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Based on interview and document review, the facility failed to ensure four of five physicians' (Physicians EE, FF, GG and II)credentialing files reviewed had current licenses. This deficient practice affects all patients in the facility. The facility census was seven.

Findings included:

1. Review of the facility By-Laws dated 05/20/09 showed upon the recommendation of the Chief of Staff, the Chief Executive Officer (CEO) may grant temporary privileges after receipt of an application for staff, copy of Missouri license, copies of Drug Enforcement Agency (DEA) and Bureau of Narcotics and Dangerous Drugs (BNDD) licenses.

Record review of the facility policies and procedures showed there was no policy and procedure for physician credentialing.

Review of a form titled, "Physician Credentialing" undated, showed direction for staff to obtain copies of the Missouri medical license, copies of Drug Enforcement Agency (DEA) and Bureau of Narcotics and Dangerous Drugs (BNDD) licenses.

Review of a form titled, "Credentialing File Verification" undated, showed directions for staff included to obtain a copy of the physician's license, insurance verification, DEA and BNDD.

2. Review of Staff EE, Doctor of Medicine (MD), Director of Radiology's credentialing file showed the physician's license expired 01/31/12.

Review of Staff FF, Doctor of Osteopathic Medicine (DO), Radiology, credentialing file showed the physician's license expired 01/31/12

Review of Staff GG, DO Director or Emergency Department 's credentialing file showed the physician's license expired 01/31/12.

Review of Staff II, MD Lab Director's credentialing file showed
-The physician's license expired 01/31/11 and;
-There was no BNDD or DEA license on file to verify license expiration.

3. During an interview on 02/29/12 at 4:30 PM, Staff B, Executive Director stated that the radiation credentialing files were incomplete and she was working on implementing a process for credentialing but had not implemented it yet.

During an interview on 02/29/12 at 5:00 PM Staff B, Executive Director stated that there was no policy and procedure for credentialing and she had not had time to work on credentialing files since being assigned responsibility on 01/03/12 for the credentialing files. She stated she used the forms titled, "Physician Credentialing" and "Credentialing File Verification".

Based on interview, the facility failed to have the required agreement with a qualified entity to provide review functions for credentialing and quality assurance. This deficient practice affects all patients in the facility. The facility census was seven.

Findings included:

During an interview on 03/08/12 at 11:00 AM, Staff I, Chief Executive Director, stated that he had no agreement or contract with another entity to review functions for credentialing and/or quality assurance.

Based on interview and document review, the facility failed to adopt Medical Staff By-Laws which give only the Governing Body the authority to grant medical staff privileges. This deficient practice affects all patients in the facility. The facility census was seven.

Findings included:

1. Review of the facility By-Laws dated 05/20/09 showed:
- The Governing Body has charged the Medical Staff with the responsibility for providing, monitoring and improving patient care in the hospital and the Chief Executive Officer (CEO) may grant temporary privileges upon the recommendation of the Chief of Staff.
- Upon the recommendation of the Chief of Staff, the CEO may grant temporary privileges after receipt of an application for staff, copy of Missouri license, certificate or proof of insurance, copies of Drug Enforcement Agency (DEA) and Bureau of Narcotics and Dangerous Drugs (BNDD) licenses.
- Temporary privileges shall be awarded for an initial period of 30 days, is contingent upon receipt of the information that continues to support granting privileges.

2. Review of Staff GG, DO Director or Emergency Department 's credentialing file showed she had been granted temporary privileges on 08/22/11, 11/22/11, 12/22/11, 01/22/12 and 02/22/12 by the CEO in consultation with the hospital chief of staff. The facility failed to have the physician's temporary privileges approved by the governing body.

During an interview upon review of Staff GG's credentialing file, Staff B Executive Director stated that she did not know why Staff GG had only been granted temporary privileges since 08/22/11.

3. Review of Staff II, MD Lab Director's credentialing file showed
he had been granted temporary privileges on 10/06/10, 01/04/11, 02/03/11, 03/04/11, 04/01/11, 05/02/11, ,06/01/11, 07/31/11, 08/29/11, 11/29/11, 12/29/11, 01/27/12 and 02/27/12 by the CEO in consultation with the hospital chief of staff. The facility failed to have the physician's temporary privileges approved by the governing body.

During an interview upon review of Staff II's credentialing file, Staff B Executive Director stated that she had no idea why Staff II had only been granted temporary privileges since 10/06/10.

Based on observation, interview, and policy review, the facility failed to:
- follow nationally recognized standards for hand hygiene and failed to ensure staff performed hand hygiene for three (#3, #5, #22) of three patients observed during care and/or during meal preparation.
- ensure correct aseptic (without potential infection) technique during care of three (#3, #5 and #14) of three patients observed during care.
- to ensure chairs used by patients in the radiology department had a washable surface.
The facility census was seven.

Findings included:

1. Review of the CDC/HICPAC (Centers for Disease Control/Healthcare Infection Control Practices Advisory Committee) hand hygiene recommendations, dated October 2002, included indications for hand washing and hand antisepsis, which showed:
-When hands are visibly dirty or contaminated or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
- Decontaminate hands before having direct contact with patients.
- Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).
- Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
- Decontaminate hands if moving from a contaminated-body site to a clean-body site during
patient care.
- Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
- Decontaminate hands after removing gloves.

Record review of the Centers for Disease Control (CDC) publication titled, "Guideline for Hand Hygiene in Health-Care Settings," dated 10/25/02 showed the following direction:
- Page 34. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel.

Review of the May 2009 AORN (Association of PeriOperative Registered Nurses) Perioperative Standards and Recommended Practices, Recommended Practices for Prevention of Transmissible Infections in the Perioperative Setting showed:
Recommendation II, hand hygiene should be performed before and after each patient contact.
- All personnel should practice general hand hygiene. Prompt and frequent hand antisepsis is the single most important measure to reduce the spread of microorganisms. Hand hygiene should be performed:
-At the beginning of a work shift
-Before and after patient contact
-After removing gloves
-Anytime there is possibility that there has been contact with blood or other potentially infectious materials, and
-Anytime when hands may have been soiled or any time the practitioner believes his or her hands may have been soiled.

Review of the facility's policy titled, "Hand Washing" undated, showed directions for staff to perform hand hygiene after each patient encounter and when hands are soiled

2. Observation on 02/27/12 at 2:04 PM showed Staff N, Registered Nurse (RN), administered medications to Patient #3. Staff N wore gloves while removing medications from the automated medication dispenser and then did not perform hand hygiene and wore the same gloves to the patient's bedside to administer oral medication to Patient #3. Staff N proceeded to set up supplies to start an IV (small catheter inserted into the vein for administering fluids and medication) and then left the room without removing the gloves and performing hand hygiene. After returning with a supply for the patient's use, Staff N removed her gloves and washed her hands in less than five seconds and then tapped her hands against the inside of the sink to remove excess water (inside of sink being a contaminated surface). Staff N put on new gloves and started the IV. During the IV start, Staff N used her gloved hands several times to brush her hair back away from her face and then returned to the task of starting the IV wearing the same gloves. Before connecting the IV tubing to the catheter in the patient's vein, Staff N wiped the sterile end of the IV tubing across the antiseptic pad that had been used against the patient's skin as preparation for the IV contaminating the sterile tubing before she connected it to the patient.

Observation on 02/27/12 at 2:50 PM showed Staff N, RN, wearing gloves, carried a urine specimen in a bag out of Patient #5's room. Staff N did not remove the gloves and perform hand hygiene but wore the gloves and went into the supply room and then went into another office area in the Emergency Department. Staff N returned to Patient #5's bedside wearing the same contaminated gloves and did not perform hand hygiene and proceeded to obtain a throat culture (use a cotton-tipped applicator to rub the back of the patient's throat to obtain a specimen to determine if infection existed) on Patient #5.

3. During an interview on 02/29/12 at 8:50 AM, Staff Y, RN, Infection Control Practitioner, stated that the expectation was to perform hand hygiene before and after every contact with the patient or with the patient's environment, before and after contact with body fluids, and after removal of gloves. Staff Y stated that gloves should be removed before leaving the patient environment. Staff Y stated that he does see problems with hand hygiene. Staff Y stated that he started hand hygiene surveillance twice but was not able to continue due to not having enough staff coverage and him providing direct patient care.

4. Observation on 02/27/12 at 2:30 PM showed Staff J, laboratory assistant, entered Patient #3's emergency department (ED) room and donned gloves but failed to perform hand hygiene. Staff J then obtained a blood sample from the patient, removed her gloves but did not perform hand hygiene. Staff J handled the blood tubes and supplies then donned clean gloves and attempted to obtain additional blood samples. Staff J exited the patient's room while still wearing soiled gloves and went to the supply room, then removed the soiled gloves. Staff J failed to perform hand hygiene after removing her gloves. Staff J opened cabinets and obtained additional supplies while in the supply room, then returned to the patient's room and donned clean gloves but failed to perform hand hygiene. Staff J obtained additional blood samples from the patient, removed her gloves, picked up the blood tubes and went to the nurse's desk. Staff J failed to perform hand hygiene.

Review of Staff J's employee file showed she received infection control training (including hand hygiene) on 09/26/11.

Observation on 02/28/12 at 3:15 PM showed Staff N, RN performed an IV sterile needle insertion into Patient #22's left arm. Once the IV insertion was completed, Staff N took off her gloves, threw the gloves in the trash, applied a new set of gloves (without performing hand hygiene) and administered an IV pain medication. Once the IV pain medication was administered, Staff N took off her gloves, threw the gloves in the trash, carried the IV supply tray (a tray that contained equipment needed to perform IV insertions and/or blood collection such as sterile needles, gauge, and empty sterile blood vials), (touching the tray handle contaminated the surface), left the patient's room and entered the medication room down the hallway without performing hand hygiene.

Observation on 02/27/12 at 2:20 PM showed Staff S, Licensed Practical Nurse (LPN) donned gloves and applied nitroglycerin paste (a medication which can be used to treat several different medical conditions related to the circulatory system and is a preparation of nitroglycerin which is designed for topical use) to Patient #14's chest. Staff S then pulled a pen out of her pocket and charted on the Medication Administration Record (MAR) with gloves on. Before leaving the room, she removed the gloves and performed hand hygiene, and returned the MAR to the nursing station.

During an interview on 02/29/12 at 10:15 AM, Staff Y, RN, Infection Control Practitioner, stated that he would expect the nurse to remove gloves and perform hand hygiene prior to charting in the MAR.

5. Review of the US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code Chapters 2 and 3 showed directions included:
-Food employees shall keep their hands and exposed portions of their arms clean;
-Hand hygiene: Rinse under clean running warm water; apply an amount of cleaning compound recommended by the cleaning compound manufacturer, rub vigorously for at least 10-15 seconds, thoroughly rinse under clean running warm water and, dry.
-Food employees shall clean their hands immediately before engaging in food prep, after handling soiled equipment or utensils, during food prep as often as necessary, when switching between working with raw food and ready to eat food, before donning gloves for working with food and after engaging in other activities that contaminate the hands.
-Food employees may not clean their hands in a sink used for food preparation.

Review of the facility's policy titled, "Dietary Department-General Conduct" dated 10/10 showed directions for staff included:
-Hands must be washed on a regular basis and at the following times: before beginning work, before handling food, after handling raw or unwashed food and between preparing different dishes. Always use soap and warm water.

6. Observation on 02/28/12 from 9:35 AM to 10:00 AM showed Staff Q, Cook obtained meat from the refrigerator, an onion, and canned goods then donned gloves but failed to perform hand hygiene. She chopped the onion then rinsed her gloves in the food prep sink (a sink meant to be used for food preparation not hand hygiene) then patted the gloves dry with a dishcloth in the bottom of the sink. She then obtained a bowl and added the meat and onion to the bowl, then used a can opener to open a can of tomato sauce, added the tomato sauce to the meat and onion mixture. She then took the empty can to the trash can, removed the lid of the trash can with the gloved hand. She then obtained a green pepper and chopped it; obtained a measuring spoon from a drawer of utensils, picked up spice jars and added spices; put her gloved hands into the meat mixture to mix the meat, onion, pepper, tomato sauce and spices. The edges of her long sleeves were also in the meat mixture. She removed her gloves after mixing but failed to perform hand hygiene. She then scooped out balls of the meat mixture and again the edges of her sleeves were in the meat mixture. Staff H Dietary Manager observed the edges of Staff Q's sleeves were in the meat mixture and pulled Staff Q's sleeves up. Staff Q removed her gloves and rinsed her hands in the food prep sink but failed to wash her hands with soap. Staff Q then used the dishcloth from the food prep sink to wipe the counter. Staff Q then opened and drained a can of green beans in the food prep sink, put the beans into a pan, rinsed her hands in the food prep sink and used the dish cloth from the sink to pat her hands dry.

During an interview on 02/28/12 at 10:00 AM Staff H stated that staff should use soap when performing hand hygiene. Staff Q confirmed she did not use soap. Staff H and Staff Q stated they did not know who the Infection Control nurse was and was not aware of any staff making hand hygiene observations in the dietary department.

During an interview on 02/28/12 at 10:50 to 11:15 AM Staff O, Registered Dietitian (RD) stated that:
-She did not know who the Infection Control nurse was;
-Did not think anyone monitored the dietary department for infection control issues;
-The food prep sink is not for hand hygiene and;
-She was not aware of a hand hygiene policy for dietary staff.

During an interview on 02/28/12 at 1:05 PM, Staff O, RD stated that she had found a policy for dietary staff that included hand hygiene.

During an interview on 02/29/12 at 8:50 AM, Staff Y, RN, Infection Control Practitioner, stated that he had not made observations in the dietary department recently and stated that the cooks failure to perform hand hygiene was not acceptable.

7. Observation on 02/28/12 at 10:40 AM in the Radiology Department's x-ray room showed an upholstered chair with rips in the fabric on the arms of the chair. The upholstered cover is not a washable surface that can be cleaned in-between patients.

During an interview on 02/28/12 at 10:40 AM, Staff R, Radiology Manager, stated that patients sat in the upholstered chair.

During an interview on 02/28/12 at 10:40 AM, I, Chief Executive Officer, stated that the upholstered chair was a surface that could not be cleaned and needed to be removed.

Observation on 02/28/12 at 11:05 AM in the Radiology Department's Ultrasound (test using sound waves for diagnostic testing) showed an upholstered chair.

During an interview on 02/28/12 at 11:05 AM, Staff R stated that patients sat in the upholstered chair.

During an interview on 02/29/12 at 8:50 AM, Staff Y stated that the chairs in patient rooms and waiting rooms throughout the hospital are not cleanable.




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Based on observation, interview and record review, facility dietary staff failed to provide patient food service, using recognized food sanitation practices to prevent cross contamination of foods and possible food borne illness by failing to serve hot and cold foods at an appropriate temperature. The facility census was seven.

Findings included:

1. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 3-202.11 potentially hazardous foods (includes foods from an animal source) should be maintained at or below forty-one (41) degrees Fahrenheit.

Record review of the facility policy, titled "Food Temperatures" #8050-4.2 dated 10/10 showed direction for dietary staff to serve cold foods and beverages at or below forty-one (41) degrees Fahrenheit.

2. Observation on 02/29/12 at 12:05 PM showed dietary staff served a test tray with foods including:
-Lettuce Salad at forty-two (42) degrees Fahrenheit;
-Mandarin Oranges at fifty-two (52) degrees Fahrenheit;
-Taco Soup at one hundred seventy (170) degrees Fahrenheit and;
-Chicken Crispitos (a fried or baked tortilla) one hundred thirty eight (138) degrees Fahrenheit.

During an interview on 02/29/12 at 12:10 PM Staff H, Director of Dietary stated cold foods should be served at or below forty-one (41) degrees Fahrenheit, the soup should have been one hundred eighty (180) degrees Fahrenheit and the Chicken Crispitos should have been one hundred fifty-five (155) degrees Fahrenheit.

Based on interview, record and policy review the facility failed to develop and/or keep current plans of care to ensure patient care, treatment and/or services were appropriately planned to meet the patient's needs for five patients (#1, #4, #6, #24 and #25) of six plans of acute care reviewed. The facility census was seven.

Findings included:

1. Review of the facility's policy titled "Care Planning" dated 02/02/07, showed directions for staff included:
-Generate a plan of care within eight (8) hours of admission;
-Individualize the plan of care based on the patient's diagnoses and patient assessment;
-Address the learning needs of the patient and/or family;
-Update the plan of care daily with revisions reflecting the reassessed needs and;
-All staff using the plan of care are responsible to establish goals and appropriate interventions as well as ongoing evaluation.

2. Record review of Patient #25's admission orders dated 01/13/12 showed the patient was admitted to the facility for fever and dehydration, with severe vomiting and diarrhea for the last couple of days. The physician ordered activity of bed rest, a diet of ice chips, until the patient had no nausea or vomiting and then to advance to a clear liquid diet. Review of the patient's nursing care plans did not reflect the patient's individual needs to include fever, nausea/vomiting/diarrhea, activity of bed rest and/or diet of ice chips, to advance to clear liquid. Therefore, the care plans were not updated to show changes and/or the resolution of these care needs prior to discharge from the facility on 01/17/12.

3. Record review of Patient #24's admission orders dated 02/06/12 showed the patient was admitted to the facility for DVT (deep vein thrombosis {blood clot}) to the right lower leg. The physician ordered Lovenox 90 mg (milligrams) subcutaneous (inject with needle into the skin layers) every 12 hours and Coumadin 11 mg PO (by mouth) daily. (Note: Lovenox and Coumadin are medications to thin blood; help prevent blood clots with risk to the patient of bruising and/or bleeding.) The physician also ordered bed rest with right leg elevated. Review of the patient's nursing care plans did not reflect the patient's individual needs to include risk of bruising, bleeding and/or activity of bed rest with right leg elevated. Therefore, the care plans were not updated to show changes and/or the resolution of these care needs prior to discharge from the facility on 02/10/12.

4. Record review of Patient #6's admission orders dated 02/22/12 showed the patient was admitted to the facility for dehydration. The physician ordered activity of bed rest and to insert a urinary catheter (tube inserted into bladder for urination). On 02/24/12, the physician ordered to discontinue the catheter and begin bladder/bowel training (assisting patient to the bathroom every two hours).

Observation on 02/27/12 at 3:15 PM showed the patient ambulated in her room without assistance and did not have a catheter.

Record review on 02/27/12 at 3:30 PM of the patient's Plan of Care dated 02/22/12 showed, "Activity Intolerance" was dated as initiated on 02/22/12 by nursing staff but was not individualized to show the patient was on bed rest; and showed, "Alteration in Bladder/Bowel Elimination" was blank and had not been initiated by the nurse. Therefore, the patient's care plans did not reflect the patient's individual needs to include bed rest, the urinary catheter or bladder/bowel training, and was not updated to reflect changes and/or resolution of these care needs.

During an interview on 02/27/12 at 3:00 PM, Staff K Registered Nurse (RN) stated that if a patient had an order for an urinary catheter, nursing staff should initiate the "Alteration in Bladder/Bowel Elimination" care plan and write-in "inserted urinary catheter" to individualize the care plan. Staff K stated that when the catheter was discontinued, nursing staff should write the date resolved (discontinued). Staff K stated that the same process would be to initiate the care plan "Alteration in Fluid" for dehydration and to update when resolved.

5. Record review of Patient #1's History & Physical (H&P) showed the patient was admitted on 02/23/12. The patient's admission diagnoses included Syncopal episode (fainting) and bradycardia (slow heart rate).

Observation of the patient's room on 02/27/12 at 3:00 PM showed a sign on the door directing staff the patient was on fall precautions.

Record review on 02/27/12 at 3:00 PM of the patient's Plan of Care dated 02/23/12 showed staff documented they initiated a plan of care for potential for injury and potential for infection but staff failed to document a goal, interventions and the date the problems were resolved.

During an interview on 02/27/12 at 3:05 PM, Staff K Registered Nurse (RN) stated that staff should have completed implementation of the plan of care for potential for injury and potential for infection. Staff K did not respond when asked how staff knew the patients care needs when the plan of care is incomplete.

During an interview on 02/27/12 at 3:10 PM, Staff L Certified Nurse Assistant (CNA) stated that the patient was at risk for falls, needed staff assistance with walking due to the patient being unsteady and was difficult to understand due to a speech impediment. Staff L stated that sometimes staff had to have the family interpret what the patient said due to the patient's unclear speech.

During an interview on 02/27/12 at 3:15 PM the patient stated staff would not let her walk without assistance due to weakness. The patient was very difficult to understand.

During an interview on 02/27/12 at 3:30 PM, Staff K reviewed the patient's plan of care and stated the plan of care should have been implemented and checked boxes on the form to show interventions had been put in place for potential for injury and potential for infection. Staff failed to implement a plan of care for the patient's speech impediment and the need for family to interpret.

6. During an interview on 02/27/12 at 3:25 PM, Patient #4 stated that she had just returned to bed from the bathroom without assistance. Patient #4 stated no one had told her that she was high risk for falls or to ask for assistance when getting out of bed. Patient #4 stated that she had read the "High Risk for Falls" bracelet on her arm and didn't know what that meant or why she was at risk.

Review of Patient #4's medical record showed she was admitted on 02/25/12. The physician's admitting orders dated 02/25/12 at 5:30 PM included "Fall Precautions." The document titled, "Nursing/Interdisciplinary Care Plan" showed the problem titled, "Knowledge Deficit" had been initiated on 02/25/12. On the document titled, "Patient Teaching Record" the nurse failed to educate the patient on being high risk for falls.





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Based on interview and policy review, the facility failed to clearly appoint a qualified director of the Medical Record department. This resulted in unclear roles and responsibilities for the Medical Record department. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "Medical Record Staffing," dated 01/09/12 showed the following:
- The medical records service shall be under the direction of a consultant who is a Registered Health Information Administrator as certified by the American Health Information Management Association, or who meets the educational or training requirements for such certification.
- If the employment of a full-time Registered Health Information Administrator is impossible, the hospital shall employ a Registered Health Information Technician on a part-time consultant basis.

Record review of the facility's organizational chart showed that the Medical Records department reported to Patient Financial Services.

2. During an interview on 02/28/12 at 2:38 PM, Staff V, Medical Records Clerk, stated there was no manager/director for the Medical Record department. Staff V stated that the manager left in 09/11. Staff V stated that she reported to Staff I, Chief Executive Officer (CEO). Staff V stated that she was not a Registered Health Information Technician (RHIT) and she wasn't sure if anyone at the facility was a RHIT. Staff V stated that the Medical Record department did not have a consultant. Staff V stated that she had just started doing chart audits for Quality Assessment Performance Improvement (QAPI). Prior to 02/12, the last chart audits done in the Medical Record department were dated 2007.

During an interview on 02/29/12 at 8:15 AM, Staff V stated she didn't know who the director of Patient Financial Services was (whom she reported to as per the facility's organizational chart).

During an interview on 02/29/12 at 10:50 AM, Staff E, Business Office Manager, stated that she approved Staff V's schedule and time off requests but anything else was taken to Staff I, CEO, because she didn't have the authority. Staff E stated that she was not a Registered Health Information Technician or Administrator and that she knew billing, not medical records. Staff E stated that she was not aware of any QAPI being done in the Medical Record department.

During an interview on 02/29/12 at 11:30 AM, Staff I, CEO, stated that Staff V, Medical Records Clerk, was the director. Staff I stated that the board had not approved a director. Staff I stated that the chart audits were being done be the Emergency Department and Director of Nursing and Staff V may have not been aware.

Based on observation, interview, and record review, the facility failed to provide two Patients (#26 and #27) of two discharged Swingbed patient records selected for review, with a discharge notice that included all components required in the discharge notice. The Swingbed census was four. The facility census was seven.

Findings included:

1. Record review on 02/29/12 at 5:00 PM of Patient#27's medical record showed the patient was discharged from the facility Swingbed program on 01/20/12. Review of the facility form titled, "An Important Message From Medicare About Your Rights", dated 01/14/12 at 12:30 PM, showed the form did not include:
- The reason for transfer or discharge;
- The effective date of transfer or discharge;
- The location to where the patient was being transferred to.

Record review on 02/29/12 at 5:30 PM of Patient #26's medical record showed the patient was discharged from the facility Swingbed program on 12/05/11. Review of the facility form titled, "Notice of Medicare Provider Non-Coverage", dated 11/29/11 at 1:00 PM, showed the form did not include:
- The reason for transfer or discharge;
- The location to where the patient was being transferred to.

2. During an interview on 02/28/12 at 11:15 AM, Staff C, Social Services stated she used the facility form titled, "Notice of Medicare Provider Non-Coverage", until December of 2011. She then began using the form titled "An Important Message From Medicare About your Rights", because she felt it contained all the information necessary. She stated she always gave the forms to patients two days prior to discharge. She stated there was no policy in regard to the discharge notice and that she was not aware that the form needed to include the reason for discharge, the effective date of discharge, and the location to where the patient was to be transferred.