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Based on interview and review of patient rights information, the hospital failed to provide written notice to patients that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week.

This information assists the patient to make informed decisions about his or her healthcare.

Reference: 42 CFR 489.20(w):
"In the case of a hospital as defined in Sec. 489.24(b), to furnish written notice to all patients at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week, in order to assist the patients in making informed decisions regarding their care, in accordance with Sec. 482.13(b)(2) of this subchapter. The notice must indicate how the hospital will meet the medical needs of any patient who develops an emergency medical condition, as defined in Sec. 489.24(b), at a time when there is no physician present in the hospital. For purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service."

Findings:

On 7/19/2011 at 3:30 PM, an interview with the hospital's Chief Nursing Officer (Staff Member #6) and the Business Office Manager (Staff Member #7) revealed that all patients were given a handout to read entitled "Patient Rights and Responsiblities" when admitted to the hospital for inpatient and outpatient care.

Review of the contents of this handout revealed that it did not include written notice to patients that a doctor of medicine or doctor of osteopathy was not present in the hospital 24 hours a day, seven days per week. There was no process for giving patients written notice indicating how the hospital would meet the medical needs of any patient who develops an emergency medical condition when a physician is not present.

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Based on observations and review of provided documentation, the hospital failed to ensure that code carts, more specifically defibrillators were checked on a daily basis.

Failure to ensure that emergency equipment is properly checked to ensure it is functioning places patients at risk of harm should the equipment be needed and/or it is not working properly.

Findings include:

1. On 7/19/2011 the surveyor reviewed the daily log sheets for the code cart located in the Emergency Department. As a result of the review it was determined that daily checks of the code cart had not been made on June 11, 2011 and July 17, 2011.

2. On 7/20/2011 the surveyor reviewed the daily log sheets for the code cart located in the Surgical department. As a result of the review it was determined that daily checks of the code cart had not been made on the previous 5 days (July 15, 2011 through July 19, 2011. Subsequent to this finding staff determined that the battery located on the defibrillator was bad (non-functioning) and that the back-up battery intended to be used was not charged.

3. On 7/21/2011 the surveyor reviewed that daily log sheets for the code cart located in the Medical unit. As a result of the review it was determined that daily checks of the code cart had not been made on April 24 and April 25, 2011.

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Based on observation and interview, the hospital failed to provide plumbing with cross connection controls as required by Washington State plumbing code.

Failure to provide cross connection controls threatens the domestic water supply and puts patients, staff and visitors of the facility at risk from contaminates introduced into the water supply as a result of back-pressure or back-siphonage.

THIS IS A REPEAT VIOLATION - Cited 7/9/2009

Findings:

During rounds of the facility on 7/202011, the surveyor observed that the water supply serving the Neptune waste management system didn't not have a Reduce Pressure Backflow Assembly (RPBA) installed in a readily visible location. As a result the surveyor asked Engineering staff (Staff Member #15) if an RPBA was serving the Neptune unit. The engineering staff member advised the surveyor that the water supply to the Neptune unit was not protected by a RPBA.

Based on observations made during the course of the survey the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 7/19/2011 - 7/21/2011.

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Based on observation the facility failed to comply with the requirements of the Life Safety Code, NFPA 101, 2000 edition, Chapter 19.3.2.7.

Refer to deficiencies written in the MEDICARE RE-CERTIFICATION SURVEY CRITICAL ACCESS HOSPITAL (FIRE LIFE SAFETY SURVEY) dated 7/19/2011- 7-21/2011 (Tag K-0211).

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1. Based on review of credentialing files, review of medical staff bylaws, and interview, the hospital failed to provide evidence that peer review and performance information was provided and considered at the time of reappointment for 8 of 8 medical staff members reviewed (Medical Staff Members #1, #2, #3, #4, #5, #6, #7. #8)

Failure to consider this information at the time of reappointment risks appointing incompetent and unsafe practitioners to the medical staff.

Findings:

a. The hospital's medical staff bylaws (Reviewed 2010) read as follows: "The Chairman of the Professional Committee or his designee collects for consideration as part of the reappointment process, all relevant information regarding the individual's professional and collegial activities, performance and conduct in the Hospital. Such information, which, together with the information obtained in Part 5.1.A above shall form the basis for recommendations and action and shall include, without limitation: 1. Practice patterns relating to patient care, utilization of hospital resources and management activities through the Medical Staff Professional Committee quality improvement and chart review."

b. On 7/21/2011 at 11:00 AM, an interview with the hospital's Medical Records Manager (Staff Member #1) revealed that at the time of reappointment, the manager prepared a form entitled "Physician Activities Reappointment Information". This form included information regarding the number of patients the medical staff member had admitted, the number of deliveries and cesarean sections the staff member had performed (if applicable), the number of delinquent charts for that staff member, the number of charts that had been reviewed of patients cared for by that staff member, and any action taken as a result of the chart review. This form was forwarded to the Medical Staff Committee at the time of reappointment to provide information regarding the staff member's performance

c. On 7/21/2011 at 11:20 AM, during an interview with the Human Resources Assistant (Staff Member #2), the assistant provided a folder of "Physician Activities Reappointment Information" forms for review. The folder did not include forms for 8 of 8 medical staff members reviewed for their current reappointment period.


2. Based on review of credentialing files, review of Medical Staff reappointment policies procedures, and interview, the hospital failed to provide evidence that members of the Medical Staff were current in Advanced Cardiac Life Support (ACLS) as directed by hospital policy for 1 of 8 medical staff members reviewed (Medical Staff Member #7).

Failure to be currently trained and competent in providing advanced cardiac life support risks patient harm during treatment for cardiopulmonary failure.

Findings:

a. The hospital's policy and procedure entitled "Verification During Reappointment" (Effective October 2001; Reviewed 6/4/2003) stated that medical staff members were to submit a certificate for ACLS at the time of reappointment.

b. Review of the credentialing file for Medical Staff Member #7 revealed that s/he had been reappointed to the hospital's medical staff in June 2011. The staff member's credentialing file included an ACLS certificate that expired in April 2010.

c. An interview with the hospital's Compliance Officer (Staff Member #3) confirmed that the file did not contain evidence of current ACLS training.

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ITEM #1 - MONITORING PATIENTS IN RESTRAINTS

Based on record review and review of facility policies, the hospital failed to follow its policy and procedure for monitoring patients while in restraints as required by Washington State Law (WAC 320-246-226) for 3 of 5 patient records reviewed (Patients #1, #2, #3).

Failure to follow established utilization guidelines for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

References:
WAC 320-246-226 Hospitals must: (3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with CFR 42.482.

42 CFR 482.13(e)(4)(2) [The use of restraint or seclusion must be--]
(ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law.

Findings

1. The hospital's policy and procedure entitled "Standard of Care for Patients in Restraints" (Reviewed May 2011) stated that patients were placed in restraints for behavioral reasons (potential threat to harm self or others) were to be observed every fifteen minutes, and that those observations were to be documented on a restraint flow sheet. This was to include assessment of circulation, respiration, skin integrity, and overall well-being.

2. Review of the records of five patients who had been restrained during their hospitalization revealed the following:

a. Patient #1 was a 32 year-old patient who had been admitted on 6/12/2010 for treatment of alcohol intoxication. The patient became confused and combative at 6:15 PM and was placed in 4-point leather restraints.

The restraint flow sheet in the patient's record lacked documentation that the patient was observed every 15 minutes between 7:30 PM and 10:00 PM on 6/12/2010.

b. Patient #2 was a 15 year-old patient who had been admitted on 1/17/2011 for a mental health evaluation for depression and assaultive behavior. The patient was placed in 4 point Velcro restraints at 10:25 PM.

The restraint flow sheet in the patient's record lacked documentation that the patient was observed every 15 minutes between 10:40 PM on 1/17/2011 and 8:30 AM on 1/18/2011. The patient's record indicated that he was in a "prone" position during this time, which could have compromised his respiratory status.

c. Patient #3 was a 51 year-old patient who had been admitted on 11/2/2010 for encephalopathy, hyponatremia, and confusion. The patient was agitated on admission had been placed in soft 4 point restraints by the ambulance transport team.

The patient's emergency department record lacked documentation that the patient was observed every 15 minutes between 11:00 AM and 1:05 PM. There was no restraint flow sheet in the patient's record.

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ITEM #2 - RESTRAINT TRAINING

Based on review of staff education records, the hospital failed to provide ongoing education and training in the proper and safe use of restraints as required by Washington State Law (WAC 320-246-226) for 3 of 8 personnel files reviewed (Staff Members #12, #13, #14).

Failure to do so places patients at risk for inadequate care and injury related to restraint use.

References:
WAC 320-246-226 Hospitals must: (3) Adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with CFR 42.482

42 CFR 482.13(6): All staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application and techniques and alternative methods for handling behavior, symptoms, and situations that traditionally have been treated through the use of restraints or seclusion.

Findings:

1. The hospital's policy and procedure entitled "Restraint Protocol" (Effective 8/2005; Revised 1/8/08; Reviewed 4/21/2011) read as follows:

"Education and training shall be provided as part of the employee's initial orientation and also as part of the employee's annual safety training for those employees having direct patient care responsibilities."

2. The education records of 8 staff members with direct patient care responsibilities were reviewed to determine compliance with the requirement for restraint training.

There was no evidence that 3 staff members [1 Licensed Practical Nurse (Staff Member #12), 1 Registered Nurse (Staff Member #13), and 1 Nursing Assistant (Staff Member #14)] had received annual restraint training as required.


ITEM #3 - ANNUAL TRAINING FOR PATIENT SAFE HANDLING

Based on review of hospital training records, the hospital failed to conduct annual staff training on all patient safe handling policies, procedures, equipment and devices as required by Washington State Law (WAC 246-320-221) for 3 of 8 personnel files reviewed.

Failure to conduct annual training on patient safe handling policies and procedures risks unpreparedness of hospital personnel to manage the safe handling needs of patients.

Reference: WAC 246-320-221 The hospital must: (2) Conduct annual staff training on all safe patient handling policies, procedures, equipment and devices;

Findings:

During review of personnel files on 7/21/2011, it was found that 1 Surgical Technician (Staff Member #10), 1 Licensed Practical Nurse (Staff Member #12), and 1 Registered Nurse (Staff Member #13) had no evidence of annual training on patient safe handling policies, procedures, equipment and devices in their employee file.


ITEM #4 - TYPES OF PATIENTS AND LEVEL OF CARE DEFINED

Based on interview and review of policy and procedure, the hospital failed to develop and implement policies and procedures,as required by State law that identified the types of patients and level of care the hospital was capable of providing for neonatal and pediatric patients (WAC 246-320-256).

Failure to clearly identify the types of patients the hospital was capable of caring for and the level of care that would be provided risks patient harm due to admission of patients that require a higher level of care than can be provided by hospital staff.

Reference:
WAC 246-320-256: If providing neonatal or pediatric care, hospitals must: (1) Adopt and implement policies and procedures that: (a) Identify the types of patients and level of care that may be used;

Findings:

An interview with Staff Member #8 on 7/19/2011 revealed that there have been times when patients were admitted that staff felt uncomfortable caring for related to staff skill level. The surveyor asked Staff Member #8 if she/he knew whether the hospital had a policy and procedure that defined the types of patients that would be appropriate admissions for the unit. Staff Member #8 looked for a policy in the policy and procedure book but could not find such a policy and procedure.

On 7/21/2011, the Chief Nursing Officer (Staff Member #6) confirmed that the hospital did not have a policy and procedure that identified the types of patients and level of care the hospital was capable of providing for neonatal and pediatric patients.

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Based on observation, interview and review of policy and procedure, the hospital failed to implement infection control measures according to hospital policy and procedure for 2 of 2 patients reviewed (Patient #4, #18).

Failure to implement appropriate and effective infection control measures risks transmission of communicable diseases to patients, staff, and visitors.

Findings:

1. Patient #4 was a 13 year-old patient admitted on 5/17/2011 for treatment of pneumococcal pneumonia. The admitting physician checked "Isolation - Yes" on the patient's admission pre-printed order set at 9:10 PM.

Review of nursing documentation indicated that the patient was not placed in droplet precaution isolation until the order was rewritten by the physician on 5/18/2011 at 9:15 AM.

An interview with the hospital's infection preventionist (Staff Member #13) on 7/21/2011 at 1:00 PM confirmed that the nurses had not followed the physician's order and the hospital's infection control isolation procedure.


2. Patient #18 was a 40 year-old patient admitted on 7/19/2011 for two diagnostic procedures; a colonoscopy (a procedure used to examine the colon and rectum) and an EGD (a procedure used to examine the esophagus, stomach and upper duodenum).

a. Observation of staff activities during the procedures revealed the following:

The colonoscopy was performed first. Once the colonoscopy was finished the team prepared to do the EGD procedure. Medical Staff Member #4 removed his/her dirty gown and gloves and put on clean gown and gloves but failed to wash his/her hands prior to putting on his/her clean gloves.

Medical Staff Member #4 was observed contaminating his/her clean gloves by touching the phone, opening a cupboard, and handling an ink pen prior to the start of the EGD procedure. Medical Staff Member #4 did not change his/her dirty gloves or wash his/her hands after touching multiple inanimate objects prior to performing the second procedure.


b. The hospital's policy and procedure entitled "Hand Hygiene" (Effective 3/22/2002; Revised 2/09; Reviewed 4/11) read as follows:

"Hand hygiene is the single most important method for preventing the transmission of disease."

Under the section entitled "Procedure: Indications for hand washing and hand antisepsis" it stated that staff should:

"G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled."

"H. Decontaminate hands if moving from a contaminated body site to a clean-body site during patient care."

"I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

"J. Decontaminate hands after removing gloves."


c. Medical Staff Member #4 did not follow hospital policy for hand hygiene while performing Patient #18's procedures.

Based on interview and review of hospital policies and procedures, the hospital failed to
ensure that hospital policies and procedures were reviewed annually by a professional group that included a physician, a member that was not a member of the CAH staff and physician's assistants that worked in the Emergency Department.

Failure to include all members of the professional group when reviewing policies and procedures risks implementation of procedures that do not meet current standards of practice
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Findings:

1. The hospital's policy and procedure entitled "Departmental Policy Review" (Reviewed 4/7/2011) stated that on an annual basis, all department managers would review their policies. Those policies which required updating would be revised and presented to the appropriate personnel for training and implementation. The hospital's Chief Executive Officer (CEO) would sign the cover page of each department's policy manual to verify policy review. If appropriate, the physician in charge would review and sign the cover page of the department's policy manual.

The policy did not identify a "professional group" for policy review that included a member that was not a member of the CAH staff and physician's assistants that worked in the Emergency Department.

2. Review of the policy and procedure manual for the pharmacy revealed that the manual had been reviewed in June 2011 by the hospital pharmacist and CEO . There was no evidence that the pharmacy's Medical Director had reviewed the manual.

3. Review of the policy and procedure manual for Infection Control revealed that the manual had been reviewed in April 2011 by the hospital's infection preventionist and the CEO . There was no evidence that the Infection Control program's Medical Director had reviewed the manual.

4. Review of the policy and procedure manual for the hospital's Medicare Swing Bed program revealed that the manual had been reviewed in June 2011 by the hospital's CEO. There was no evidence the the Chief Nursing Officer or Medical Director had reviewed the manual.

5. An interview with the hospital's Chief Nursing Officer (Staff Member #6) on 7/21/2011 at 1:40 PM confirmed that the policies and procedures had not been reviewed according to facility policy and regulatory requirements.

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ITEM #1 - TIMING PHYSICIAN ORDERS

Based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure that physician orders were signed, dated and timed in accordance with current state hospital regulations in 6 of 23 patient records reviewed (Patients #4, #5, #6, #7, #8, #9).

Failure to ensure that physician entries are authenticated by signature, date and time puts patients at risk for medical errors.

Reference: WAC 240-360-166(4)(e): "Hospitals must create medical records that have accurately written, signed, dated, and timed entries."

Findings:

1. Review of 23 medical records on 7/19-21/2011 revealed the following:

a. Patient #4: 3 of 5 physician orders were not timed
b. Patient #5: 1 of 3 physician orders was not timed
c. Patient #6: 3 of 4 physician orders were not timed
d. Patient #7: 7 of 29 physician orders were not timed
e. Patient #8: 8 of 24 physician orders were not timed
f. Patient #9: The patient's pre-printed admission order was not signed

2. The hospital's medical staff Rules and Regulations (Reviewed 2010) read as follows: "All entries in the medical record will be dated. Ideally, there will be a time with the entry, but this is not required." The Rules and Regulations had not been written in accordance with state hospital WAC's.



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ITEM #2 - PHYSICIAN ORDERS FOR PROCEDURAL SEDATION

Based on observation, interview, record review, and review of policy and procedure, the hospital failed to ensure requirements, of chapter 246-873 WAC, PHARMACY - HOSPITAL STANDARDS, were followed in 1 of 1 patient procedures observed (Patient #18).

Failure to follow pharmacy hospital standards places patients at risk for harm due to medication errors.

Reference:

WAC 246-873-080 (6) Medication Orders. Drugs are to be dispensed and administered only upon orders of authorized practitioners.

WAC 246-873-090 (1) ...Verbal orders for drugs shall only be issued in emergency or unusual circumstances and shall be accepted only by a licensed nurse, pharmacist, or physician, and shall be immediately recorded and signed by the person receiving the order.

Findings:

1. The hospital policy and procedure entitled "Moderate Sedation-IV i.e. Conscious Sedation" (Effective 4/27/2004; Reviewed 6/11) stated that "the nurse shall be directed by the physician, within the scope of his or her knowledge and experience, as to what medications and dosages shall be used, and when to administer them."

2. Patient #18 was a 40 year-old patient who was admitted to the hospital on 7/19/2011 to undergo a diagnostic procedure. During the procedure a registered nurse (Staff Member #11) administered procedural sedation (medications to make the patient drowsy and relaxed).

Late in the procedure, as observed by the surveyor, a conversation about administering more Versed occurred between the nurse and the physician but no verbal orders for medication were given by the physician.

Following the procedure the registered nurse (Staff Member #11) documented the amount of medication she/he administered during the procedure and then the physician (Medical Staff Member #4) signed the order form. The patient received a total of 8 mg of Versed and 150 mcg of Fentanyl.

3. Patient #18's medical record contained a pre-printed order form entitled "Procedure Room Physician Order" that read as follows:

"Titrate for Conscious [Procedural] Sedation"
"Versed__________mg IV (Total)"
"Fentanyl_________mcg IV (Total)"

There were no physician orders documented prior to the procedure to guide nursing staff in administration of procedural sedation medications.

3. An interview with Staff Member #11 on 7/19/2011 revealed that nursing staff administering procedural sedation medications do so in the presence of the physician but the physician does not give verbal orders for the medications nor does the physician document orders in advance of the procedure.


ITEM #3 - MEDICATION LABELS

Based on observation, interview, and review of policy and procedure, the hospital failed to ensure that syringes, cups and basins placed on the sterile field in the operating room were labeled according to acceptable standards of practice.

Failure to properly label syringes and containers in the operating room presents a high risk of catastrophic error and places the patient at risk of harm.


Reference:

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span (2006) read as follows:

"Label all medications and delivery devices with a minimum of the medication name, strength, and concentration when needed."

"Label the medication container on the sterile field immediately before receipt of the medication."


Findings:

1. During observation of a surgical procedure on 7/20/2011, it was noted that a syringe containing clear liquid was on the sterile field and was not labeled.

At one point during the surgical procedure a nurse (Staff Member #11) poured medication into a cup that the surgical technician (Staff Member #10) was holding. The surgical technician placed the cup containing the medication on the sterile field. There was no label on the cup to identify the clear liquid that had been poured into the cup.

2. An interview with the surgical technician (Staff Member #10) on 7/20/2011 revealed that it was not common practice in the operating room to label cups and basins nor was it common practice to label syringes unless more than one syringe containing medication was placed on the sterile field.

3. The hospital policy entitled "Patient Safety in the Operating Room" (Effective 6/8/1999; Reviewed 12/07) stated that if more than one drug was present on the sterile field, each drug must be properly identified.

The policy did not address the need to label medication/solution containing cups and basins placed on the sterile field nor did the policy comply with current standards of practice for labeling of all medications/solutions placed on the sterile field.


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Based on record review, review of hospital policies, and interview, the facility failed to develop an individualized plan for patient care based on an initial assessment according to facility policy for 10 of 23 patient records reviewed (Patients #4, #5, #6, #9, #10, #11, #12, #13, #14, #15)

Failure to assess the patient's healthcare needs and develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment.

Findings:

1. The hospital's policy and procedure entitled "Interdisciplinary Patient Care Record" (Reviewed May 2011), read as follows: "The admitting RN will assess each body system within 2 hours of admission... Any abnormal clinical findings are circled or entered in the "Interdisciplinary Assessment" column under the appropriate body system, and those for which nursing has an outcome goal will be established. Use the preprinted Standard of Care forms located in the white notebook at the nurses' station for goals and care rendered. If there is not a preprinted Standard of Care, an individual care plan will be created. Place this form in the patient's chart for individual care plan."

2. Review of 23 patient care records on 2/14/2011 and 2/16/2011 revealed the following:

a. Patient #4 was a 13 year-old patient who had been admitted on 5/17/2011 for treatment of pneumococcal pneumonia. The patient's record did not include an admission nursing assessment or a patient plan for care as described in the policy above.

Similar findings were found in the records of Patient #9.

b. Patient #5 was a a 8 month 26 day-old patient who had been admitted on 2/12/2011 for treatment of pneumonia and dehydration. The patient's record did not include a plan for care as described in the policy above.

Similar findings were found in the records of Patient #6.

c. Patient #10 was a 27 year-old patient who had been admitted on 7/19/2011 to the labor and delivery unit. The patient's record did not include a plan for care as described in the policy above.

d. Patient #11 was a 17 year-old patient who had been admitted on 5/18/2011 to the labor and delivery unit. The patient's record did not include a plan for care as described in the policy above.

Similar findings were found in the record of Patient #12.

e. Patient #14 was a newborn infant who had been delivered on 5/18/2011. The newborn's patient record did not include a plan for care as described in the policy above.

Similar findings were found in the record of Patient #15.

3. During an interview on 7/19/2011, the nurse manager of the labor and delivery unit (Staff Member #4) stated that individualized care plans were not developed for laboring patients. Nurses used the mother's birth plan as the plan for care.

The manager stated that individualized care plans were not developed for post-partum patients or newborn babies. . Nurses used the "Mother/Infant Care and Discharge Checklist" as the plan for care.

4. During an interview on 7/21/2011 at 1:45 PM, an interview with the hospital's Chief Nursing Officer (Staff Member #6) confirmed that assessments and care planning had not been performed in accordance with facility policy and procedure.

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Reference: ?483.10(b) Notice of Rights and Services -

(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing;

This standard is not met as evidenced by:
Surveyor #13692

Based on record review, interview, and review of the hospital's patient rights information, the hospital failed to provide evidence that swing bed (long-term care ) patients were informed of their rights when admitted to the hospital according to 42 CFR 483.10 for 2 of 5 swing-bed patient records reviewed (Patient #16, #17)

Failure to inform patients of their rights limits the patient's ability to exercise those rights

Findings:

1. On 7/20/2011 at 10:00 AM, an interview with the hospital's swing-bed program coordinator (Staff Member #5) revealed that all patients were to be given a handout to read entitled "Patient Information, Rights and Responsibilities" when admitted to the hospital for swing-bed care. The patient was to sign a statement verifying they had received this information.

2. Review of the records 5 swing-bed patients revealed that 2 of 5 records lacked evidence that the patients had been given the patient rights handout on admission to the hospital.

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