HospitalInspections.org

Based on observation, document review, and staff interview, it was determined that the hospital's governing body failed to ensure the hospital met all Federal regulations, assume full responsibility for determining, implementing, and monitoring policies governing the hospital's total operation. The governing body failed to ensure they met the requirements for the notice of rights (the patient and/or the patient's representative are informed of the patient's rights and the patient and/or the patient's representative are informed of whom to contact to file a grievance) (refer to A-116), to inform each patient and/or the patient's representative of their rights on admission to the hospital (refer to A-117), inform each patient and/or the patient's representative of their right on admission to the hospital who to contact to file a grievance (refer to A-118), ensure the patient and/or patient's representative exercised their right to participate in the development and implementation of their plan of care (refer to A-130), include in their Patient Bill of Rights the patient has the right to be free from all forms of abuse or harassment (refer to A-145), ensure the patient's right to the safe application and implementation of restraints or seclusion by trained staff (refer to A-194), conduct staff training in the use of restraints and seclusion in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for the patient during orientation and periodically based on hospital policy (refer to A-196), conduct staff (including contract or agency staff) training for the use of restraints and seclusion that include clinical techniques used to identify patient and staff behaviors, events and environmental factors that may require the use of restraints or seclusion (refer to A-199), ensure the staff have training in the use of nonphysical intervention skills before the use of restraints or seclusion (refer to A-200), conduct staff training in choosing the least restrictive intervention for the use of restraints and seclusion (refer to A-201) conduct staff training to ensure staff know the safe application of restraint or seclusion (refer to A-202), conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued (refer to A-204), conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued (refer to A-205), Hospital lacked evidence of training and demonstration of competency in the use of restraints or seclusion during orientation or periodically (refer to A-208), Hospital failed to establish and implement policies and procedures for the requirements of reporting deaths associated with the use of restraints or seclusion (refer to A-213), establish and implement a tracking system or log to document any death that occurs when the only restraint used on a patient was soft restraints on the wrist and any death that occurs 24 hours after the use of soft wrist restraints (refer to A-214), inform each patient and/or the patient's representative of their visitation rights on admission (refer to 216), failed to ensure the providers date and time all entries into the medical record (refer to A-0450), failed to ensure providers sign orders given in the emergency room (refer to A-0454), failed to ensure the providers complete a history and physical within twenty-four hours after admission (refer to A-0458), failed to ensure patients entering the hospital for services completed a consent for medical and/or surgical treatment (A-0466), and failed to ensure the providers complete a discharge summary within thirty days after discharge (refer to A-0469), and failed to develop an active infection control system (refer to A-0749).




The cumulative effect of the systematic failure to ensure failed to ensure they met the requirements for the notice of rights, to inform each patient and/or the patient's representative of their rights on admission to the hospital, inform each patient and/or the patient's representative of their right on admission to the hospital who to contact to file a grievance, ensure the patient and/or patient's representative exercised their right to participate in the development and implementation of their plan of care, to include in their Patient Bill of Rights the patient has the right to be free from all forms of abuse or harassment, ensure the patient's right to the safe application and implementation of restraints or seclusion by trained staff, conduct staff training in the use of restraints, conduct staff training for the use of restraints and seclusion, events and environmental factors that may require the use of restraints or seclusion, ensure the staff have training in the use of nonphysical intervention skills before the use of restraints or seclusion, conduct staff training in choosing the least restrictive intervention for the use of restraints and seclusion, conduct staff training to ensure staff know the safe application of restraint or seclusion, conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued, conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued, failed to establish and implement policies and procedures for the requirements of reporting deaths associated with the use of restraints or seclusion, establish and implement a tracking system or log to document any death that occurs when in restraints, inform each patient and/or the patient's representative of their visitation rights on admission, failed to ensure providers date and time all entries into the medical record, sign orders given in the emergency room, complete a history and physical within twenty-four hours after admission, complete medical records within thirty days after discharge, and ensure patients complete a consent for treatment, and failed to develop an active infection control system and ensure a hospital-wide quality assessment program resulted in the hospitals inability to provide care in a safe and effective manner.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on Medical Staff Credentialing file review and staff interview the hospital Governing Body failed to ensure medical staff requirements are met through a current reappointment for two of eight Medical Staff Credentialing files reviewed. This deficient practice had the potential to affect quality patient care.

Finding include:

- The hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 5/27/14 at 3:30pm directed, "...Reappointments and appointments shall be for a period of two medical staff years..."

- Medical Staff T's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/18/11. The Governing Body failed to insure practitioner T, listed as the hospital's consulting pathologist, had a current reappointment to the medical staff.

- Medical Staff U's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/14/11. The Governing Body failed to insure practitioner U, an active staff physician, had a current reappointment to the medical staff.

Medical Records staff E interviewed on 5/27/14 at 3:30pm acknowledged Medical Staff T and U failed to have a current reappointment to the Medical Staff by the hospital Governing Body.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on Medical Staff Credentialing file review and staff interview the hospital Governing Body failed to consider the recommendations of medical staff and ensure medical staff requirements are met through a current reappointment for two of eight Medical Staff Credentialing files reviewed.

Finding include:

- The hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 5/27/14 at 3:30pm directed, "...Reappointments and appointments shall be for a period of two medical staff years..."

- Medical Staff T's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/18/11. The Governing Body failed to insure practitioner T, listed as the hospital's consulting pathologist, had a current reappointment to the medical staff.

- Medical Staff U's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/14/11. The Governing Body failed to insure practitioner U, an active staff physician, had a current reappointment to the medical staff.

Medical Records staff E interviewed on 5/27/14 at 3:30pm acknowledged Medical Staff T and U failed to have a current reappointment to the Medical Staff by the hospital Governing Body.

Based on medical record review, policy review and staff interview the Hospital failed to: ensure they met the requirements for the notice of rights (refer to A-116); inform each patient and/or the patient's representative of their rights on admission to the hospital (refer to A-117); inform each patient and/or the patient's representative whom to contact to file a grievance (refer to A-118); ensure the patient and/or patient's representative exercised their right to participate in the development and implementation of their plan of care (refer to A-130); include in their Patient Bill of Rights that the patient has the right to be free from all forms of abuse or harassment (refer to A-145); ensure the patient's right to the safe application and implementation of restraints or seclusion by trained staff (refer to A-194); conduct staff training in the use of restraints and seclusion in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for the patient during orientation and periodically based on hospital policy (refer to A-196); conduct staff (including contract or agency staff) training for the use of restraints and seclusion that include clinical techniques used to identify patient and staff behaviors, events and environmental factors that may require the use of restraints or seclusion (refer to A-199); ensure the staff have training in the use of nonphysical intervention skills before the use of restraints or seclusion (refer to A-200); conduct staff training in choosing the least restrictive intervention for the use of restraints and seclusion (refer to A-201); conduct staff training to ensure staff know the safe application of restraint or seclusion (refer to A-202); conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued (refer to A-204); conduct staff training to ensure staff know to monitor the physical and psychological wall being of the patient in restraint or seclusion (refer to A-205); provide evidence of training and demonstration of competency in the use of restraints or seclusion during orientation or periodically (refer to A-208); establish and implement policies and procedures for the requirements of reporting deaths associated with the use of restraints or seclusion (refer to A-213); establish and implement a tracking system or log to document any death that occurs when the only restraint used on a patient was soft restraints on the wrist and any death that occurs 24 hours after the use of soft wrist restraints (refer to A-214); inform each patient and/or the patient's representative of their visitation rights on admission (refer to A-216).

The cumulative effect of the systemic failure to provide patient rights to all patients entering the hospital for services and the lack of staff training in regard to the use of restraints and seclusion resulted in the hospitals inability to provide care in a safe and effective manner.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on medical record review, policy review and staff interview the Hospital failed to ensure they met the requirements for the notice of rights (the patient and/or the patient's representative are informed of the patient's rights and the patient and/or the patient's representative are informed of whom to contact to file a grievance) for 12 of 20 inpatient records reviewed (patient #'s 11, 12, 13, 15, 17, 19, 20, 26, 27, 28, 29, and 30) and 8,803 reported outpatients who presented for outpatient services. This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The Hospital's policy titled "Patient Rights (effective date of 11/6/07)" reviewed on 5/27/1 directed, "...1. Admission personnel are to offer to read the Patient's Rights form to the patient or patient's representative...3. Patient or representative are to sign the last page showing that they did receive the form...5. The signed page will be taken to the nurses station and put in patient's chart..."

- The Hospital's policy titled "PATIENT RIGHTS POLICY AND PROCEDURE (revised 1/02)" reviewed on 5/27/14 directed, "... Admission personnel are to get a signed and witnessed Patient Rights pamphlet. Patients who are admitted to the hospital as inpatient, swingbed, Gero-psych, observation or ambulatory surgery will sign...The form is to be read and signed each time the patient is admitted to the MORTON COUNTY HEALTH SYSTEM..."

Findings include:

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #15's medical record reviewed on 5/21/14 revealed an admission date of 2/24/14 and discharged on 2/28/14 with diagnoses of congestive heart failure and swelling of both lower legs. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.


-Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. ). Patient #19's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.


-Patient #27's medical record reviewed on 5/22/14 revealed an admission date of 1/28/14 and discharged on 2/1/14 with a diagnosis of chronic obstructive pulmonary disease (COPD). Patient #27's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 2/7/14 and discharged on 2/13/14 with a diagnosis of abdominal pain. Patient #29's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.


-Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

Staff W, Administrative Staff, interviewed on 5/21/14 at 8:45pm explained the admission process starts in registration. Registration gives the patient the Patient's Handbook, tear off the back page (form) and have the patient sign the form that is kept in registration.
Staff W, Administrative Staff, interviewed on 5/21/14 at 9:30am acknowledged that no emergency room or outpatients receive the patient rights. Staff W explained if a patient has previously been at the hospital less than six months the patient does not get the patient rights.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on medical record review, policy review and staff interview the Hospital failed to inform each patient and/or the patient's representative of their rights on admission to the hospital for 12 of 20 inpatient records reviewed (patient #'s 11, 12, 13, 15, 17, 19, 20, 26, 27, 28, 29, and 30) and 8,803 reported outpatients who presented for outpatient services. This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The Hospital's policy titled "Patient Rights (effective date of 11/6/07)" reviewed on 5/27/1 directed, "...1. Admission personnel are to offer to read the Patient's Rights form to the patient or patient's representative...3. Patient or representative are to sign the last page showing that they did receive the form...5. The signed page will be taken to the nurses station and put in patient's chart..."

- The Hospital's policy titled "PATIENT RIGHTS POLICY AND PROCEDURE (revised 1/02)" reviewed on 5/27/14 directed, "... Admission personnel are to get a signed and witnessed Patient Rights pamphlet. Patients who are admitted to the hospital as inpatient, swingbed, Gero-psych, observation or ambulatory surgery will sign...The form is to be read and signed each time the patient is admitted to the MORTON COUNTY HEALTH SYSTEM..."

Findings include:

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The Hospital failed to protect and promote patient rights.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The Hospital failed to protect and promote patient rights.

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The Hospital failed to protect and promote patient rights.

- Patient #15's medical record reviewed on 5/21/14 revealed an admission date of 2/24/14 and discharged on 2/28/14 with diagnoses of congestive heart failure and swelling of both lower legs. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The Hospital failed to protect and promote patient rights.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The Hospital failed to protect and promote patient rights.


-Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. ). Patient #19's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.

-Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.

-Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.


-Patient #27's medical record reviewed on 5/22/14 revealed an admission date of 1/28/14 and discharged on 2/1/14 with a diagnosis of chronic obstructive pulmonary disease (COPD). Patient #27's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.

-Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.

Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 2/7/14 and discharged on 2/13/14 with a diagnosis of abdominal pain. Patient #29's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.


-Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission. The hospital failed to protect and promote patient rights.

Staff W, Administrative Staff, interviewed on 5/21/14 at 8:45pm explained the admission process starts in registration. Registration gives the patient the Patient's Handbook, tear off the back page (form) and have the patient sign the form that is kept in registration.
Staff W, Administrative Staff, interviewed on 5/21/14 at 9:30am acknowledged that no emergency room or outpatients receive the patient rights. Staff W explained if a patient has previously been at the hospital less than six months the patient does not get the patient rights.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on medical record review, policy review and staff interview the Hospital failed to inform each patient and/or the patient's representative of their right on admission to the hospital whom to contact to file a grievance for 12 of 20 inpatient records reviewed (patient #'s 11, 12, 13, 15, 17, 19, 20, 26, 27, 28, 29, and 30) and 8,803 reported outpatients who presented for outpatient services. This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The Hospital's policy titled "Patient Rights (effective date of 11/6/07)" reviewed on 5/27/1 directed, "...1. Admission personnel are to offer to read the Patient's Rights form to the patient or patient's representative...3. Patient or representative are to sign the last page showing that they did receive the form...5. The signed page will be taken to the nurses station and put in patient's chart..."

- The Hospital's policy titled "PATIENT RIGHTS POLICY AND PROCEDURE (revised 1/02)" reviewed on 5/27/14 directed, "... Admission personnel are to get a signed and witnessed Patient Rights pamphlet. Patients who are admitted to the hospital as inpatient, swingbed, Gero-psych, observation or ambulatory surgery will sign...The form is to be read and signed each time the patient is admitted to the MORTON COUNTY HEALTH SYSTEM..."

Findings include:

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to cantact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whome to contact to file a grievance . The Hospital failed to protect and promote patient rights.

- Patient #15's medical record reviewed on 5/21/14 revealed an admission date of 2/24/14 and discharged on 2/28/14 with diagnoses of congestive heart failure and swelling of both lower legs. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission includidng informing them whom to contact to file a grievance. The Hospital failed to protect and promote patient rights.


-Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. ). Patient #19's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.


-Patient #27's medical record reviewed on 5/22/14 revealed an admission date of 1/28/14 and discharged on 2/1/14 with a diagnosis of chronic obstructive pulmonary disease (COPD). Patient #27's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

-Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 2/7/14 and discharged on 2/13/14 with a diagnosis of abdominal pain. Patient #29's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.


-Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including informing them whom to contact to file a grievance. The hospital failed to protect and promote patient rights.

Staff W, Administrative Staff, interviewed on 5/21/14 at 8:45pm explained the admission process starts in registration. Registration gives the patient the Patient's Handbook, tear off the back page (form) and have the patient sign the form that is kept in registration.
Staff W, Administrative Staff, interviewed on 5/21/14 at 9:30am acknowledged that no emergency room or outpatients receive the patient rights. Staff W explained if a patient has previously been at the hospital less than six months the patient does not get the patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, hospital policy review, and staff interview the hospital failed to ensure the patient and/or patient's representative exercised their right to participate in the development and implementation of their plan of care for nine of fifteen acute care sampled patients (# ' s 13, 17, 18, 19, 20, 26, 28, and 30). This deficient practice places all patients at risk for inadequate nursing care.


Findings include:


-The hospital ' s policy for care plans reviewed on 5/27/14 at 11:00am directed, " ...To organize a plan of care and identify diagnoses that meet patient ' s needs and provide for continuity of care ...care planning is to be initiated within 24 hours of admission ...evaluate patient ' s needs in reference to patient ' s illness, physical condition and rehabilitation ...care planning should be an ongoing process and should be updated weekly and as necessary ...both the nurse and the patient should sign the care plan..."

- Patient #11 ' s medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #12 ' s medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.
- Patient #14 ' s closed medical record reviewed on 5/21/14 revealed an admission date of 2/5/14 and expired on 2/21/14 with a diagnosis of cancer of the pancreas and liver. Patient #14 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.



-Patient #19 ' s medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. Patient #19 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

-Patient #20 ' s medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

-Patient #28 ' s medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

-Patient #29 ' s medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of abdominal pain. Patient #29 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

-Patient #30 ' s medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30 ' s medical record lacked evidence of a care plan that identified needs and sets treatment goals.

Administrative nursing staff B, interviewed on 5/21/14 at 5:00pm acknowledged the medical records for patient # ' s 11, 12 and 14 lacked evidence of a care plan that identified and sets treatment goals.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on review of patient rights and staff interview the Hospital failed to include in their Patient Bill of Rights the patient has the right to be free from all forms of abuse or harassment. This deficient practice fails to protect and promote the rights of each resident

Findings include:

- Review of the Patient Handbook on 5/22/12 at 6:30am revealed the "PATIENTS BILL OF RIGHTS" lacked the patient right that the patient has the right to be free from all forms of abuse and harassment.

Staff BB, QAPI coordinator interviewed on5/28/14 at 8:40am acknowledged the "PATIENTS BILL OF RIGHTS" needs to be reviewed and revised.



































































Surveyor: Finck, Lavonne
The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on review of patient rights and staff interview the Hospital failed to include in their Patient Bill of Rights the patient has the right to be free from all forms of abuse or harassment. This deficient practice fails to protect and promote the rights of each resident

Findings include:

- Review of the Patient Handbook on 5/22/12 at 6:30am revealed the "PATIENTS BILL OF RIGHTS" lacked the patient right that the patient has the right to be free from all forms of abuse and harassment.

Staff , QAPI coordinator interviewed on5/28/14 at 8:40am acknowledged the "PATIENTS BILL OF RIGHTS" need to be reviewed and revised.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to ensure the patient's right to the safe application and implementation of restraints or seclusion by trained staff. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.

- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff training in the use of restraints and seclusion in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for the patient during orientation and periodically based on hospital policy. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion and lacked a policy and procedure regarding when staff training occurs.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff (including contract or agency staff) training for the use of restraints and seclusion that include clinical techniques used to identify patient and staff behaviors, events and environmental factors that may require the use of restraints or seclusion. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the hospital failed to ensure the staff have training in the use of nonphysical intervention skills before the use of restraints or seclusion. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff training in choosing the least restrictive intervention for the use of restraints and seclusion.

The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.



- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff training to ensure staff know the safe application of restraint or seclusion. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff training to ensure staff know specific behavioral changes that could indicate that restraints or seclusion can be safely discontinued. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.



- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to conduct staff training to ensure staff know how to monitor the physical and psychological well-being of the patient who is restrained or secluded. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.



- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital lacked evidence of training and demonstration of competency in the use of restraints or seclusion during orientation or periodically. The lack of staff training of the application and implementation of restraints or seclusion puts all patients who require the use of restraints or seclusion at risk.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to conduct staff training regarding the use of restraints and seclusion.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to establish and implement policies and procedures for the requirements of reporting deaths associated with the use of restraints or seclusion.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to establish and implement policies and procedures for the requirements of reporting deaths associated with the use of restraints or seclusion. Staff B explained they have not had any deaths of patients in restraints.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on staff interview the Hospital failed to establish and implement a tracking system or log to document any death that occurs when the only restraint used on a patient was soft restraints on the wrist and any death that occurs 24 hours after the use of soft wrist restraints.

Findings include:

- Staff B, Administrative Staff, interviewed on 5/28/14 at 9:00am acknowledged the Hospital failed to establish and implement a tracking system or log to document any death that occurs when the patient has soft wrist restraints and any death death that occurs 24 hours after the use of soft wrist restraints.


- Staff DD, Education Coordinator, interviewed on 5/28/14 at 8:25am acknowledged the Hospital failed to conduct restraint training for the Hospital staff.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on medical record review, policy review and staff interview the Hospital failed to inform each patient and/or the patient's representative of their visitation rights on admission to the hospital for 12 of 20 inpatient records reviewed (patient #'s 11, 12, 13, 15, 17, 19, 20, 26, 27, 28, 29, and 30) and 8,803 reported outpatients who presented for outpatient services. This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The Hospital's policy titled "Patient Rights (effective date of 11/6/07)" reviewed on 5/27/1 directed, "...1. Admission personnel are to offer to read the Patient's Rights form to the patient or patient's representative...3. Patient or representative are to sign the last page showing that they did receive the form...5. The signed page will be taken to the nurses station and put in patient's chart..."

- The Hospital's policy titled "PATIENT RIGHTS POLICY AND PROCEDURE (revised 1/02)" reviewed on 5/27/14 directed, "... Admission personnel are to get a signed and witnessed Patient Rights pamphlet. Patients who are admitted to the hospital as inpatient, swingbed, Gero-psych, observation or ambulatory surgery will sign...The form is to be read and signed each time the patient is admitted to the MORTON COUNTY HEALTH SYSTEM..."

Findings include:

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The Hospital failed to protect and promote patient rights.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The Hospital failed to protect and promote patient rights.

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The Hospital failed to protect and promote patient rights.

- Patient #15's medical record reviewed on 5/21/14 revealed an admission date of 2/24/14 and discharged on 2/28/14 with diagnoses of congestive heart failure and swelling of both lower legs. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The Hospital failed to protect and promote patient rights.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #15's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The Hospital failed to protect and promote patient rights.


-Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. ). Patient #19's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.

-Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.

-Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.


-Patient #27's medical record reviewed on 5/22/14 revealed an admission date of 1/28/14 and discharged on 2/1/14 with a diagnosis of chronic obstructive pulmonary disease (COPD). Patient #27's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.

-Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.

Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 2/7/14 and discharged on 2/13/14 with a diagnosis of abdominal pain. Patient #29's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.


-Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record lacked evidence the patient and/or the patient's representative received patient rights on admission including their visitation rights. The hospital failed to protect and promote patient rights.

Staff W, Administrative Staff, interviewed on 5/21/14 at 8:45pm explained the admission process starts in registration. Registration gives the patient the Patient's Handbook, tear off the back page (form) and have the patient sign the form that is kept in registration.
Staff W, Administrative Staff, interviewed on 5/21/14 at 9:30am acknowledged that no emergency room or outpatients receive the patient rights. Staff W explained if a patient has previously been at the hospital less than six months the patient does not get the patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on Medical Staff Credentialing file review, Medical Staff Rules and Regulation review and staff interview the hospital Medical Staff failed to ensure medical staff requirements are met through a current reappointment for two of eight Medical Staff Credentialing files reviewed. This deficient practice had the potential to affect quality patient care.

Finding include:

- The hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 5/27/14 at 3:30pm directed, "...Reappointments and appointments shall be for a period of two medical staff years..."

- Medical Staff T's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/18/11. The Medical Staff failed to insure practitioner T, listed as the hospital's consulting pathologist, had a current reappointment to the medical staff.

- Medical Staff U's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/14/11. The Medical Staff failed to insure practitioner U, an active staff physician, had a current reappointment to the medical staff.

Medical Records staff E interviewed on 5/27/14 at 3:30pm acknowledged Medical Staff
T and U failed to have a current reappointment to the Medical Staff.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on Medical Staff Credentialing file review, Medical Staff Rules and Regulations, and staff interview the hospital Medical Staff failed to examine credentials and make recommendations to the Governing Body on appointment to the Medical Staff for two of eight Medical Staff Credentialing files reviewed.

Finding include:

- The hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 5/27/14 at 3:30pm directed, "...Reappointments and appointments shall be for a period of two medical staff years..."

- Medical Staff T's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/18/11. The Governing Body failed to insure practitioner T, listed as the hospital's consulting pathologist, had a current reappointment to the medical staff.

- Medical Staff U's credentialing file reviewed on 5/27/14 at 2:35pm revealed a reappointment date of 7/14/11. The Governing Body failed to insure practitioner U, an active staff physician, had a current reappointment to the medical staff.

Medical Records staff E interviewed on 5/27/14 at 3:30pm acknowledged the Medical Staff failed to examine credentials and make recommendations to the Governing Body on appointment to the Medical Staff for Medical Staff T and U.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, hospital policy review, and staff interview the hospital failed to ensure nursing staff developed and kept current a nursing care plan for eight of fifteen acute care sampled patients (#'s 11, 12, 14, 19, 20, 26, 28, and 30). This deficient practice places all patients at risk for inadequate nursing care.


Findings include:


- The hospital's policy for care plans reviewed on 5/27/14 at 11:00am directed, "...To organize a plan of care and identify diagnoses that meet patient's needs and provide for continuity of care...care planning is to be initiated within 24 hours of admission ...evaluate patient's needs in reference to patient's illness, physical condition and rehabilitation...care planning should be an ongoing process and should be updated weekly and as necessary...both the nurse and the patient should sign the care plan..."

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence of a care plan that identified needs and sets treatment goals.
- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence of a care plan that identified needs and sets treatment goals.
- Patient #14's closed medical record reviewed on 5/21/14 revealed an admission date of 2/5/14 and expired on 2/21/14 with a diagnosis of cancer of the pancreas and liver. Patient #14's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. Patient #19's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of abdominal pain. Patient #29's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

- Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record lacked evidence of a care plan that identified needs and sets treatment goals.

Administrative nursing staff B, interviewed on 5/21/14 at 5:00pm acknowledged the medical records for patient #'s 11, 12 and 14 lacked evidence of a care plan that identified and sets treatment goals

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, policy review, employee personnel file review, and staff interview the hospital failed to ensure authorized personnel accepted verbal orders for four of four current sampled inpatients (patient #'s 11, 12, 13, and 21).

Findings include:

- The hospital's policy for processing doctor's orders reviewed on 5/27/14 at 4:30pm directed, "...Telephone and verbal orders may be accepted only by a RN (Registered Nurse) or LPN (Licensed Practical Nurse)..."

- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record revealed twenty-six verbal orders transcribed by the scribe on 5/17/14.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record revealed eighteen verbal orders transcribed by the scribe on 5/17/14.

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record revealed five verbal orders transcribed by the scribe on 5/15/14, six verbal orders transcribed by the scribe on 5/16/14, and five verbal orders transcribed by the scribe on 5/21/13.

- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record revealed twenty-two verbal orders transcribed by the scribe on 5/7/14 and two verbal orders transcribed by the scribe on 5/19/14.

- Administrative staff B interviewed on 5/19/14 at 1:00pm indicated the hospital started physician documentation into the electronic medical record on 4/28/14. Staff B indicated the physicians had trouble with the computer program so they used a "scribe" staff F to place orders in the computer and the physician later co-signs the orders.

- Staff F's employee personnel file reviewed on 5/27/14 at 11:15am revealed staff F failed to have a license permitted by hospital policy to accept a verbal order.

Based on medical record review, document review, and staff interview the hospital failed to: ensure the providers date and time all entries into the medical record (refer to A-0450); ensure providers sign orders given in the emergency room (refer to A-0454); ensure the providers complete a history and physical within twenty-four hours after admission (refer to A-0458); ensure patients entering the hospital for services completed a consent for medical and/or surgical treatment (refer to A-0466); and ensure the providers complete a discharge summary within thirty days after discharge (refer to A-0469).


The cumulative effect of the systematic failure to ensure providers date and time all entries into the medical record, sign orders given in the emergency room, complete a history and physical within twenty-four hours after admission, complete medical records within thirty days after discharge, and ensure patients complete a consent for treatment resulted in the hospitals inability to provide care in a safe and effective manner.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, policy review, and staff interview the hospital failed to ensure the providers date and time all entries into the medical record for seventeen of twenty-two sampled patient ' s medical record (#'s 13, 14, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). This deficient practice places patients at risk for inadequate care.

Findings include:

- The hospital's policy for health information reviewed on 5/27/14 at 4:05pm directed, "...All entries in the record are to be dated and authenticated (signed)..."

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/1/14 with diagnosis of right lower abdominal pain. Patient #13's medical record revealed four verbal/telephone orders lacked a date and time when the physician authenticated the document and one verbal/telephone order authenticated lacked a date and time when authenticated.

- Patient #14's closed medical record reviewed on 5/21/14 revealed an admission date of 2/5/14 and expired on 2/21/14 with a diagnosis of cancer of the pancreas and liver. Patient #14's medical record revealed 20 verbal/telephone orders lacked a date and time when the physician authenticated the document, and 23 progress notes lacked a time when the physician authenticated the document.

- Patient #16's closed medical record reviewed on 5/22/14 revealed an admission date of 1/31/14 and discharged on 2/12/14 for a surgical procedure of right ureteral lasertripsy and suprapubic catheter placement. Patient #16's medical record revealed one operative report lacked a signature, date and time, two verbal/telephone orders lacked a date and time when the physician authenticated the document, one written post-operative order lacked a time when the physician authenticated the document, and two progress notes lacked a time when the physician authenticated the document.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #17's medical record revealed one verbal/telephone order lacked a signature, date and time, six verbal/telephone orders lacked a date and time when the physician authenticated the document, and six progress notes lacked a time when the physician authenticated the document.

- Patient #18's closed medical record reviewed on 5/22/14 revealed an admission date of 4/1/14 and discharged on 4/7/14 with diagnoses of dehydration and paralytic ileus (lower bowel not working). Patient # 18's medical record revealed 15 verbal/telephone orders lacked a date and time when the physician authenticated the document, four verbal/telephone orders lacked a signature, date and time, and eight progress notes lacked a time when the physician authenticated the document.


- Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. Patient #19's medical record revealed eleven telephone/verbal orders lacked a date or time when the physician authenticated the document.

- Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's medical record revealed seven telephone/verbal orders lacked a date and time when the physician authenticated the document, two verbal orders not authenticated, two progress notes lacked a time, and three progress notes co-signed lacked a date and time when the physician authenticated the documents.

- Patient #22's medical record reviewed on 5/21/14 revealed an admission date of 1/31/14 and discharged on 2/3/14 with a diagnosis of urinary tract infection. Patient #22's medical record revealed one telephone/verbal order lacked a date and time when the physician authenticated the document.

- Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (a disorder of the kidneys). Patient #23's medical record revealed three telephone/verbal orders lacked a date and time when the physician authenticated the document and seven progress notes lacked a time when the physician authenticated the documents.

- Patient #24's medical record reviewed on 5/21/14 revealed an admission date of 1/15/14 and discharged on 3/15/14 with a diagnosis of cancer pain. Patient #24's medical record revealed fifteen telephone/verbal orders lacked a date and time when the physician authenticated the document and thirty-three progress notes lacked a time when the physician authenticated the documents.

- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record revealed thirteen telephone/verbal orders, a discharge summary lacked a date and time when the physician authenticated the documents, and seventeen progress notes lacked a time when the physician authenticated the documents.

- Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's medical record revealed three telephone/verbal orders lacked a date and time when the physician authenticated the documents and ten progress notes lacked a time when the physician authenticated the documents.

- Patient #27's medical record reviewed on 5/22/14 revealed an admission date of 1/28/14 and discharged on 2/1/14 with a diagnosis of chronic obstructive pulmonary disease (COPD). Patient #27's medical record revealed four telephone/verbal orders lacked a date and time when the physician authenticated the document and five progress notes lacked a time when the physician authenticated the documents.

- Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's medical record revealed eight telephone/verbal orders lacked a date and time when the physician authenticated the documents and one progress note lacked time when the physician authenticated the document.

- Patient #29's medical record reviewed on 5/22/14 revealed an admission date of 2/7/14 and discharged on 2/13/14 with a diagnosis of abdominal pain. Patient #29's medical record revealed seven telephone/verbal orders lacked a date and time when the physician authenticated the documents and seven progress note lacked time when the physician authenticated the document.

- Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's medical record revealed one telephone/verbal order lacked a date and time when the physician authenticated the document, two verbal orders not authenticated and four progress notes lacked a time when the physician authenticated the documents.

- Patient #31's outpatient closed medical record reviewed on 5/22/14 revealed an admission date of 4/29/14 for an upper gastric scope and colonoscopy. Patient #31's medical record revealed four progress notes lacked a time when the physician authenticated the document.

The hospitals policy for health information failed to direct staff to time all entries into the medical record.

Medical Records staff H interviewed on 5/20/14 at 3:40pm acknowledged they were aware the hospital had a date and time issue for entries into the medical record.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, and staff interview the hospital failed to ensure providers sign orders given in the emergency room (ER) for eight of ten sampled patients (#'s 1, 2, 3, 4, 5, 7, 8, and 9). This deficient practice places patients at risk for inadequate care.
Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 5/27/14 at 4:00pm directed, "...All orders, including verbal orders, must be dated, timed and authenticated written or electronic..."

- Patient #1's medical record, reviewed on 5/19/14 revealed they presented to the ER on12/14/13 with difficulty urinating. Nursing notes indicated the patient received lab test and a Foley catheter. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #2's medical record, reviewed on 5/19/14 revealed they presented to the ER on 5/7/14 with back pain following a motor vehicle accident. Nursing notes indicated the patient received lab test, x-rays, IV fluids, and medications prior to a transfer. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #3's medical record, reviewed on 5/19/14 revealed they presented to the ER on 4/26/14 with syncope (fainting). Nursing notes indicated the patient received lab test, an EKG, and IV fluids. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #4's medical record, reviewed on 5/19/14 revealed they presented to the ER on 4/14/14 with a fall. Nursing notes indicated the patient received x-rays. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #5's medical record, reviewed on 5/19/14 revealed they presented to the ER on 4/4/14 with a drug overdose. Nursing notes indicated the patient received lab work, telemetry, and an EKG. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #7's medical record, reviewed on 5/19/14 revealed they presented to the ER on 5/9/14 12/14/13 with abdominal pain. Nursing notes indicated the patient received lab test and medication. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #8's medical record, reviewed on 5/19/14 revealed they presented to the ER on 4/26/14 with narcotic withdrawal. Nursing notes indicated the patient received lab test, IV fluids and medications. The medical record lacked evidence of signed physician orders for the care provided.

- Patient #9's medical record, reviewed on 5/21/14 revealed they presented to the ER on 3/26/14 in cardiopulmonary arrest. Nursing notes indicated the patient received x-rays, medication, and a chest tube. The medical record lacked evidence of signed physician orders for the care provided.

Administrative staff B interviewed on 5/19.14 at 4:30pm acknowledged the ER medical records lacked evidence of signed physician orders for patient #'s 1, 2, 3, 4, 5, 7, 8, and 9.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, policy review, and staff interview the hospital failed to ensure the providers complete a history and physical within twenty-four hours after admission for eight of twenty sampled inpatients (#'s 13, 17, 18, 19, 20, 26, 28, and 30). This deficient practice had the potential to affect the patient's planned course.

Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 5/27/14 at 4:00pm directed, "...A complete history and physical examination shall be written or dictated within twenty-four hours after admission of the patient..."

- The hospital's policy for incomplete medical records reviewed on 5/27/14 at 4:05pm directed, "...A history and physical must be dictated within 48 hours of admission..."

- Patient #13's medical record reviewed on 5/20/14 revealed an admission date of 5/14/14 with a diagnosis of right lower abdominal pain. Patient #13's medical record lacked a history and physical.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient#17's history and physical indicated a dictation date of 4/21/14 (28 days after admission).

- Patient #18's closed medical record reviewed on 5/22/14 revealed an admission date of 4/1/14 and discharged on 4/7/14 with diagnoses of dehydration and paralytic ileus (lower bowel not working). Patient #18's history and physical indicated a dictation date of 4/29/14 (28 days after admission).

- Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. Patient #19's history and physical indicated a dictation date of 4/6/14 (31 days after admission).

- Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's history and physical indicated a dictation date of 3/21/14 (15 days after admission).

- Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's history and physical indicated a dictation date of 2/26/14 (8 days after admission).

- Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's history and physical indicated a dictation date of 2/13/14 (75 days after admission).

- Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's history and physical indicated a dictation date of 2/23/14 (8 days after admission).

Medical Records staff H interviewed on 5/20/14 at 3:40pm acknowledged hospital Medical Staff failed to complete a history and physical within twenty-four hours after admission for many patients and they have failed to have a corrective action plan.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. The Hospital failed to ensure patients entering the hospital for services completed the consent for medical and/or surgical treatment for three of twenty sampled records reviewed (patient #'s 11, 12, and 17).

Findings include:

- The Hospital's policy titled, "AUTHORIZATION FOR TREATMENT- INFORMED CONSENT" reviewed on 5/27/14 at 11:00am directed, "...Admission/ward clerk will have patient or patient's representative sign ...consent form.


- Patient #11's medical record reviewed on 5/19/14 revealed an admission date of 5/17/14 with a diagnosis of cellulitis of the right hand. Patient #11's medical record lacked evidence the patient signed the "Conditions of Admission" consent form when admitted to the Hospital.

- Patient #12's medical record reviewed on 5/19/14 revealed an admission date of 5/16/14 with diagnoses of hypoxemia (shortness of breath) and bradycardia (slow heart rate). Patient #12's medical record lacked evidence the patient signed the "Conditions of Admission" consent form when admitted to the Hospital.

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #17's medical record lacked evidence the patient signed the "Conditions of Admission" consent form when admitted to the Hospital.

Staff W, Chief Financial Officer, interviewed on 5/21/14 at 8:45am acknowledged the Hospital failed to ensure patients entering the hospital for services signed the "Conditions of Admission" consent to treatment form.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, policy review, and staff interview the hospital failed to ensure the providers complete a discharge summary within thirty days after discharge for twelve of sixteen sampled discharged patients (#'s 14, 15, 17, 18, 19, 20, 22, 24, 25, 26, 28, and 30). This deficient practice had the potential for inadequate post-hospitalization follow-up care.

Findings include:

- The hospital's Medical Staff Rules and Regulations reviewed on 5/27/14 at 4:00pm directed, "...All medical records must be completed within 30 days following discharge..."

- The hospital's policy for incomplete medical records reviewed on 5/27/14 at 4:05pm directed, "...A Discharge Summary must be dictated within 14 days after discharge..."

- Patient #14's closed medical record reviewed on 5/21/14 revealed an admission date of 2/5/14 and expired on 2/21/14 with a diagnosis of cancer of the pancreas and liver. Patient #14's discharge summary indicated a dictation date of 3/21/14 and typed on 3/21/14. The discharge summary indicated the physician signed the discharge summary on 3/25/14 (32 days after discharge).

- Patient #15's closed medical record reviewed on 5/21/14 revealed an admission date of 2/24/14 and discharged on 2/28/14 with diagnoses of congestive heart failure and swelling, and pain of both lower legs. Patient #15's discharge summary indicated a dictation date of 3/3/14 and typed on 3/4/14. The discharge summary lacked the provider's signature at the time of medical record review (82 days after discharge).

- Patient #17's closed medical record reviewed on 5/22/14 revealed an admission date of 3/24/14 and discharged on 4/1/14 with diagnoses of cancer of the lung and diarrhea. Patient #17's discharge summary indicated a dictation date of 4/4/14 and typed on 4/7/14. The discharge summary lacked the provider's signature at the time of medical record review (51 days after discharge).

- Patient #18's closed medical record reviewed on 5/22/14 revealed an admission date of 4/1/14 and discharged on 4/7/14 with diagnoses of dehydration and paralytic ileus (lower bowel not working). Patient #18's discharge summary indicated a dictation date of 4/29/14 and typed on 5/1/14. The discharge summary lacked the provider's signature at the time of medical record review (45 days after discharge).

- Patient #19's medical record reviewed on 5/22/14 revealed an admission date of 3/7/14 and discharged on 3/20/14 with a diagnosis of acute abdominal pain. Patient #19's discharge summary indicated a dictation date of 3/21/14 and typed on 3/26/14. The discharge summary lacked the provider's signature at the time of medical record review (63 days after discharge).

- Patient #20's medical record reviewed on 5/22/14 revealed an admission date of 3/6/14 and discharged on 3/11/14 with a diagnosis of acute renal failure. Patient #20's discharge summary indicated a dictation date of 3/17/14 and typed on 3/18/14. The discharge summary lacked the provider's signature at the time of medical record review (72 days after discharge).

- Patient #22's medical record reviewed on 5/21/14 revealed an admission date of 1/31/14 and discharged on 2/3/14 with a diagnosis of urinary tract infection. Patient #22's discharge summary indicated a dictation date of 3/21/14 and typed on 3/25/14. The discharge summary lacked the provider's signature at the time of medical record review (101 days after discharge).

- Patient #24's medical record reviewed on 5/21/14 revealed an admission date of 1/15/14 and discharged on 3/15/14 with a diagnosis of cancer pain. Patient #24's medical record failed to contain a discharge summary (67 days after discharge).

- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's discharge summary indicated a dictation date of 3/21/14 and typed on 3/25/14. The provider signed the discharge summary on 3/25/14 (34 days after discharge).

- Patient #26's medical record reviewed on 5/22/14 revealed an admission date of 2/18/14 and discharged on 2/26/14 with a diagnosis of leg weakness. Patient #26's discharge summary indicated a dictation date of 2/26/14 and typed on 2/28/14. The discharge summary lacked the provider's signature at the time of medical record review (85 days after discharge).

- Patient #28's medical record reviewed on 5/22/14 revealed an admission date of 12/11/13 and discharged on 12/12/13 with a diagnosis of chest pain. Patient #28's discharge summary indicated a dictation date of 2/13/14 and typed on 2/13/14. The discharge summary lacked the provider ' s signature at the time of medical record review (88 days after discharge).

- Patient #30's medical record reviewed on 5/22/14 revealed an admission date of 2/15/14 and discharged on 2/18/14 with a diagnosis of cellulitis of the left foot. Patient #30's discharge summary indicated a dictation date of 2/23/14 and typed on 2/27/14. The discharge summary lacked the provider's signature at the time of medical record review (94 days after discharge).

Medical Records staff H interviewed on 5/20/14 at 3:40pm acknowledged hospital Medical Staff failed to complete a discharge summary within thirty days after discharge for many patients and they failed to have a corrective action plan.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on observation, policy review, and staff interview the pharmacy director failed to supervise the activities of the Hospital's pharmacy services and have knowledge of pharmacy services in the operating room area.

Findings include:

- The Hospital's policy titled, "REPORTING OF THE ABUSE OR LOSS OF CONTROLLED SUBSTANCES TO THE PROPER AUTHORITIES POLICY AND PROCEDURE" reviewed on 5/27/14 directed, "...All controlled drugs, dispensed from a Nursing Unit will be counted at the beginning and end of each shift that the Unit is opened..."

- The Hospital's policy titled, "Storage and Maintenance of Medications", reviewed on 5/28/14 directed, "...Surgery Department- medications will be checked monthly for outdates by the OR Supervisor..."

- Observation on 5/20/14 between 10:00am and 3:00pm of the operating room (OR) area revealed, a fluid warmer with 25 total intravenous and irrigation fluids without a date indicating when they were placed in the warmer, 25 total expired medications in two operating room medication carts and anesthesia's office, 20 total expired medications in one anesthesia medication cart, and six syringes labeled with the medication contained in them but lacked date, time, dose, and who filled the syringes in one anesthesia cart, and four open vials of medication in one anesthesia cart lacked a date when they were opened.

- Staff D, Operating Room (OR) supervisor, interviewed on 5/20/14 at 11:10pm acknowledged the expired medications in the two OR medication carts and the undated fluids in the fluid warmer.

- Staff D, OR supervisor, interviewed on 5/20/14 at 11:25pm acknowledged they were unaware of the expired medications, lack of documentation of narcotic count, and filled syringes improperly labeled in one anesthesia cart. Staff D explained anesthesia is responsible for the anesthesia cart and its content.

- Staff J, Pharmacist, interviewed on 5/20/14 at 3:30pm acknowledged they were unaware of the expired medications in the two medication carts in the OR, the lack of a narcotic count documentation of narcotics, expired medications, filled syringes without proper labels, and open vials of medications lacked a date when opened in the anesthesia cart. Staff J explained it is the OR supervisors responsibility to check all medications monthly.

The Pharmacy Director failed to supervise the activities of the hospital's pharmacy services and have knowledge of pharmacy practices in the OR area.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on observation, policy review, narcotic count sheet, and staff interview the pharmacist failed to ensure that all controlled medications are accounted for in one of one anesthesia cart.

Findings include:

- The Hospital's policy titled, "REPORTING OF THE ABUSE OR LOSS OF CONTROLLED SUBSTANCES TO THE PROPER AUTHORITIES POLICY AND PROCEDURE" reviewed on 5/27/14 directed, "...All controlled drugs, dispensed from a Nursing Unit will be counted at the beginning and end of each shift that the Unit is opened..."

- Observation on 5/20/14 between 11:18 am to 12:00pm of the anesthesia cart in Operating Room (OR) #1 revealed a locked narcotic (controlled medications) box in it. The narcotic box contained the following controlled medications.
4 vials-Fentanyl (used in general anesthesia to relieve pain) 100mcg (micrograms)
4 vials-Sufenta (used in general anesthesia to relieve pain) 50mg (milligrams) per ml (milliliter)
1 vial-Fentanyl (used in general anesthesia to relieve pain) 250mcg/5ml
8 vials-Ketamine ((used to start and maintain anesthesia (sleep) during surgery) 500mg/10ml
16 vials-Versed (used to relieve anxiety during surgery) 2mg/ml
20 vials-Morphine (used to relieve pain) 5mg/ml
23 vials-Demerol (used to relieve pain) 25mg/ml

Review of the narcotic count record on 5/20/14 at 12:00pm revealed the last documented count of the narcotics in the narcotic box occurred on 1/13/14.

Staff I, Certified Nurse Nurse Anesthetist, interviewed on 5/27/14 at 3:30pm acknowledged they failed to conduct a narcotic count and document as required.

Staff J, Pharmacist, interviewed on 5/20/14 at 3:30pm acknowledged they were unaware the anesthetist and/or OR staff failed to conduct narcotic counts as required.

The Hospital reported an average daily census of 3.3patients with a current census of four patients, three acute care patients and one swing bed patient. Based on observation, policy review and staff interview the Hospital failed to ensure outdated, mislabeled drugs and biologicals are not available for patient use for three of three fluid warmers, two of two medication carts in the Operating Room (OR) and one of one anesthesia cart in OR.

Findings include:

- The Hospital's policy titled, "Storage and Maintenance of Medications" reviewed on 5/28/14 directed, "...Surgery Department - medications will be checked monthly for outdates by the OR supervisor..."

- Observation in the OR area on 5/20/14 between 10:00am and 3:00pm revealed the following unusable and expired medications:
A medication cart in the recovery room-
one -vial of Naloxone Hydrochloride (reverses the effects of narcotics) 2mg (milligrams)/ml (milliliter) intravenous (IV), expired on 2/14
two-vials of Zantac (antacid) 50mg/ml IV, expired on 4/14
two-vials of Adrenalin (used to reverse allergic reactions) 1:1000, 1mg/ml IV, expired 8/13
two-vials of Benadryl ( an antihistamine) 50mg/ml IV expired 2/14
one-1000ml IV bag of 5% dextrose in normal saline with 250mg of Dobutamine (used to increase cardiac function) IV, expired 4/1/14

A medication cart in hallway between the two ORs-
five-syringes of Sodium Bicarbonate 50ml each IV, expired 4/13
two-vials of sterile D5W (dextrose in water) 50ml each IV, expired 7/13
four-vials of Lasix (dieretic) 40mg/4ml IV, expired 1/14
two-vials of Calcium Chloride (used in cardiac c resuscitation) 10ml IV, expired 12/13
two-vials of Lidocaine 2% (used in cardiac resuscitation) 20mg/ml IV, 4/13

Anesthesia's Office-
one- bottle of Lidocaine Hydrochloride (local anesthesia) oral topical solution 100ml with approximately 20ml left in the bottle, expired 1/11
one-bottle of Xylocaine (local anesthesia) 4% topical solution 50ml, expired 8/13

Anesthesia Cart in OR#1-
eight-vials of Methylene Blue (a dye used to turn the urine blue) 10ml each IV, expired 8/13
four-vials of Neostigmine (used to reverse the effects of muscle blockers after surgery) 1:1000 (10mg/ml) IV, expired 1/14
three- vials of Benadryl 1ml IV, expired 1/14
one-vial of Vecuronium (a muscle blocker) 10mg IV, expired 2/14
two-vials of Terbutaline (used to reverse airway obstruction) 1mg/ml IV, expired on 2/14
two-opened vials of Neostigmine 1:1000 (10mg/ml) IV, lacked a date when opened
one-opened single use vial of Glycopyrrolate (decreases salivation and excessive secretions in the airway) .4mg/2ml IV, lacked a date when opened.

1-syringe labeled Robinal (Glycopyrrolate) 2and 1/4ml
1-syringe labeled Anectine (a muscle blocker) 8ml
1-syringe labeled Norcuron (Vecuronium) 10cc
1-syringe unable to read label 1cc
1-syringe labeled Atropine (used to treat slow heart beat) 2.4ml also had date 1/10
1-syringe labeled Ephedrine 10% (used to treat shortness of breath) 6ml
All syringes lacked a date when filled, who filled them, and dosage of each medication.

Staff D, OR supervisor, interviewed on 5/20/14 at 11:25am acknowledged the expired and unusable medications.

Staff I, Certified Registered Nurse Anesthetist, interviewed on 5/27/14 at 3:30pm acknowledged the expired and unusable medications. Staff I explained they draw up the syringes of medication in case they need them during surgery and then place them in the anesthesia cart in case they get called in during the night and need them. The medications are discarded the next day. However one of the syringes had a date of 1/10 on it.


-The manufactures instructions for Omnipaque (an IV contrast used I some radiology test) reviewed on 5/19/14 at 4:35pm directed, " ...may be stored in a contrast media warmer for up to one month ... "
-The manufactures instructions for Omtiray (an IV contrast used I some radiology test) reviewed on 5/19/14 at 3:20pm directed, " ...may be stored up to 40 degrees Celsius for up to one month in a contrast media warmer ... "

- Observation in the Radiology Department on 5/19/14 at 3:15pm revealed a fluid warming cabinet with one 150ml (milliliter) vial of Omnipaque and seven 50ml vials of Opitray. The vials lacked a date when staff placed the bottles in the warmer or when to remove them from use.

Radiology administrative staff S interviewed on 5/19/14 at 3:15pm was unaware of the manufactures requirement to dispose of fluids in the warmer longer than two weeks.

-The manufacturer ' s instructions for Hospira IV solutions reviewed on 5/21/14 at 9:05am directed, " ...solutions for injection may be warmed at a temperature not to exceed 40 degrees Celsius for a period no longer than two weeks ... "

-Observation in the emergency department on 5/20/14 at 7:40am revealed a fluid warming cabinet with a temperature of 40 degrees Celsius with four 1000ml containers of sterile water for irrigation, three 1000ml containers of lactated ringers IV solution, one 1000ml container of Normasol M IV solution, one 1000ml container of normal saline IV solution, and three 500ml containers of mannitol, IV solution. The IV fluids lacked a date when staff placed the bottles in the warmer or when to remove them from use.

Administrative nursing staff B interviewed on 5/20/14 at 7:40am acknowledged the IV solutions in the warming cabinet and all lacked a date when placed in the warmer or a date when to remove the solutions.

- Observation in the OR area on 5/20/14 at 10:00am revealed a fluid warming cabinet with five 1000ml containers of sterile water for irrigation, 12-500ml containers of normal saline for irrigation, two 1000ml containers of D5 in 1/2 normal saline IV solution, three 1000ml containers of Normal Saline IV solution, and three 1000ml containers of lactated ringers IV solution. The irrigation solutions and IV fluids lacked a date when staff placed the containers in the warmer or when to remove them from use.

Staff D, OR Supervisor, interviewed on 5/20/14 at 10:00am acknowledged the containers in the warming cabinet lacked a date when placed in the warmer or a date when to remove the solutions. Staff D explained they were not aware of the manufacturer's recommendations.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on observation, interview, and document review the hospital failed to follow routine maintenance throughout the hospital for eighteen of twenty six patient rooms (room #'s 201, 202, 203, 204, 205, 208, 209, 210, 211, 212, 214, 215, 216, 218, 219, 220, 222, and intensive care (ICU) room 4). The hospital failed to ensure the safety and well-being of patients.

Findings include:

- Tour of the hospital on 5/20/14 between 8:55am to 10:45am revealed multiple areas of unsafe and unmaintained areas of the environment which included:

1. Patient room #'s 201, 202, 203, 204, 205, 208, 209, 210, 211, 214, 215, 216, 218, 219, 220, and 222 with the wood doors scraped and chipped, and the doorframes with chipped paint.
2. Patient room #'s 201, 212, 215, and 219 with rusted drains in the bathroom showers.
3. Patient room #'s 203, 205, 211, 213, and 215 with cracked vinyl chairs.
4. Patient room #'s 215, 216, 218, 220, and 222 with scraped and chipped paint on the walls.
5. ICU room #4 and the ER hallway with a large area of cracked and lifted linoleum.


Maintenance staff C interviewed on 5/20/14 between 8:55am and 10:45am acknowledged the scraped and chipped doors, rusted drains, cracked vinyl chairs, chipped paint on walls and the cracked and lifted linoleum. Staff C acknowledged patients, visitors, and staff could be injured by the unmaintained areas of the environment.

Maintenance staff C interviewed on 5/28/14 at 8:30am acknowledged the hospital failed to have a schedule or a policy for maintaining the hospital's environment.

The Hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute care patients and one swing bed patient. Based on observation and staff interview the Hospital failed to maintain supplies to ensure quality and safety in one of one pediatric emergency cart in the Operating Room (OR). The failure to maintain pediatric emergency supplies put the pediatric patients at risk in case of an emergency.

Findings include:

- Observation during tour of the OR on 5/20/14 at 10:00am revealed a pediatric emergency cart with the following expired supplies:
8-Intravenous (IV) start kits with an expiration date of 8/10
2-IV start kits with an expiration date of 9/12
6-Oxygen masks with an expiration date of 2/11
5-Intubation modules (used to place a tube in the airway of the patient) with an expiration date of 11/12
1-Intubation module with an expiration date of 9/12
1-Intubation module with an expiration date of 5/11
1-Intubation module with an expiration date of 8/12
5-Interosseus Kits (a needle placed in the upper leg bone amused for delivering IV fluids through the bone marrow) with and expiration date of 9/12
1-Carbon Dioxide detector (an instrument used to measure the air the patient breaths out) with an expiration date of 3/14

Staff D, OR supervisor interviewed on 5/20/14 at 10:00am acknowledged the expired supplies and the failure to maintain the pediatric supplies puts the pediatric patient at risk.

Based on observation, staff interview and document review, the hospital's infection control officer failed to develop an active infection control system (refer to A-0749).


The cumulative effect of the systematic failure to develop an active infection control system resulted in the hospitals inability to provide care in a safe and effective manner.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on observation, staff interview and document review, the hospital's infection control officer failed to develop an active infection control system ensuring hospital personnel followed basic infection control practices during two of two observed glucometer (blood sugar analyzer) tests, one of one observed surgical procedure, one of one observed cleaning of a discharged patient room, and four of five observed medication passes. The infection control officer failed to develop a system to track employee health/illness and patients with infections. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:

- The hospital's policy for infection control reviewed on 5/28/14 at 8:00am directed, " ...To conduct a surveillance program of infections within the hospital...To collect and analyze data that is meaningful in the prevention of the spread of infection...To provide the Infection Control Committee and the Medical Staff with information that will aid in the treatment and prevention of infection in hospital patients...Reporting activity summaries quarterly to the Medical Staff, Board of Directors, and CEO...Monitor all admissions to acute or swing bed, those who are identified as having an infection will be followed..."

- The Hospital's policy titled, "Cleaning of Complete Rooms" reviewed on 5/20/14 at 10:30am directed, "...Wipe counter tops, beds, dressers, drawers, over the bed table, bed stands with Quat Stat disinfectant. Leave wet for 10 minutes..."

- The manufacturer's guidelines for the disinfectant "Quat Stat" reviewed on 5/20/14 at 10:30am directed, "...Apply solution...so as to wet all surfaces thoroughly. Allow to remain wet for 10 minutes..."
- The manufacturer's guidelines for the disinfectant "VIBRIGHT" reviewed on 5/20/14 at 10:30am directed, "...Empty toilet bowl or urinal and apply solution of 1 to 2 ounces of the product to exposed surfaces including under the rim...brush or swab thoroughly and allow to stand for 10 minutes and flush..."
- Housekeeping staff L observed on 5/19/14 between 2:15pm to 3:30pm performed terminal cleaning of room 211 (a discharged patient room). Staff L, using cloths wet with "Quat Stat" wiped the sink, counter tops, bedside stand, over bed table, bed frame, mattress, light fixture, telephone, call light, and inside of the closet. The surfaces remained wet from 1.5 minutes to 5 minutes, not the required 10 minutes to disinfect the surfaces.
Staff L using "VIBRIGHT" sprayed the inside of the toilet bowl with the solution (not measured), then using the toilet bowl brush cleaned under the rim and sides of the toilet bowl. Staff L flushed the toilet after 5 minutes of cleaning the inside of the toilet bowl. Staff L failed to follow the manufacturer's guidelines to empty the toilet and allow the solution to stand for 10 minutes to achieve disinfection of the toilet bowl.
Staff CC, director of housekeeping, interviewed on 5/19/14 at 3:45pm acknowledged staff L failed to follow the manufacturer's guidelines for the use of the "Quat Stat" and "VIBRIGHT", to achieve disinfection of the surfaces of furniture and equipment in the room and the toilet bowl.


- The hospital's policy for standard precautions reviewed on 5/27/14 at 11:00am directed, "...wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn, after gloves are removed, between patient contact, when otherwise indicated to avoid transfer of microorganisms to other patients or environment...patient care equipment...handle used patient care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevent...transfer of microorganisms to other patients or environments..."

- Nursing staff G, observed on 5/19/14 at 5:10pm, performed a glucometer test on patient #21. Staff G entered patient #21's room, failed to perform hand hygiene, laid the glucometer and the patient's insulin medication pen on the bedside table, applied gloves, and completed the blood test, removed their gloves, and reapplied a pair of gloves without performing hand hygiene. Staff G provided patient #21with two oral medications, an insulin injection, removed their gloves, removed the glucometer from the table and left patient #21's room without performing hand hygiene. Staff G failed to clean the glucometer and insulin medication pen that lay directly on patient #21's bedside table and placed the contaminated glucometer and insulin medication pen in a box at the nurse's station.

- Observation of staff G registered nurse (RN) on 5/20/14 at 8:10am during medication pass revealed staff G entered patient room 207 to hang an intravenous (IV) bag of 1000ml (milliliters) of D5 in normal saline. Staff G entered the room applied gloves, removed used IV bag and hung the new bag, removed gloves and adjusted the IV pump. Staff G failed to perform hand hygiene when entering the room and after removing the gloves before they adjusted the IV pump.


- Nursing staff K, observed on 5/20/14 at 1:00pm, performed a glucometer test on patient #21. Staff K entered patient #21's room, perform hand hygiene, laid the glucometer and the patient's insulin medication pen on the bedside table, applied gloves, and completed the blood test, removed their gloves, performed hand hygiene. Staff K provided patient #21with an oral medication, an insulin injection, performed hand hygiene, wiped the surface of the glucometer with an alcohol wipe, failed to clean the insulin medication pen and left patient #21's room. Staff K failed to clean the insulin medication pen that lay directly on patient #21's bedside table and placed the contaminated insulin medication pen in a box at the nurse's station.

- Nursing staff G, observed on 5/20/14 at 2:00pm, provided patient #13 with an IV medication. Staff G entered patient #13's room, failed to perform hand hygiene, applied gloves, connected the IV medication to the IV pump, provided patient #13 with ear drops, removed their gloves and left the room without performing hand hygiene.

Administrative nursing staff B interviewed on 5/20/14 at 5:00pm, acknowledged staff should perform hand hygiene when entering patient rooms, leaving patient rooms, after glove removal, and staff should disinfect patient care equipment after use.

- Association of periOperative Registered Nurses (AORN) 2012 Recommendation IV reads:
" All personnel should cover their head and facial hair when in semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skull caps are not recommended because they do not completely cover the wearer ' s hair and skin: they fail to cover the side hair above and in front of the ears and hair at the nape of the neck ... "

- The Hospital's policy titled, "Dress Code for Operating Room and PACU" reviewed on 5/28/14 at 8:30pm directed, "...All hair must be covered with a cap. If a surgeon or technician should have a beard, a hood will be worn so that no hair is seen...masks are to be changed between cases..."

- Observation during tour of the Operating Room (OR) on 5/20/14 at 10:00am revealed staff P registered nurse (RN) wearing a bouffant skull cap with exposed hair around the ears and nape of neck.

- Observation in the OR on 5/27/14 at 1:35pm revealed staff O, RN and staff R, RN with surgical masks dangling around their neck.

- Observation in the OR on 5/27/14 at 2:00pm revealed staff D, RN with a surgical mask on with exposed facial (beard) hair at the bottom of the mask around the chin.

- Observation in the OR staff lounge on 5/27/14 at 2:15pm revealed staff P, RN with a mask dangling around their neck eating lunch. Staff P left the staff lounge, put mask over their face and entered the operating room.

- Observation in the OR on 5/27/14 at 2:45pm revealed staff Q removed non-sterile gloves and applied another pair of non-sterile gloves on without performing hand hygiene.

- Observation in the OR on 5/27/14 at 3:10pm revealed staff I, Certified Nurse Anesthetist (CRNA) and Staff Q removed their non-sterile gloves and failed to perform hand hygiene.

- Observation in the OR on 5/27/14 at 3:15pm revealed staff P and staff Q removed their non-sterile gloves and failed to perform hand hygiene.

- Observation in the OR on 5/27/14 at 3:45pm revealed staff I, CRNA removed and applied non-sterile gloves four times without performing hand hygiene.

- Observation in the OR on 5/27/14 at 3:47pm revealed staff R with used mask dangling around their neck.

Staff D, RN, OR Supervisor interviewed on 5/27/14 at 3:45pm acknowledged the staff failed to perform hand hygiene before and after applying gloves, staff wearing the masks dangling around their neck and the exposed facial hair and exposed hair around the bouffant skull cap. Staff D explained they use AORN practice guidelines.


- Infection Control Officer staff N interviewed on 5/20/14 at 4:00pm acknowledged they were responsible for the management of the infection control program since 11/2013. The hospital's Infection Control Committee had met once since they started in the position. Staff N provided meeting minutes from 4/16/14 which indicated staff N started reviewing policies. The meeting minutes failed to include identification, reporting, and investigation of infection control issues related to patients and staff. Staff N acknowledged they had not started employee health monitoring or tracking of patients with infections. Staff N indicated they had made a grid to track infections but had not implemented the tracking tool. Staff N indicated they had not included housekeeping, Medical Staff, or the Governing Body in their reporting. Staff N indicated they conducted hand hygiene surveillance once a month but had not conducted a hospital wide surveillance for staff practices.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on employee personnel files, job description, and staff interview the hospital failed to ensure emergency room (ER) staff possess required certification for one of one ER Clinical Coordinator. This deficient practice had the potential to affect quality patient care.

Finding include:

- The hospital's job description for the Clinical Coordinator Emergency Unit reviewed on 5/27/14 at 5:50pm directed, "...Education/Qualifications...current ACLS (advanced cardiac life support) certification, TNCC (trauma nurse core course)..."

- Registered Nurse (RN) staff B's personnel file on 5/27/14 at 11:15am revealed staff B, identified as the Clinical Coordinator for the ER, failed to possess a current ACLS or TNCC certification.

- Registered Nurse (RN) staff B interviewed on 5/27/14 at 3:30pm acknowledged they coordinate ER services. Staff acknowledged they lacked a current ACLS certification.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review and staff interview the hospital failed to ensure that each swing bed resident knows their rights on admission to the hospital for three of five sampled swing bed residents (patient #'s 21, 23 and 25). This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The hospital's policy for Patient Rights reviewed on 5/27/14 at 11:00am directed, "...Admission personnel are to offer the Patient's Rights form to the patient or patient's representative...patient or representative are to sign the last page showing that they die receive the form...The signed page will be taken to the nurse's station and put in patient chart..."

- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record lacked evidence the patient received swing bed patient rights on admission. The hospital failed to protect and promote patient rights.

- Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (an illness affecting the kidneys). Patient #23's medical record lacked evidence the patient received swing bed patient rights on admission. The hospital failed to protect and promote patient rights.


- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record lacked evidence the patient received swing bed patient rights on admission. The hospital failed to protect and promote patient rights.

Nursing staff V interviewed on 5/11/14 at 8:00am acknowledged patient #21's medical record lacked evidence they received their patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Patient Rights review, and staff interview the hospital failed to ensure that each swing bed resident knows their right to refuse treatment on admission to the hospital for three of five sampled swing bed residents (patient #'s 21, 23 and 25). This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The hospital's policy for Patient Rights reviewed on 5/27/14 at 11:00am directed, "...Admission personnel are to offer the Patient's Rights form to the patient or patient's representative...patient or representative are to sign the last page showing that they did receive the form...The signed page will be taken to the nurse's station and put in patient chart..."

- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record lacked evidence the patient received swing bed patient rights on admission including the right to refuse treatment. The hospital failed to protect and promote patient rights.

- Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (an illness affecting the kidneys). Patient #23's medical record lacked evidence the patient received swing bed patient rights on admission including the right to refuse treatment. The hospital failed to protect and promote patient rights.


- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record lacked evidence the patient received swing bed patient rights on admission including the right to refuse treatment. The hospital failed to protect and promote patient rights.

Nursing staff V interviewed on 5/11/14 at 8:00am acknowledged patient #21's medical record lacked evidence they received their patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Patient Rights review, and staff interview the hospital failed to ensure that each swing bed resident knows their right to be informed of services available, charges for those services, including services not covered by their insurance on admission to the hospital for three of five sampled swing bed residents (patient #'s 21, 23 and 25). This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The hospital's policy for Patient Rights reviewed on 5/27/14 at 11:00am directed, "...Admission personnel are to offer the Patient's Rights form to the patient or patient's representative...patient or representative are to sign the last page showing that they did receive the form...The signed page will be taken to the nurse's station and put in patient chart..."

- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record lacked evidence the patient received swing bed patient rights on admission including their right to be informed of services available, charges for those services, including services not covered by their insurance. The hospital failed to protect and promote patient rights.

Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (an illness affecting the kidneys). Patient #23's medical record lacked evidence the patient received swing bed patient rights on admission including their right to be informed of services available, charges for those services, including services not covered by their insurance. The hospital failed to protect and promote patient rights.


- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record lacked evidence the patient received swing bed patient rights on admission including their right to be informed of services available, charges for those services, including services not covered by their insurance. The hospital failed to protect and promote patient rights.

Nursing staff V interviewed on 5/11/14 at 8:00am acknowledged patient #21's medical record lacked evidence they received their patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Patient Rights review, and staff interview the hospital failed to ensure that each swing bed resident knows their right to participate in planning of care on admission to the hospital for three of five sampled swing bed residents (patient #'s 21, 23 and 25). This deficient practice fails to protect and promote the rights of each resident.

Findings include:

- The hospital's policy for Patient Rights reviewed on 5/27/14 at 11:00am directed, "...Admission personnel are to offer the Patient's Rights form to the patient or patient's representative...patient or representative are to sign the last page showing that they did receive the form...The signed page will be taken to the nurse's station and put in patient chart..."

- The hospital's policy for care plans reviewed on 5/27/14 at 11:00am directed, "..To organize a plan of care and identify diagnoses that meet patient ' s needs and provide for continuity of care...care planning is to be initiated within 24 hours of admission...evaluate patient's needs in reference to patient's illness, physical condition and rehabilitation...care planning should be an ongoing process and should be updated weekly and as necessary...both the nurse and the patient should sign the care plan..."


- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record lacked evidence the patient received swing bed patient rights on admission including their right participate in their plan of care. Patient #21's medical record lacked evidence of a comprehensive care plan that identified physical, social, and activity needs and sets treatment goals. The hospital failed to protect and promote patient rights.


- Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (an illness affecting the kidneys). Patient #23's medical record lacked evidence the patient received swing bed patient rights on admission including their right participate in their plan of care. Patient #23's medical record lacked evidence of a comprehensive care plan that identified physical, social, and activity needs and sets treatment goals. The hospital failed to protect and promote patient rights.


- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record lacked evidence the patient received swing bed patient rights on admission including their right participate in their plan of care. Patient #25's medical record lacked evidence of a comprehensive care plan that identified physical, social, and activity needs and sets treatment goals. The hospital failed to protect and promote patient rights.

Nursing staff V interviewed on 5/11/14 at 8:00am acknowledged patient #21's medical record lacked evidence they received their patient rights.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, policy review, and staff interview the hospital failed to provide a qualified professional to direct the activities program, failed to assess the patient's activity needs and plan appropriate interventions in the plan of care, and failed to provide appropriate activities for five of five sampled swing bed records reviewed (patient #'s 21, 22, 23, 24, and 25). This deficient practice had the potential to affect all current and future swing bed patients of the CAH.

Findings include:

- The hospital's policy for swing bed patient's reviewed on 5/20/14 at 5:30pm directed, "...An activity assessment and plan appropriate for individual needs will be formulated and provided by Therapeutic Activity personnel..."

- Patient #21's medical record reviewed on 5/19/14 revealed an admission date of 5/7/14 with a diagnosis of congestive heart failure (CHF). Patient #21's medical record lacked evidence of an activity assessment, a care plan addressing activities, scheduled activities, or documentation activities were conducted.


- Patient #22's medical record reviewed on 5/21/14 revealed an admission date of 1/31/14 and discharged on 2/3/14 with a diagnosis of urinary tract infection. Patient #22's medical record lacked evidence of a care plan addressing activities, scheduled activities, or documentation activities were conducted.

- Patient #23's medical record reviewed on 5/21/14 revealed an admission date of 4/9/14 and discharged on 4/17/14 with a diagnosis of Hydronephrosis (an illness affecting the kidneys). Patient #23's medical record lacked evidence of a care plan addressing activities, scheduled activities, or documentation activities were conducted.


- Patient #24's medical record reviewed on 5/21/14 revealed an admission date of 1/15/14 and discharged on 3/15/14 with a diagnosis of cancer pain. Patient #24's medical record lacked evidence of an activity assessment, a care plan addressing activities, scheduled activities, or documentation activities were conducted.

- Patient #25's medical record reviewed on 5/21/14 revealed an admission date of 2/10/14 and discharged on 2/21/14 with a diagnosis of anemia. Patient #25's medical record lacked evidence of an activity assessment, a care plan addressing activities, scheduled activities, or documentation activities were conducted.

Registered Nurse staff V interviewed on 5/22/14 at 8:00am acknowledged Patient #'s 21, 22, 23, 24, and 25 medical record lacked evidence of a care plan addressing activities, scheduled activities, or documentation activities were conducted and Patient #'s 21, 22, and 25 lacked evidence of an activity assessment.

Administrative staff B interviewed on 5/27/14 at 12:05pm acknowledged the hospital failed to have a qualified Activities Director on staff.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on medical record review, Medical Staff Rules and Regulations, policy review, and staff interview the hospital failed to ensure providers completed a discharge summary for one of five sampled swing bed patient (#24) . This deficient practice had the potential for inadequate post-hospitalization follow-up care.
Findings include:
- The hospital's Medical Staff Rules and Regulations reviewed on 5/27/14 at 4:00pm directed, "...All medical records must be completed within 30 days following discharge..."
- The hospital's policy for incomplete medical records reviewed on 5/27/14 at 4:05pm directed, "...A Discharge Summary must be dictated within 14 days after discharge..."

- Patient #24's medical record reviewed on 5/21/14 revealed an admission date of 1/15/14 and discharged on 3/15/14 with a diagnosis of cancer pain. Patient #24's medical record failed to contain a discharge summary that included a recapitulation of the residents stay in the hospital (67 days after discharge).

Medical Records staff H interviewed on 5/20/14 at 3:40pm acknowledged hospital Medical Staff failed to complete a discharge summary within thirty days after discharge for many patients including Patient #24 and they failed to have a corrective action plan.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on interview the hospital failed to have a contract or agreement for provision of routine and emergency dental care for the swing bed patients. Noncompliance with this requirement had the potential to affect all swing bed patients.

Findings include:

- Administrative staff B interviewed on 5/22/14 at 10:30am confirmed the hospital failed to have an agreement or contract with a dentist for provision of routine and emergency dental care for swing bed patients.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on staff interview the hospital failed to provide for routine and emergency dental service for swing bed patients. The hospital failed to have a contract or agreement for provision of routine and emergency dental care for the swing bed patients. Noncompliance with this requirement had the potential to affect all swing bed patients.

Findings include:

- Administrative staff B interviewed on 5/22/14 at 10:30am confirmed the hospital failed to have an agreement or contract with a dentist for provision of routine and emergency dental care for swing bed patients.

The hospital reported an average daily census of 3.3 patients with a current census of four patients, three acute and one swing bed patients. Based on staff interview the hospital failed to provide for routine and emergency dental service for swing bed patients. The hospital failed to have a contract or agreement for provision of routine and emergency dental care for the swing bed patients. Noncompliance with this requirement had the potential to affect all swing bed patients.

Findings include:

- Administrative staff B interviewed on 5/22/14 at 10:30am confirmed the hospital failed to have an agreement or contract with a dentist for provision of routine and emergency dental care for swing bed patients.