

Findings include:

1. Review of policies/procedures revealed the lack of a policy/procedure that addressed the periodic program evaluation including the number of patients served and the volume of services provided.

2. Review of document titled "Annual Periodic Program Evaluation", dated 2015 lacked the number of patients served and the volume of services Nutrition, Physical Therapy, Infusion, Pharmacy, Radiology, Laboratory, Ultrasound, Occupational Therapy, Speech Therapy, and Enterostomal.

3. During an interview on 3/9/16 at 9:30 AM, Staff A, Director of Patient Care Services, verified the lack of a policy/procedure that addressed the periodic program evaluation including the number of patients served and the volume of services provided. Staff A acknowledged the periodic program evaluation lacked documentation of the number of patients served and the volume of services for Nutrition, Physical Therapy, Infusion, Pharmacy, Radiology, Laboratory, Ultrasound, Occupational Therapy, Speech Therapy, and Enterostomal.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present all of the required patient rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient rights:
a. (1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
b. (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.
c. (3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.
d. (4) In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.
e. (ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

3. During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient rights:
(i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section.
§483.10(b)(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

3. During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights (§483.10(d)(1)): The resident has the right to - Choose a personal attending physician.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights (§483.10(d)(2)): The resident has the right to - Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights (§483.10(d)(3)): The resident has the right to - Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
The resident has the right to personal privacy and confidentiality of his or her personal and clinical records.
(1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident;
(2) Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility;
(3) The resident's right to refuse release of personal and clinical records does not apply when-
(i) The resident is transferred to another health care institution; or
(ii) Record release is required by law."

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights - work
The resident has the right to -
(1) Refuse to perform services for the facility;
(2) Perform services for the facility, if he or she chooses, when-
(i) The facility has documented the need or desire for work in the plan of care;
(ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid;
(iii) Compensation for paid services is at or above prevailing rates; and
(iv) The resident agrees to the work arrangement described in the plan of care."

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights - mail
The resident has the right to privacy in written communications, including the right to-
(1) Send and promptly receive mail that is unopened; and
(2) Have access to stationery, postage, and writing implements at the resident's own expense.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights - access and visitation
"(1) The resident has the right and the facility must provide immediate access to any resident by the following:
(vii) Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and
(viii) Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident."

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights - personal property
The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other residents.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident rights - married couples
The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident behavior and facility practices - restraints:
The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on review of policies/procedures, documentation, medical records, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure that 2 of 2 current skilled patients and 5 of 5 discharged skilled patients received a complete list of the required patient rights for swing bed patients (Patients # 11, 12, 21, 22, 23, 24, and 25). The CAH staff identified a current census of 2 skilled patients at the start of the survey and an average of 2 skilled patients per day.

Failure to present and explain all of the required rights to the patients admitted to swing beds and/or their legal representative could result in the patients and/or their legal representatives' being unaware of all of their rights as swing bed patients while they are continuing to receive skilled level care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of policy/procedure titled "Admission to Skilled Care", dated 10/14, revealed in part, ". . . The Resident Admission Agreement, Resident Bill of Rights and the welcome to Skilled Nursing pamphlet are given and reviewed with the patient and/or significant other. The patient/significant other signs 'Receipt of Document' form which is placed in the medical record. If the patient is unable to sign, the next of kin or guardian signs the form. Document the patient's inability to sign. . . ."

Review of undated patient handout given to skilled patients titled "Patient Handbook and Resource Guide" lacked the following patient right:
Resident behavior and facility practices - abuse:
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

2. Review of medical records for skilled patients # 11, 12, 21, 22, 23, 24, and 25 lacked documentation the patient received the "Resident Bill of Rights" and signed the "Receipt of Document" form that verified the patients received skilled patient rights.

During an interview on 3/9/16 at 2:10 PM, Staff D, Registered Nurse, confirmed medical records for skilled patients #21, 22, 23, 24, and 25 did not contain documentation for staff providing the receipt of skilled rights to these patients.

3. During an interview on 3/8/16 at 2:45 PM, Staff C, Clinical Leader, verified the patient rights handbook titled "Patient Handbook and Resource Guide" that skilled patients received lacked the patient rights listed above.

During an interview on 3/8/16 at 2:35 PM, Patient #11 verified the patient rights received when admitted to skilled care was the "Patient Handbook and Resource Guide".

During an interview on 3/8/16 at 3:25 PM, Staff A, Director of Patient Care Services, and Staff C, Clinical Leader, acknowledged the CAH staff had not provided "Resident Rights" to skilled patient per policy for at least 2 years.

Based on document review, and patient and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. The CAH staff identified a current census of 3 patients at the start of the survey.

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of undated patient handout given to inpatients titled "Patient Handbook and Resource Guide" and undated patient brochure given to outpatients titled "Your Rights and Responsibilities as a Patient" revealed the documents lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 3/8/16 at 1:20 PM, Staff A, Director of Patient Care Services, acknowledged the inpatients receive "Patient Handbook and Resource Guide" for their visitation rights and outpatients receive "Your Rights and Responsibilities as a Patient" brochure for their visitation rights. An additional interview on 3/8/16 at 1:45 PM, Staff A acknowledged the information the inpatients and outpatients receive lacked the required visitation rights language as stated in the regulations.

During an interview on 3/8/16 at 1:30 PM, Staff B, Hospital Admissions, stated the outpatients receive "Your Rights and Responsibilities as a Patient" brochure for their visitation rights when they register as an outpatient.

During an interview on 3/8/16 at 2:25 PM, Patient #13 stated they received "Patient Handbook and Resource Guide" for their visitation rights.

During an interview on 3/8/16 at 2:35 PM, Patient #11 stated they received "Patient Handbook and Resource Guide" for their visitation rights.