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Based on observation, document review, and staff interview, the critical access hospital's (CAH) administrative staff failed to ensure staff performed preventative maintenance on 2 of 2 ventilators and 2 of 2 CPAP (Continuous Positive Air Pressure) machines on 2 of 2 ambulances. Failure to perform preventative maintenance could potentially result in the ventilators and CPAP machines failing to provide life support if needed in an emergency situation, and potentially result in significant disability or death. The CAH's administrative staff identified an average of 85 ambulance runs per month.


Findings include:

1. Observations during a tour of the ambulances on 10/9/18 at 10:00 AM revealed 2 ambulances, 1 ambulance used for first response, and 1 ambulance used as a back-up ambulance. Each ambulance had 1 ventilator (a device used to breathe for a patient) and 1 CPAP machine (a device used to support a patient's airway with positive pressure, and possibly prevent the need for the patient to go on a ventilator).

2. Review of the document, Detail History Report, revealed the following information:

a. The CAH's biomedical department (individuals trained to service medical equipment) last checked the ventilator on the primary response ambulance on 11/5/15 (approximately 3 years since last service date).

b. The CAH's biomedical department last checked the CPAP machine on the primary response ambulance on 11/5/15 (approximately 3 years since last service date).

c. The CAH's biomedical department last checked the ventilator on the secondary response ambulance on 10/10/16 (approximately 2 years since the last service date).

d. The CAH's biomedical department last checked the CPAP machine on the secondary response ambulance on 10/10/16 (approximately 2 years since the last service date.


3. During an interview on 10/16/18 at 10:00, the Director of Purchasing and Facilities stated he expected the biomedical company to check life support equipment, such as ventilators and CPAP machines, to undergo quarterly (every three months) preventative maintenance to ensure the equipment functioned in an emergency situation.


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Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 1 of 1 inpatient units (Medical/Surgical) and 2 of 6 outpatient areas (Operating Room, Laboratory draw room). The CAH staff reported furnishing patient care for approximately 8 inpatients per day, performing approximately 6 vaginal ultrasounds per month, 100 outpatient blood draws per month, and 40 Intect 7 urine tests per month in the outpatient department. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, indicating the staff should not use the supplies for patient care.

Findings include:

1. Observations on 10/8/18 at 11:30 AM, during a tour of the Medical/Surgical Unit, revealed the following expired supplies in the emergency supply cart:
a. 3 of 5 PDI Lubricating Jelly packets, expired 6/2018
b. 1 of 2 8.5 mm (millimeter) Endotracheal Tubes, expired 1/2017
c. 2 of 2 8.0 mm Endotracheal Tubes, expired 5/2017
d. 2 of 2 5.4 mg (milligram) Potassium EDTA Vacutainer tubes, expired 1/31/2018 and 7/31/2018
e. 1 of 1 5.9 ml SST Vacutainer tube, expired 3/31/2018
f. 1 of 1 3.0 ml PST Gel and Lithium Heparin Vacutainer tube, expired 5/31/2018
g. 1 of 1 3.2 percent Sodium Citrate Vacutainer tube, expired 2/28/2018
h. 1 of 1 Serum Vacutainer, expired 4/30/2018

During an interview on 10/8/2018 at the time of the tour, Staff B, Director of Emergency Services and Inpatient, verified the outdated supplies in the emergency supply cart.

2. Observations during a tour of the Operating Rooms on 10/9/2018 at approximately 3:00 PM revealed 2 of 2 bottles of Cidex OPA test strips, expired 9/28/2018.

During an interview on 10/9/2018 at the time of the tour, the Director of Outpatient Clinics and Surgical Services, verified the outdated supplies in the Operating Room.

3. Observations 10/9/2018 at 1:20 PM, during a tour of the Laboratory Department, revealed the following expired supplies in the laboratory draw room:
a. 1 of 1 bottle of Intect 7 urine test strips for Adulteration Detection, expired 9/30/2018
b. 1 of 1 Oxivir TB Wipes, expired 10/2017

During an interview on 10/9/2018, at the time of the tour, the Director of the Laboratory verified the outdated supplies in the laboratory draw room.

4. During an interview on 10/10/18 at 10:25 AM with the CNO (Chief Nursing Officer) verbalized the laboratory department and surgical services failed to have a policy on checking for outdated supplies.

5. Review of CAH Nursing Policy, "Crash Cart Checks", dated 9/27/2018, revealed in part, "The contents of the cart will be checked to assure....outdates replaced".

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) failed to have a system in place that ensured the Radiology staff in the Computed Tomography room (CT - computer-processed x-rays that produce tomographic images or 'slices' of specific areas of the body) used intravenous (IV) solution bags labeled "single dose" for only 1 patient per IV bag. The Radiology staff identified an average of 40 CT procedures are performed per month using the IV solution bag.

Failure to ensure staff uses a separate single-dose or single-use bag of IV solution for each patient increases the risk of transmitting infectious diseases between 1 patient and another, or between a patient and healthcare personnel during preparation and administration of IV solutions.

Findings include:

1. Single-dose IV solutions are intended for use in a single patient for a single case, procedure, or injection. Single-dose solutions are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

According to the Centers for Disease Control (CDC), healthcare staff may not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solutions to more than one patient (e.g, do not use a bag of saline as a common source supply for multiple patients). The CDC also says, do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient.

2. Observation, during a tour of the Radiology area on 10/10/2018 at 9:25 AM, with the Director of Ancillary Services, revealed 1 of 1 250 ml (milliliter) "single dose" bag of IV 0.9% normal saline (a solution of sodium chloride and water used for IV infusion) dated by Radiology staff as hung on 10/10/18 at 4:05 AM. Additional observation showed a tubing (transfer set) attached to the IV bag, a transfer set tubing that transfers the fluid from the IV bag to the contrast infusion set used to inject contrast media into a patient's vein. The IV bag had approximately 175 ml of 0.9% normal saline remaining in the bag.

3. Review of the product label printed directly on the 250 ml 0.9% normal saline IV solution bag showed the bag of IV solution was "single-dose container".

Review of facility policies showed they did not have a policy that addressed single-dose IV solutions.

Review of the product information for the transfer set tubing revealed the instructions for use ". . . Do not use the opened transfer set for more than 12 hours. . . ."

4. Review of CAH policy titled "Contrast Media Injections", dated 3-2018, revealed in part, ". . . NS [normal saline] bags shall be hung and spiked upon the ordered CT scan with IV contrast. The date and time the bag was spiked shall be documented on the back side of the bag. The bag is only good for twenty-four (24) hours. After the twenty four hour period, the bag shall be discarded."

5. During an interview on 10/10/2018 at 9:40 AM, Staff T, Director of Ancillary Services, confirmed Radiology staff used the 250 ml 0.9% normal saline IV solution bag and tubing hanging in the CT room for more that one patient and may use the same set up for 24 hours. On further interview, Staff T stated she was not aware the IV solution bag stated 'single-dose container' and the manufacture's instructions for use of the transfer set tubing stated to not use the opened transfer set for more than 12 hours.

During an interview on 10/10/2018 at 2:00 PM, Staff A, Inpatient Supervisor/Infection Preventionist, stated she was not aware that Radiology staff used the 250 ml 0.9% normal saline IV solution bag and tubing for more than one patient.



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II. Based on observation, staff interview, and document review, the critical access hospital (CAH) administrative staff failed to ensure 1 of 1 observed surgeon (Urologist W) and 1 of 1 observed CRNA (Certified Registered Nurse Anesthetist) performing pain procedures (CRNA X) wore a hair covering during surgical procedures that fully covered their hair in accordance with accepted standards of practice. Failure to fully cover hair during a surgical procedure could potentially result in bacteria, viruses, or fungi on the hair falling from the staff member's head and potentially causing the patient to develop a life threatening infection. The CAH administrative staff identified Urologist W performing an average of 4 surgical procedures per month, and CRNA X performing an average of 31 surgical procedures per month.


Findings include:

1. Observations on 10/10/18 at 07:35 AM revealed Urologist W (a physician with specialized training in the bladder, kidneys, and male reproductive organs) entered the operating room. Urologist W wore a skull cap (a style of head covering commonly worn by surgeons that does not fully cover the surgeon's hair). The skull cap failed to cover the hair on the sides of Urologist W's head and the hair at the nape of Urologist W's neck.

2. Observations on 10/10/18 at 11:05 AM revealed CRNA X (a nurse with specialized education on administering medications to put patients to sleep for surgery and alleviate pain) entered the operating room. CRNA X wore a skull cap. The skull cap failed to cover the hair on the sides of CRNA X's head and the hair at the nape of CRNA X's neck.

3. During an interview on 10/10/18 at 10:55 AM, the Director of Outpatient Clinics and Surgical Services stated the hospital staff followed the Association for peri-Operative Registered Nurses (AORN, a widely accepted processional standards organization for surgical services) for surgical attire.

4. Review of the AORN standard, "Guidelines for Perioperative Practice: Surgical Attire," copyright 2018, revealed in part, "Surgical head covering confines hair and completely covers ears, scalp skin, sideburns, and nape of the neck."

5. During an interview on 10/10/18 at 11:45, the Director of Outpatient Clinics and Surgical Services acknowledged the AORN policy required the surgical staff, including Urologist W and CRNA X, to wear head covering the included covering their sideburns and the nape of their neck. The Director of Outpatient Clinics and Surgical Services acknowledged the skull caps failed to cover Urologist W and CRNA X's sideburns and the nape of their necks.


III. Based on observation, document review, and staff interviews, the critical access hospital (CAH)'s administrative staff failed to ensure 1 of 1 observed CRNA during an operative procedure (CRNA Y) did not push sterile needles and syringes through the paper packaging. Pushing sterile syringes and needles allows the sterile areas of the needles and syringes to come in contact with the non-sterile outside of the packaging and potentially allow paper fibers to fall into the sterile fluid pathway, potentially contaminating the sterile fluid and potentially allowing the fibers to go into the patient's blood stream. Allowing the sterile parts of the needle and syringes to contact the non-sterile packaging could potentially result in bacteria, viruses, and fungi from the packaging to get into the patient's blood stream, and potentially cause a life threatening infection. Allowing the paper fibers to get into the patient's blood stream could potentially result in the patient developing a blood clot or allergic reaction related to the patient's body's response to the foreign material. The CAH's administrative staff identified CRNA Y performed an average of 57 surgical procedures per month.


Findings include:

1. Observations on 10/10/18 at 7:15 AM revealed CRNA Y preparing medication for Patient #9's surgical procedure. CRNA Y performed the following actions:

a. removed 200 mg of Propofol (a medication to put patients to sleep for surgery) from a vial. CRNA Y pushed the sterile needle through the paper packaging, instead of peeling the packaging apart and maintaining the sterility of the needle.

b. removed 50 mg of lidocaine (a medication to numb pain) from a vial. CRNA Y pushed the sterile needle and syringe through the paper packaging, instead of peeling the packaging apart and maintaining the sterility of the needle and syringe.

c. removed 200 mg of Propofol from a vial. CRNA Y pushed the sterile needle through the paper packaging, instead of peeling the packaging apart and maintaining the sterility of the needle.

d. removed 10 mg of Reglan (a medication to control nausea) form a vial. CRNA Y pushed the sterile needle and syringe through the paper packaging, instead of peeling the packaging apart and maintaining the sterility of the needle and syringe.


2. Review of the policy "Medication Administration - General Policy," effective 9/14/17, revealed the policy lacked a requirement for the CAH staff to maintain the sterility of needles and syringes when the staff removed them from the packaging.

3. During an interview on 10/10/18 at 2:00 PM, the Infection Preventionist acknowledged the CAH lacked a policy requiring the staff to maintain the sterility of needles and syringes when the staff removed them from the packaging, and the Infection Preventionist expected the staff to peel apart the packaging to maintain the sterility of the needles and syringes.


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IV. Based on document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure health exams were regularly completed as part of their system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 8 of 18 employees and 1 of 1 volunteers selected for review (Staff J, K, L, M, N, O, P, Q and R).

Failure to identify infections and communicable diseases among employees and volunteers could potentially result in the transmission of a communicable disease to patients.

Findings include:

Review of employee health information for Staff J, Housekeeping, revealed a health exam dated 2/2/13.

Review of employee health information for Staff K, Surgical Technician, revealed a health exam dated 7/14/14.

Review of employee health information for Staff L, Pharmacy Technician, revealed a health exam dated 4/29/11.

Review of employee health information for Staff M, Licensed Practical Nurse, revealed a health exam dated 3/7/14.

Review of employee health information for Staff N, Lab Technician, revealed a health exam dated 6/7/14.

Review of employee health information for Staff O, Registered Nurse, revealed a health exam dated 9/18/09.

Review of employee health information for Staff P, Interim Director of Food and Nutrition Services, revealed a health exam dated 8/22/14.

Review of employee health information for Staff Q, Emergency Medical Technician, revealed a health exam dated 4/16/14.

Review of volunteer file for Staff R, Volunteer, revealed it lacked documentation of a tuberculosis test and a health exam.

During an interview on 10/11/18, at 8:30 AM, Staff A, Employee Health/Infection Preventionist, reported she assumed her current position about a year ago and discovered the employee health policy did not define a frequency for repeating health. She reported the employee health policy update now defined health exams are done every 4 years and she is working on completing any that are outside of this timeframe. Staff A acknowledged there were employees who had not had a health exam in the past 4 years.

During a follow-up interview on 10/11/18, at 9:30 AM, Staff A reported approximately 4 months ago she discovered through association with the network, the state regulatory authority required a health exam every four years. She recalled the CAH had previously repeated health exams every 3 or 4 years but not sure when or why they discontinued the practice.

Review of a CAH policy titled "Employee Health Reassessment", reviewed/revised 2/2/2018, revealed the CAH requires a health assessment every four years.

Review of a CAH policy titled "Volunteer Policy", reviewed/revised 5/25/28, revealed the policy identified volunteers are required to have a Tuberculosis skin test and failed to identify the need for a health assessment as part of their health requirements.

Based on observation, document review, and staff interviews, the critical access hospital's (CAH) administrative staff failed to ensure 1 of 1 observed surgeon (Urologist W) had surgical privileges to perform lithotripsy prior to performing the surgical procedure. Failure to ensure Urologist W had surgical privileges to perform lithotripsy could potentially result in the CAH staff allowing Urologist W to perform a procedure that he lacked competence and skill to safely perform. The CAH staff identified Urologist W performed an average of 4 lithotripsy procedures per month.

Findings include:

1. Observations on 10/10/18, starting at 06:15 AM, revealed Urologist W performed a lithotripsy (a surgical procedure using sound waves to break up kidney stones) on Patient #9.

2. Review of Urologist W's surgical privileges (a list of procedures the medical staff and governing body of the CAH approved Urologist W to perform at the CAH) revealed Urologist W lacked approval by the medical staff and governing body to perform lithotripsy.

3. Review of the Credential Manual, approved 12/4/17 by the Governing Body, revealed in part, "Every provider at Story [County] Medical [Center] practicing by virtue of Medical Staff membership ... shall... be entitled to exercise only those clinical privileges specifically granted to him/her by the Story [County] Medical [Center] Board..."

4. During an interview on 10/10/18 at 10:55 AM, the Director of Outpatient Clinics and Surgical Services acknowledged Urologist W lacked surgical privileges to perform the observed lithotripsy procedure on 10/10/18 at 06:15 AM.

5. During an interview on 10/11/18 at 07:50 AM with Urologist W, when questioned about his process for requesting/reviewing his privileges, stated that an employee in his organization handled everything related to his privileges, including reviewing his privileges and signing the privilege form.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 1 pediatric dentists selected for review, received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital (Physician I).

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff reported Physician I, Pediatric Dentist, provided services to 6 patients from 7/1/28 to 10/11/18.

Findings include:

1. Review of the CAH's network agreement, dated 2/1/13, revealed in part ". . . The responsibility of Hospital's governing board in the quality assurance process . . . and the methods by which participation in the Hospital's quality assurance process is periodically evaluated shall be as set forth in Hospital's quality assurance plan . . . CIHC (Central Iowa Hospital Corporation) shall assist Hospital in reviewing the quality and appropriateness of the diagnoses and treatment furnished by Hospital's physicians and other practitioners for purposes of carrying out the requirements of its quality assurance plan. This process shall be accomplished through external peer review, to be conducted by CIHC . . . on a quarterly basis for selected physicians based on specialty, quality concerns or other areas identified by Hospital . . ."

2. Review of a CAH policy titled "Peer Review Plan (Internal and External)" reviewed/revised 5/31/18 revealed in part ". . . The goals of the peer review process are to both identify opportunities for improvement and to provide constructive feedback related to the performance of the Story County Medical Center (Story Medical) staff . . . A minimum of one chart per provider providing services at Story Medical will be submitted to and/or reviewed via a cooperative review process with our Network Hospital . . . for external physician peer review per credentialing period (every two years) . . . Board of Directors grants or denies continued privileges of medical staff with consideration of the information received through the Peer review and quality documenting . . ."

During an interview on 10/10/18, at 11:10 AM, Staff S, Chief Nursing Officer (CNO), reported she is responsible to send out cases for external peer review and ensure they are returned but Physician I's reappointment came up before she became employed in her current position. She found Staff I's name had been submitted, along with several other physicians, on 10/6/16, but had been unable to locate the results of the review.

During a follow-up interview on 10/11/18, at 9:00 AM, Staff S CNO, acknowledged the external peer review is used to evaluate the physician's quality of care as part of the re-appointment process.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited, his or her medical condition.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse treatment and to refuse to participate in experimental research.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to choose a personal attending physician.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to be informed in advance about care and treatment and of any changes in that care or treatment that may affect the patient's well-being.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to personal privacy and confidentiality of his or her personal and clinical records.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to refuse to perform services for the facility or perform services for the facility if he or she chooses.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to privacy in written communication, including the right to send and promptly receive mail that is unopened, and have access to stationary, postage, and writing implements at the patient's own expense.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to immediate access to visitation subject to the patient's right to deny or withdraw consent at any time.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights and safety of other patients.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, swing bed patient rights, swing bed packet, and patient medical records, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion for 5 of 5 open swing bed patients. (Patients #1, 2, 3, 4, and 5) The CAH staff reported a current census of 4 Swing Bed patients at the start of the survey.

Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of CAH policy titled "Patient Rights, Notification Of", dated 9/14/17, revealed in part, ". . . Every SNF. . . Swing Bed patient will be offered a copy of the "Swing Bed Resident Rights and Responsibilities" (attached), as part of the SNF/NF patient admission packet. . .The Swing bed patient or legal guardian will sign that they have received the Notice of Patient Rights as an acknowledgement of having been informed of his/her rights. . . ."

Review of CAH policy titled "Swing Bed Patient Bill of Rights", dated 9/14/2018, contained the required language for the skilled patient rights.

Review of document titled "Your Rights and Responsibilities As A Swing Bed Resident", dated 9/1/2018, contained the required language for the skilled patient rights.

Review of a swing bed packet provided to swing bed patients lacked "Your Rights and Responsibilities As A Swing Bed Resident".

2. Review of Patient #1, admitted to Swing Bed on 9/5/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Review of Patient #2, admitted to Swing Bed on 9/17/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Review of Patient #3, admitted to Swing Bed on 9/28/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Review of Patient #4, admitted to Swing Bed on 10/1/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Review of Patient #5, admitted to Swing Bed on 10/8/2018, medical record revealed the lack of documentation the patient received Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

3. During an interview on 10/9/2018 at 9:10 AM, Staff A, Inpatient Supervisor, acknowledged the swing bed packet that was provided to swing bed patient upon admission did not include "Your Rights and Responsibilities As A Swing Bed Resident". Staff A confirmed swing bed patients did not receive the Swing Bed Patient Rights and Responsibilities to include the patient has the right to be free from from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

During an interview on 10/9/2018 at 9:20 AM, Staff V, Informatisist, confirmed the swing bed patient medical records lacked documentation the patient signed they had received the Notice of Patient Rights as an acknowledgement of having been informed of his/her swing bed rights.

Based on review of policies, patient medical records, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation (rehab) services for swing bed patients. Problem identified with 5 of 5 open swing bed patient medical records and 3 of 3 closed swing bed patient medical records. ( Patients #1, 2, 3, 4, 5, 6, 7, and 8) The CAH staff identified a current census of 4 patients at the start of the survey.

Failure to ensure a physician ordered specialized rehab services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition.

Findings include:

1. Review of CAH policy titled "Swing Bed Program", dated 9/14/17, stated in part ". . . The following guidelines are used for a swing bed admission: Admitted under the direction of a Medical Provider. . . ."

2. Review of Patient #1's open medical record revealed Patient #1 was admitted for swing bed services on 9/5/2018 at 1:16 PM for swing bed services with diagnosis of history of rare brain cancer, treated with chemotherapy and radiation, and recent progression of right sided weakness, speech difficulties, and frequent falls. Patient needed strengthening to their right side.

An electronic order placed in Patient #1's medical record dated 9/5/2018 at 12:01 PM, revealed Practitioner G, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.

An electronic order placed in Patient #1's medical record dated 9/5/2018 at 12:19 PM, revealed Practitioner G, Physician's Assistant (PA) ordered Speech and Language Evaluation and Treat.


Review of Patient #2's open medical record revealed Patient #2 was admitted for swing bed services on 9/17/2018 at 3:49 PM for swing bed services with diagnosis of history of a fall on 9/4/2018 with right distal fibula fracture (bone in the calf area of the leg) that was not surgically repaired. Patient needed physical and occupational therapy due to difficulty moving.

An electronic order placed in Patient #2's medical record dated 9/17/2018 at 4:16 PM, revealed Practitioner F, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #3's open medical record revealed Patient #3 was admitted for swing bed services on 9/28/2018 at 8:37 PM for swing bed services with diagnosis of recent fall with unknown cause and recent weakness. Patient needed physical and occupational therapy for strengthening and assessment for home safety.

An electronic order placed in Patient #3's medical record dated 9/28/2018 at 8:37 PM, revealed Practitioner E, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #4's open medical record revealed Patient #4 was admitted for swing bed services on 10/1/2018 at 4:29 PM for swing bed services with diagnosis of history of a stroke with right sided weakness. Patient has had increased weakness and 2 recent falls. Patient needed physical and occupational therapy for strengthening and difficulty moving.

An electronic order placed in Patient #4's medical record dated 10/1/2018 at 4:29 PM, revealed Practitioner F, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #5's open medical record revealed Patient #5 was admitted for swing bed services on 10/8/2018 at 3:43 PM for swing bed services with diagnosis of a fall on 10/3/2018 with a right femur (thigh bone) fracture that was not a candidate for surgical repair. The patient needed physical and occupational therapy for transfers and activities of daily living.

An electronic order placed in Patient #5's medical record dated 10/8/2018 at 3:51 PM, revealed Practitioner F, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #6's closed medical record revealed Patient #6 was admitted for swing bed services on 8/6/2018 at 3:15 PM for swing bed services with diagnosis of history of recurrent brain cancer. The patient needed physical and occupational therapy.

An electronic order placed in Patient #6's medical record dated 8/6/2018 at 3:30 PM, revealed Practitioner F, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #7's open medical record revealed Patient #7 was admitted for swing bed services on 7/9/2018 at 11:37 PM for swing bed services with diagnosis of left total knee replacement on 7/16/2018 and the patient needed physical and occupational therapy.

An electronic order placed in Patient #7's medical record dated 7/9/2018 at 11:40 AM, revealed Practitioner G, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat and Occupational Therapy Evaluation and Treat.


Review of Patient #8's open medical record revealed Patient #8 was admitted for swing bed services on 3/14/2018 at 11:30 A for swing bed services with diagnosis of recent nausea/vomiting and dehydration and the patient needed physical, occupational, and speech therapy.

An electronic order placed in Patient #8's medical record dated 3/14/2018 at 12:56 PM, revealed Practitioner H, Physician's Assistant (PA) ordered Physical Therapy Evaluation and Treat, Occupational Therapy Evaluation and Treat, and Speech and Language Evaluation and Treat.

3. During an interview on 10/9/2018 at 4:00 PM, Staff A, Inpatient Supervisor, acknowledged a mid-level provider ordered specialized rehabilitation (rehab) services for swing bed patients and not a physician for skilled patients #1, 2, 3, 4, 5, 6, 7, and 8.

During an interview on 10/9/2018 at 10:30 AM, Staff G, PA, confirmed the mid-level provider wrote orders to admit patients to swing bed including physical, occupational, and speech therapy.

During an interview on 10/11/2018 at 8:15 AM, Staff S, Chief Nursing Officer (CNO), acknowledged the lack of a policy to address a physician needs to write the orders for specialized rehabilitation (rehab) services for swing bed patients and not a mid-level provider.

Based on policy/procedure review and staff interview, the Critical Access Hospital (CAH) staff failed to update the visitation rights policy to ensure all patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients. The CAH staff identified a current census of 4 patients at the start of the survey.

The CAH staff identified an average of the following patients per month:
- Acute patients discharged - 9
- Swing bed patients discharged - 13
- Observation patients - 13
- Outpatient visits - 2,885

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of CAH policy titled "Medical Center Visiting", dated effective 4/1/2013, revealed in part, ". . . All visitors will enjoy full and equal visitation privileges consistent with patient preferences. No restriction or limitation will be based on race, color, national origin, sex, gender identity, sexual orientation, or disability."

The policy lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

2. During an interview on 10/9/18 at 9:40 AM, Staff B, Director of Emergency Services and Patient Care, acknowledged the Patient Rights policy lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients. The CAH staff identified a current census of 4 patients at the start of the survey.

The CAH staff identified an average of the following patients per month:
- Acute patients discharged - 9
- Swing bed patients discharged - 13
- Observation patients - 13
- Outpatient visits - 2,885

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of CAH policy titled "Medical Center Visiting", dated effective 4/1/2013, revealed in part, ". . . All visitors will enjoy full and equal visitation privileges consistent with patient preferences. No restriction or limitation will be based on race, color, national origin, sex, gender identity, sexual orientation, or disability."

The policy lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

Review of undated document titled "Notification of: Advance Directives, Visitation Rights and Physician Coverage", revealed in part, ". . . Visitation: Story Medical patient areas maintain open visiting hours. As a patient you have the right to give or withhold consent to any designated visitors. If you wish to deny visitation privileges to specific visitors simply let your nurse know your wishes. . . ."

The document titled "Notification of: Advance Directives, Visitation Rights and Physician Coverage", lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

2. Interviews of staff where registration of inpatients and outpatients occurred included the following:

a. During an interview on 10/8/18 at 9:20 AM, Staff A, Registered Nurse (RN), Inpatient Supervisor, stated at the time a patient was admitted the patient was provided a copy of the document titled "Notification of: Advance Directives, Visitation Rights and Physician Coverage".

b. During an interview on 10/9/18 at 2:40 PM, Staff C and Staff D, Patient Access Representatives, stated at the time all outpatients was registered was offered a copy of an undated document titled "Patient Rights and Responsibilities".

The document titled "Patient Rights and Responsibilities" lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all outpatients.

c. During an interview on 10/9/18 at 9:40 AM, Staff B, Director of Emergency Services and Patient Care:
- stated at the time a patient was admitted the patient was provided a copy of the document titled "Notification of: Advance Directives, Visitation Rights and Physician Coverage".
- confirmed the policy titled , "Medical Center Visiting", lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.
- confirmed the document titled "Notification of: Advance Directives, Visitation Rights and Physician Coverage", lacked information to ensure patients (or support person where appropriate were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

3. Observation, during a tour of 1 of 2 CAH off-site location on 10/11/2018 at 9:45 AM, revealed a brochure "Notice of Privacy Practices" available to patient's who presented to the off-site location. (Story County Natural Health)

During an interview on 10/11/2018 at approximately 10:00 AM, Staff U, Receptionist Story County Natural Health, when asked for information provided to patient's who presented to the off-site location regarding patient visitation rights, provided a brochure titled "Notice of Privacy Practices"

The brochure titled "Notice of Privacy Practices" failed to include patient visitation rights.