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Based on the review of procedures and policies and interviews with management, it was determined that the hospital failed to ensure the implementation of patient rights according to OAR 333-505-0033. Patient Rights which states: "A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13."

Findings include:

A review of Southern Coos Hospital Nursing Services Policy #1.18 titled "Patient Rights," revised 09/04, revealed that all of the patient rights as identified in 42 CFR 482.13 were not identified.

The following items are to be included:

1. The hospital must establish a process for prompt resolution of patient grievance and must inform each patient whom to contact to file a grievance.
2. The hospital's governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.
3. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.
4. The hospital must establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital.
5. The grievance process must specify time frames for review of the grievance and the provision of a response. (7 days is an appropriate time frame)
6. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
7. Patient Visitation Rights - A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. (Effective 1/2011).

A review of the Southern Coos Hospital Administrative Human Resources policy titled "Grievance Procedure" was written for employees of the hospital regarding employee related grievances. A policy for patients outlining the process they must go through when filing a grievance or complaint should be developed also.

Based on observation of the Medical Imaging Department (ED) at 0852 on June 14, 2011 it was determined that the hospital failed to ensure that outdated supplies and medications were not available for use in treating emergency cases. Findings:

Observation of X-ray Room 1 at 0852 on June 14, 2011 revealed the following outdated supplies:
-Thirteen 0.1 oz foil packets of MediChoice lubricating jelly with 11 of the packets expired on 06/2010 and 2 of the packets expired on 3/2008;
-One 16 fl.oz. container of Betadine solution expired on 07/2006;
-One EZ Paste Barium Sulfate esophageal cream expired 11/2006;
-One 16 fl.oz. container of hydrogen peroxide expired on 11/2009;
-Fourteen Povidone Iodine individually wrapped swabsticks expired on 6/2007;
-One half-filled 2 liter container of Barium Sulfate suspension expired 3/2011; and
-One 4" x 4" gauze sponge expired on 7/2005.

Observation of Mammography Room at 0858 on June 14, 2011 revealed the following outdated supplies:
-Two sets of size 8 powder free latex surgical gloves expired on 1/2008;
-Seven modified disposable Kopan's spring hook localization needle use by 4/2011;
-One modified disposable Kopan's spring hook localization needle use by 3/2011;
-Three 2"' x 2"' gauze sponge expired on 9/2005; and
- Three Povidone Iodine individually wrapped swabsticks two expired on 3/2008 and one expired on 8/2009.

Observation of C.T .Room at 0916 on June 14, 2011 revealed the following outdated supplies:
-Two 24 gauge 0.7x1.4, expired 8/2010; and
-Two disposable syringe fill tubes expired 6/2002.
-An MRI kit containing:
-Nine 20 gauge 1.16" Insyte Autogaurd with 6 expired on 1/2010 and 3 expired on 5/2011;
-One prefilled 10 ml syringe with 0.9% Sodium Chloride expired on 6/1/2011;
-Two Tegaderm dressings with one expired on 10/2004 and one expired on 7/2007; and
-Two pneumothorax sets use by 3/2011.

Based on review of documentation and an interview with hospital staff, it was determined that the hospital's medical staff failed to meet this regulation by not identifying who is qualified to complete the medical screening exam in the hospital bylaws or rules and regulations..

Findings include:

1. A review of Southern Coos Hospital Emergency Department policy titled "EMTALA Guidelines for Emergency Department Services" effective 4/08 lists the following information:

"MEDICAL SCREENING EXAMS:

Medical Screening Exams should include at a minimum the following:
. Emergency Department Log entry including disposition of patient
. Patient's triage record
. Vital signs
. History
. Physical exam of affected systems and potentially affected systems
. Exam of known chronic conditions
. Necessary testing to rule out emergency medical condition
. Notification and use of on-call personnel to complete previously mentioned guidelines
. Notification and use of on-call physicians to diagnose and/or stabilize the patient as necessary
.Vital signs upon discharge or transfer
.Complete documentation of the medical screening exam"

This policy lacks the documentation of who is qualified to perform the initial medical screening exam. The health practitioners designated to perform medical screening exams are to be identified in the hospital by-laws or in the rules and regulations that govern the medical staff following governing body approval per CFR 482.55.

2. The emergency department director was interviewed on 6/15/2011 and this information was confirmed.