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Based on medical record review and interview with key personnel on September 14, 2011, it was determined that the facility failed to be in compliance with the Patient ' s Rights Federal Regulations 483.13(e)(4), which required that the use of restraints must be in accordance with a written modification to the patient ' s plan of care.

Findings include:

1. In 1 of 2 (one of two) restraint records reviewed (Record VV) on September 14, 2011, there was no documentation that the care plan of this patient was updated to reflect the use of restraints.
2. This finding was confirmed by the Director of Nursing on September 14, 2011.


Based on medical record review, policy review and interview with key personnel on September 15, 2011, it was determined that the facility failed to be in compliance with the Patient ' s Rights Federal Regulations 482.13(e)(9), which required that the restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

1. The PVH policy titled Patient/Resident Restraints (PCS-203A) was reviewed on September 14, 2011 and directed staff, " release and remove restraint at least every 2 hours. Document. "
2. Documentation in the medical record (RecordVV) indicated documentation at 1830 on July 21, 2010. No further documentation after that time to indicate further checking and release of the restraint, or discontinuation of the restraint.
3. This finding was confirmed by the Director of Nursing on September 14, 2011.


Based on review of information provided and interview with key personnel on September 15, 2011, it was determined that the facility failed to be in compliance with the Patient ' s Rights Federal Regulations 482.13(a)(2)(iii), which required that in its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. The PVH policy titled Patient Complaints, Handling of (ADM-302) was reviewed on September 15, 2011 and directed staff, " PVH strives to handle patient complaints from receiving them to finalizing a response within two weeks. "
2. Review of five complaints chosen from the complaint log indicated that for 2 of 5 (two of five), there was no documented response to the patient complaint following the facility investigation.
3. This finding was confirmed by the Director of Nursing on September 15, 2011.

Based on review of policies and procedures, review of medical records and interviews with key staff on September 14-15, 2011, it was determined that the CAH (Critical Access Hospital) failed to document the Registered Nurse's determination whether side rail use is considered an enablement or a restraint.

Findings include:

1. Observations on September 14-15, 2011, three patients (Patients SS, LL, FF), indicated that they were lying in bed with either 2 (two) full side rails raised or 4 (four) half rails raised.
2. Review of the medical records of these patients indicated a lack of documentation of whether these side rails were used as an enabler or as a restraint.
3. This was confirmed by the Director of Nursing and the Unit Manager on September 15, 2011.

Based on record review and interview with key personnel on September 14, 2011, it was determined that the facility failed to obtain informed consent from patients prior to treatment.


Findings include:

1. The facility policy " Informed Consent for Care and Treatment " states "It is a medical provider responsibility to obtain informed patient consent prior to invasive procedures and treatments..."

2. Review of 19 active medical records (patients currently in the facility) revealed that in 1 of 19 active records (Record KK) there was no signed informed consent form. In addition, in 1 of 19 active records (Record GG) there was no signed informed consent until two days after admission and treatment had begun.

3. The surveyor confirmed this finding with the Director of Nursing on September 14, 2011.

Based on review of information provided and interviews with key personnel on September, 14, 2011, it was determined that the hospital failed to ensure that all the records reviewed was representative of all the services furnished.

Findings include;

1. The review of audits of open and closed records was completed on September 15, 2011. There were no records of the provider based physician offices included in that review.
2. During an interview with the Senior Director of Quality improvement on September 15, 2011, it was verified that the provider based physicians ' offices did not review open and closed records.

Based on review of information provided and interviews with key personnel on September, 14, 2011, it was determined that the hospital failed to ensure that all contracted services were required to provide the governing body with quality assurance data .

Findings include:

1. Clinical contracts were reviewed on September 14, 2011. Two (2) of the five (5) contracts did not contain a requirement that the contractee participate in the hospital ' s quality program.
2. During an interview with the Chief Executive Officer on September 14, 2011, he stated that in November of 2010 he developed an addendum to contracts regarding participation in the hospital ' s quality program. He further stated that this addendum would be added to all contracts.