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Based on review of facility policies and procedures, medical records and staff interviews, the facility failed to inform each Medicare patient of their in-patient, discharge and appeal rights for eight (8) patients (#s 1, 2, 8, 9, 10, 11, 13 and 18) of the twenty (20) sampled patients.

Findings include:

The facility failed to have a policy which addressed which personnel would be responsible for deliverance of the Important Message from Medicare (IM) to the patient or the patient's representative both on admission and discharge from the facility and how compliance would be monitored. Review of the facility's two (2) sources information, entitled Medicare Claims Processing Manual, Chapter 30-Financial Liability Protections and Notice Instructions-Important Message from Medicare, no effective dates, revealed that it was the a requirement that the facility provide to in-patients, who had Medicare insurance, the Important Message from Medicare and to inform in-patients and/or their representatives when their condition and/or treatment plan was not appropriate for the level of healthcare services requested nor covered under their insurance plan. The information dictated that the procedure to be followed was to provide the in-patient who had Medicare insurance with the IM within two (2) days of admission and this copy was then placed in the patient's medical record after the patient signed and dated the form. According to the policy, a copy of the Important Message would again be provided to the Medicare in-patient forty-eight (48) hours prior to discharge and this form was also signed and dated by the patient and placed in the patient's medical record.

Six (6) Medicare patient records (#s 2, 8, 9, 10, 13 and 18) out of eight (8) Medicare patient records (#s 1, 2, 8, 9, 10, 11, 13 and 18) in a total of twenty (20) sampled medical records (#s 1-20) revealed that the initial IM was missing in two (2) patient records (#s 8 and 10) and that the second IM was missing in four (4) patient records (#s 2, 9, 13 and 18).

During an interview on 03/12/014 at 11:00 a.m., the director of Quality Assurance (QA) confirmed that the facility failed to have a policy which addressed the personnel responsible for deliverance of the Important Message, and that the forms were not being completed.

During an interview on 03/12/14 at 1:00 p.m., the director of Health Information Management (HIM) stated that she/he was not aware of the procedure used to deliver the IM to patients and the time frames or personnel involved, and that he/she was unaware of a facility policy which addressed this. The HIM director provided surveyor with information on the IM that they had received from Center for Medicaid/Medicare (CMS).

Based on observation, policy review, manufacturer's safety data sheet, and interview, the facility failed to provide an appropriate and safe storage area for one (1) can of flammable anesthetic gas.

Findings include:

On 3/10/14 at 3:00 p.m. observation revealed a can of Gebauer Ethyl Chloride (a flammable medication used to numb the skin for injection or incision) in one (1) of two (2) operating rooms. The can was secured in a locked and unvented metal cabinet with other medications.

Review of facility policy 3-02 "Title: Fire safety in an oxygen enriched environment-Operating Room" revealed no evidence of Ethyl Chloride.

A review of the manufacturer's safety data sheet confirmed that the storage of the chemical should be in a "well ventillated" area.

The Director of Surgical Services confirmed that the cabinet in current use was where the Ethyl Chloride was normally kept when not in use.

Based on record review, policy and procedure review, and staff interview the facility failed to provide evidence that two (2) swing bed patients (#3 and #5) were under the care of a Medical Doctor.

Findings include::

Review of the medical record for swing bed patient #3 revealed that he/she was admitted on 10/31/2013 by a Nurse Practitioner (NP) # 8. The patient remained hospitalized 8 days until the date of discharge on 11/7/2013. The admission order was co-signed by the sponsoring Medical Doctor for the NP after the date of discharge on 12/14/2013.

Review of the medical record for swing bed patient #5 revealed that he/she was admitted on 9/19/2013 by a NP # 8. The patient remained hospitalized 12 days until the date of discharge on 10/1/2013. The admission order was co-signed by the sponsoring Medical Doctor for the NP after the date of discharge on 10/9/2013.

Review of facility policies, medical staff bylaws, and rules and regulations revealed no evidence of a policy, or bylaw that documented how the facility would document and ensure that the patient's medical record demonstrated MD responsibility/care.

An interview with the Director of Quality Assurance on 3/11/2014 at 12:00 p.m. confirmed the above findings. The director stated the facility bylaws address MD oversight for all admission by a NP on page 10, but the bylaws do not specify a timeframe for documentation. The admission order should be signed during the time of admission.