HospitalInspections.org

I. Based on observations, documentation, and staff interviews, the Critical Access Hospital (CAH) staff failed to document the dates of 12 of 12 bottles of Accu Check controls were opened in accordance with the manufacturer's requirements in Medical-Surgical area - 2 glucometers, Obstetrics, Emergency Room, Laboratory, and Cardiac Rehabilitation. The facility was unable to identify the number of glucometer checks performed on patients in each area.

Failure to document the date the staff opened the high and low glucometer controls could potentially allow staff to use the high and low glucometer controls after the manufacturer's shortened expiration date, potentially resulting in treatments based on inaccurate test results for patients.

Findings include:

Review of the manufacturer's instructions for the Glucometer high and low controls stated in part, "Discard 3 months after opening or after 'use by' date on label".

1. Observation on 3/2/15 at 9:30 AM, during tour of the Medical-Surgical area with Staff A, Medical-Surgical Director, revealed 2 glucometers in cases and each glucometer case contained 1 opened bottle of high control and 1 opened bottle of low control available for use. The control bottles were dated when the controls were initially opened but the date was not clear enough to read to ensure the control solutions were discarded at the time of the shortened expiration date.

During an interview at the time of the tour of the Medical-Surgical area, Staff A acknowledged the Glucometer high control and low control bottles lacked a readable date the bottles were opened to reflect the shortened expiration date, as required by the manufacturer.

2. Observation on 3/2/15 at 9:40 AM, during tour of the Obstetrics area with Staff C, Obstetrics Director, revealed 1 glucometer in a case and the case contained 1 of 1 opened bottle of high control and 1 of 1 opened bottle of low control. The high and low bottles of control solutions lacked documented evidence of the date the staff first opened the bottles.

During an interview at the time of the tour of the Obstetrics area, Staff C acknowledged the Glucometer high control and low control bottles lacked the date the bottles were opened to reflect the shortened expiration date, as required by the manufacturer.

3. Observation on 3/2/15 at 9:45 AM, during tour of the Emergency Room area with Staff E, Emergency Room Registered Nurse, revealed 1 glucometer in a case and the case contained 1 of 1 opened bottle of high control and 1 of 1 opened bottle of low control. The high and low bottles of control solutions lacked documented evidence of the date the staff first opened the bottles.

During an interview at the time of the tour of the Emergency Room area, Staff E acknowledged the Glucometer high control and low control bottles lacked evidence of the date the staff opened the bottles to reflect the shortened expiration date, as required by the manufacturer.

4. Observation on 3/2/15 at 9:50 AM, during tour of the Laboratory area with Staff D, Laboratory Technologist, revealed 1 glucometer in a case and the case contained 1 of 1 opened bottle of high control and 1 of 1 opened bottle of low control. The high and low bottles of control solutions lacked documented evidence of the date the staff first opened the bottles.

During an interview at the time of the tour of the Laboratory area, Staff D acknowledged the Glucometer high control and low control bottles lacked evidence of the date the staff opened the bottles to reflect the shortened expiration date, as required by the manufacturer.

5. Observation on 3/2/15 at 3:15 PM, during tour of the Cardiac Rehabilitation area with Staff P, Cardiac Rehabilitation Registered Nurse, revealed 1 glucometer in a case and the case contained 1 of 1 opened bottle of high control and 1 of 1 opened bottle of low control. The high and low bottles of control solutions lacked documented evidence of the date the staff first opened the bottles.

During an interview at the time of the tour of the Cardiac Rehabilitation area, Staff P acknowledged the Glucometer high control and low control bottles lacked evidence of the date the staff opened the bottles to reflect the shortened expiration date, as required by the manufacturer.


II. Based on observation, documentation, and staff interview, the Critical Access Hospital (CAH) staff failed to document the date 1 of 1 bottle of test strips for the Steris 1E processor used to sterilize endoscopes was opened in accordance with the manufacturer's requirements in the Surgery area. The facility reported an average of 37 endoscopic procedures performed per month.

Failure to document the date staff opened the bottle of Steris test strips could potentially allow staff to use the test strips after the manufacturer's shortened expiration date and potentially resulting in inaccurate test results.

Findings include:

1. Review of the manufacturer's instructions for the Steris test strips stated in part, new expire date - 6 months, not greater than expiration date after opening.

2. Observation on 3/3/13 at 3:40 PM, during tour of the Surgery area with Staff B, Director of Surgery, revealed 1 of 1 opened bottle of Steris test strips available for use. The bottle of Steris test strips lacked documented evidence of the date the staff opened the bottle.

3. During an interview at the time of the tour, Staff B acknowledged the Steris test strips lacked documented evidence of the date the staff opened the bottle to reflect the shortened expiration date, as required by the manufacturer.

Based on review of policies and procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners, for 3 of 3 mid-level practitioners. (Practitioners C, D, and E)

The CAH staff reported the volume of services by the mid-level practitioners identified, 9/1/14 to 3/3/15 as follows:
Practitioner C: 264 patients
Practitioner D: 190 patients and 192 patients in the specialty wound clinic
Practitioner E: 291 patients

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioners does not allow opportunities for continued learning and improving the quality of patient care at the CAH.

Findings include:

1. At the time of review, the CAH's Medical Staff By-Laws and Rules and Regulations revealed lacked the requirement to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners. During an interview on 3/4/15 at 1:05 PM, the Chief Nursing Officer (CNO) acknowledged the CAH lacked policies to ensure the physician periodically reviewed the mid-level practitioners' medical records, in conjunction with the mid-level practitioners.

2. Review of available documentation revealed there was no documentation showing the physician review of the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners.

3. During an interview on 3/4/15 at 8:15 AM, Practitioner C, Advanced Practice Registered Nurse (ARNP) reported the supervising physician meet occasionally with the mid-level practitioners to review their medical records however these meetings were informal and there was no documentation to show the physician reviewed the mid-level practitioners' medical records, in conjunction with the mid-level practitioners.

4. During an interview on 3/4/15 at 11:30 AM, Staff M, Associate Administrator, acknowledged Mid-level Practitioners C, D, and E provided care to patients at the CAH and acknowledged there is no documentation to show the physician reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner, for 3 of 3 mid-level practitioner (Practitioners C, D, and E).

The CAH staff reported the volume of services by the mid-level practitioners identified, 9/1/14 to 3/3/15 as follows:
Practitioner C: 264 patients;
Practitioner D: 190 patients and 192 patients in the specialty wound clinic; and
Practitioner E: 291 patients.

Failure of the mid-level practicioners to review the CAH patient records periodically in conjunction with the physician does not allow opportunities for continued learning and improving the quality of patient care at the CAH.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed the policies/procedures lacked the requirement to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners. During an interview on 3/4/15 at 1:05 PM, the Chief Nursing Officer (CNO) acknowledged the CAH lacked policies/procedures to ensure the physician periodically reviewed the mid-level practitioners' medical records, in conjunction with the mid-level practitioners.

2. Review of documentation revealed no documentation of the mid-level practitioners review of the patient medical records, in conjunction with physician.

3. During an interview on 3/4/15 at 8:15 AM, Practitioner C, Advanced Practice Registered Nurse (ARNP) said the supervising physician meets occasionally with the mid-level practitioners to review their medical records however these meetings were informal and there was no documentation to show the physician reviewed the mid-level practitioners' medical records, in conjunction with the mid-level practitioners.

4. During an interview on 3/4/15 at 11:30 AM, Staff M, Associate Administrator, acknowledged Mid-level Practitioners C, D, and E provided care to patients at the CAH and acknowledged there was no documentation to show the physician reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioners.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies for 21 of 21 patient care departments. (Environmental Services, Infection Prevention, Recovery Room, Swing Bed, Rehabilitation Services, Patient Care Services, Obstetrics, Respiratory Therapy, Pharmacy, Laboratory, Emergency Room, Plant Operations, Safety, Anesthesia, Surgery, Intensive Care Unit, Employee Health, Nursery, Radiology, Cardiac Rehabilitation, and Dietary)

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care items not addressed in the CAH policies/procedures and those policies needing updating.

Findings include:

1. Review of CAH policy titled "CAH Professional/Advisory Committee", dated 10/2014, revealed in part, ". . . Wayne County Hospital will have a professional advisory committee to carry out its responsibility for CAH conditions of participation. The committee shall meet a minimum of one time a year, and will meet more often as needed, for policy approval and review. . . The committee shall consist of the CEO or his/her designee, one physician medical staff member, one nurse practitioner or physician assistants, one QI Council member, and the Chief Nursing Officer."

2. Review of CAH Policy Review Minutes for February 20, 2014 documented the absence of a physician at the meeting and the committee approved policies for Environmental Services and Infection Prevention.

Review of CAH Policy Review Minutes for March 30, 2014 documented the absence of a physician at the meeting and the committee approved policies for Recovery Room and Swing Bed.

Review of CAH Policy Review Minutes for April 16, 2014 documented the absence of a physician at the meeting and the committee approved policies for Rehabilitation Services.

Review of CAH Policy Review Minutes for May 28, 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Patient Care Services.

Review of CAH Policy Review Minutes for June 18, 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Obstetrics and Respiratory Therapy.

Review of CAH Policy Review Minutes for July 16, 2014 documented the absence of a physician at the meeting and the committee approved policies for Pharmacy, Laboratory, and Emergency Room.

Review of CAH Policy Review Minutes for August 20, 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Plant Operations and Safety.

Review of CAH Policy Review Minutes for September 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Anesthesia and Surgery.

Review of CAH Policy Review Minutes for October 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Intensive Care Unit.

Review of CAH Policy Review Minutes for November 20, 2014 documented the absence of a physician at the meeting and the committee approved policies for Employee Health.

Review of CAH Policy Review Minutes for December 22, 2014 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Nursery and Radiology.

Review of CAH Policy Review Minutes for January 2015 documented the absence of a physician and a mid-level provider at the meeting and the committee approved policies for Cardiac Rehabilitation and Dietary.

3. During an interview on 3/4/15 at 2:10 PM, Staff F, Chief Nursing Officer, acknowledged a physician was not present at the CAH Policy Review Committee meeting on February 20, 2014; March 30, 2014; April 16, 2014; May 28, 2014; June 18, 2014; July 16, 2014; August 20, 2014; September 2014; October 2014; November 20, 2014; December 22, 2014; and January 2015 for annual review of the above stated policies/procedures and lacked documentation a physician reviewed those policies.

Staff F acknowledged a mid-level provider was not present at the CAH Policy Review Committee meeting on May 28, 2014; June 18, 2014; August 20, 2014; September 2014; October 2014; November 20, 2014; December 22, 2014; and January 2015 for annual review of the above stated policies/procedures and lacked documentation a mid-level provider reviewed those policies.

I. Based on review of records and staff interview the Critical Access Hospital (CAH) failed to obtain physical health screening for 1 of 1 contracted PTA (Physical Therapy Assistant). The PT Department (Physical Therapy) staff identified 192 PT encounters per month.

Failure to maintain physical health screenings for employees, including contracted employees, could potentially result in employees lacking the physical ability to perform the necessary cares for patients.

Finding include:

1. A review of personal records revealed the CAH failed to maintain the physical health screening for 1 of 1 contracted employee. Review of the document titled Employee Health Coordination dated 1/1/13, states in part ...Physicals are required by ALL employees at hire and every 4 years.

2. An interview on 3/4/15 at 11:00 AM, with Staff I HR (Human Resource) Generalist, revealed a lack of the physical health screening for 1 of 1 contracted PTA employee. The CAH failed to produce the total number of contracted employees providing care to its patients.

II. Based on review of documents and staff interview the CAH (Critical Access Hospital) failed to identify the infections and positive lab results for patients of the ED (Emergency Department). The ED administrative staff reported 240 ED visits per month.

Failure to monitor the ED infections could potentially result in unnecessary exposure to infections by staff and the community.

Findings include:

1. A review of the policy titled Infection Prevention Committee dated 2/2014 states in part ...The Infection Prevention designee will adopt a surveillance program that will be useful in lowering the risk of infection and/or other related adverse events in the facility. The surveillance program will be able to provide the following: Early identification of potential outbreaks. A report of " Reportable Diseases " to the Health Department as required by local, state and federal law.

2. An interview on 3/4/15 at 3:00 PM, with Staff K CEO (Chief Executive Officer), revealed the hospital lacked a system for tracking and trending the infections and positive lab results of ED patients.

An interview on 3/4/15 at 2:00 PM, with Director of Case Management revealed a lack of follow-up with ED patients with positive lab results indicating an infectious process.

Based on review of records and staff interview the Critical Access Hospital (CAH) failed to privilege 1 of 1 RN (Registered Nurse) providing assistance to the physician during surgery (Other Staff AA). The RN is employed by the physician and has provided assistance in 409 surgical cases since 3/28/2012.

Failure to privilege providers for surgical procedures could potentially result in the inability of the CAH to ensure the RN has the necessary skills to adequately provide care to patients.

Findings include:

1. A review of credentialing files revealed a lack of surgical privileges for the RN assisting the physician (Practitioner B). Other Staff AA accompanies Practitioner B, Doctor of Ophthalmology, to perform surgical procedures.

A review of the policy titled Credentials Verification dated 9/2014, states in part ...Persons employed by or in an assistive role to physicians, dentists, or podiatrists who are granted privileges to practice at the CAH may perform duties within the hospital.
A review of the Medical Staff Bylaws dated 4/2011, states in part ...Medical and surgical assistants are persons who are not employees of the hospital, and who are not members of the medical staff or of the regular allied health professional staff, but who work from time to time in the hospital and are employed by and responsible to members of the medical staff member and work under the medical staff member ' s direction and supervision. Applicants shall submit information pertaining to their educational background and their experience and training in the specialty in which the privileges are requested.

2. An interview on 3/4/15 at 3:00 PM, with Staff L Director of Administrative Services, verified a lack of privileges for Practitioner A. Staff L provided additional information; Other Staff AA has assisted Practitioner B in surgical procedures since 3/28/2012.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 8 departments (Nuclear Medicine, Ultrasound, Cardiac Rehab, Environmental Services, Chemotherapy infusion, Specialty Clinic, Magnetic Resonance Imaging (MRI) and Plant Operations within their organizational-wide system. The CAH administrative staff reported a census of 19 inpatients at the time of the survey.

Failure to monitor and evaluate all patient care services for quality of care limits opportunities for improving patient services, patient care, and patient outcomes.

Findings include:

1. Review of CAH policy "Quality Assurance/Quality Improvement Program"(QA/QI) reviewed 5/14, revealed it stated in part, ..."to develop a system for monitoring, evaluating, and improving outcomes in all aspects of the organization...to determine accountability for quality of patient care services to the Board of Trustees, Medical Staff, Hospital staff...the QA/QI committee will hold a monthly meeting. Each department is responsible to complete their reports as required...The committee reviews summaries data from Measurement, Monitoring, and Analysis of quality across the organization. . . ."

2. Review of QI Council Meeting minutes from December 22, 2014 to June 26, 2015 lacked evidence that Nuclear Medicine, Ultrasound, Environmental Services, Chemotherapy infusion, Specialty Clinic, Magnetic Resonance Imaging (MRI) and Plant Operations monitored, evaluated and reported quality improvement activities regarding patient care services.

3. During an interview on 3/3/15 at 3:20 PM, Staff O, Specialty Clinic Coordinator, said they did not have a current QI monitoring program and lacked reports to the QI committee. Staff O admitted this was currently identified as a "weakness" and an area of "improvement" they planned on correcting immediately.

During an interview on 3/3/15 at 4:20 PM, Staff N, Director of Environmental Services said they had not participated in the QI monitoring program for a year or more. Staff N said although she currently conducted random audits for their department she failed to document the results and submit information to the QI committee.

During an interview on 3/4/15 at 12:15 PM, Staff J, QA/QI Director acknowledged the Nuclear Medicine, MRI and ultrasound services lacked evidence of QI activities since 2012. Staff J said they were currently in the process of developing a QI plan for chemotherapy services and acknowledged they lacked reports for this service to the QI committee.

During an interview on 3/5/15 at 9:50 AM, Staff F, Chief Nursing Officer (CNO) said she was responsible for oversight of the Cardiac Rehab services and acknowledged they failed to conduct QI monitoring activities since 2012. Staff F said she was aware that this was a requirement and acknowledged they failed to follow their QI plan.

During an interview on 3/5/14 at 10:10 AM, Staff M, Associate Administrator, said he was responsible for oversight of the Specialty Clinic, Environmental Services, and Radiological services. Staff M said he was aware they failed to have quality markers for all of these areas and by doing so they failed to follow the QI plan.

Based on review of records and staff interview the Critical Access Hospital (CAH) failed to complete the external entity review for all practitioners credentialed at the hospital. The hospital administrative staff identified 4 of 8 applicable credentialed practitioners files lacked evidence of external entity review.

Failure to complete external entity review for all providers could potential result in the CAH's inability to ensure providers delivered safe, quality care to patients of the CAH.

Findings include:

1. The review of 8 applicable practitioner credentialing files revealed 4 (Practitioners F, G, H, and I) lacked an external entity review. The external entity review is completed by providers of the network hospital and provides information related to the quality and appropriateness of the diagnoses and treatment furnished by the CAH's providers.

The review of the Critical Access Network Agreement, dated 7/1/14 states in part ...medical records review as part of the quality and medical necessity of medical care at CAH. Such review may be performed by direct inspection by member or another designated employee of or physician affiliated with Mercy, by analysis of CAH's internal chart audits, or by examination of external peer review reports.

2. An interview on 3/4/15 at 3:00 PM, with Staff L Director of Administrative Services acknowledged external peer review has not been completed on all practitioners, or has not been completed in a timely fashion to allow for review at time of the practitioners' credentialing reapplication.

Based on review of swing bed patient rights and staff interview, the CAH staff failed to ensure all swing bed patients, admitted and discharged from swing bed services for post-acute skilled level of care, received a complete list of the required Patient Rights for swing bed patients. The CAH staff reported a current census of 6 Swing Bed patients at the time of the survey with an average daily census of 7 Swing Bed patients.

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 the "Resident Notice of Rights", dated 1/11, lacked the following patient rights:

a. In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.

b. Upon an oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays).

2. During an interview on 3/4/15 at 9:40 AM, Staff F, Chief Nursing Officer, and Staff H, Director of Case Management, acknowledged the Patient Rights given to swing bed patients lacked a complete list of all of the required patient rights and patients that received the incomplete Resident Rights did not receive a complete copy of the patient rights.

Based on review of swing bed policies, medical records, and interviews with staff, the swing bed skilled interdisciplinary team and nurse manager failed to ensure the attending physician participated in the interdisciplinary care conferences for the development of the patient's individualized care plan.

Failure to obtain input from the attending physician while formulating and revising the patient's individualized care plan potentially result in delays in implementing treatment modalities to improve the patient's functional abilities, to enhance healing, and to shorten the stay at the hospital.

The Case Management Director reported a current census of 6 Swing Bed patients at the time of the survey with an average daily census of 7 Swing Bed patients.

Concerns were noted for 6 of 6 swing bed in-patients (Patients #1, #2, #3, #4, #5, and #6).

Findings include:

1. Review of CAH policies/procedures, revealed they lacked the requirement to ensure physician involvement in development of the care plan and participation in the interdisciplinary care plan meetings.

2. During an interview on 3/4/15 at 8:20 AM, Staff H, Director of Case Management said the physician signs after the interdisciplinary team meetings and documents on a progress note plan prior to the weekly care plan meetings.

3. Review of the swing bed in-patients medical records for Patient #1, #2, #3, #4, #5, and #6 revealed the following information.

a. A physician's order, dated 2/23/15, for Patient #1 to receive skilled nursing services including physical and occupation therapy services status post right hip replacement was in the medical record.

A review of the patient's medical record revealed a care conference occurred on 2/24/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

b. A physician's order, dated 2/16/15, for Patient #2 to receive skilled nursing services for physical and occupational therapy services status post pneumonia with weakness was in the medical record.

A review of the patient's medical record revealed care conferences occurred on 2/17 and 2/24/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

c. A physician's order, dated 2/16/15, for Patient #3 to receive skilled nursing services for physical therapy services for degenerative disc disease with weakness in the lower extremities was in the medical record.

A review of the patient's medical record revealed care conferences occurred on 2/17 and 2/24/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

d. A physician's order, dated 2/19/15, for Patient #4 to receive skilled nursing services for physical and occupation therapy services for strengthening and conditioning for lower extremity cellulitis and debility was in the medical record.

A review of the patient's medical record revealed a care conference occurred on 2/24/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

e. A physician's order, dated 2/26/15, for Patient #5 to received skilled nursing services for physical and occupation therapy services status post left hip fracture with replacement was in the medical record.

A review of the patient's medical record revealed a care conference occurred on 3/3/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

f. A physician's order, dated 3/1/15, for Patient #6 to receive skilled nursing services for physical therapy services status post right knee replacement was in the medical record.

A review of the patient's medical record revealed a care conference occurred on 2/24/15, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference. The medical record lacked a physician progress note plan prior to the weekly care plan meeting.

4. During an follow up interview on 3/4/15 at 4:00 PM, Staff H stated she was responsible to coordinate and manage the interdisciplinary care conferences and confirmed the physician did not attend care conferences. Staff H acknowledged the active swing bed patients medical records lacked evidence of physician involvement in care plan meetings and a progress note prior to the meetings. Staff H said she updates the physicians prior to care plan meetings however she was unaware that she needed to document this on the patient's interdisciplinary team meeting notes.

5. During an interview on 3/4/15 at 4:40 PM, the Chief Nursing Officer (CNO) acknowledged that although the CAH lacked a policy ensuring physician involvement in the interdisciplinary care plan that this was a federal guideline that they were not following.

Based on review of policies/procedures and staff interviews, the Critical Access Hospital (CAH) failed to ensure all patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Failure to provide patients with current visitation rights could potentially result in patient's visitors being restricted.

The CAH staff identified an average number of patients served in the following areas:
- Average daily inpatient (acute and swing bed) census - 7
- Physical Therapy patient visits - 3,475 per year
- Occupational Therapy patient visits - 634 per year
- Speech Therapy patient visits - 50 per year
- Cardiac Rehabilitation patients - 61 per year
- Respiratory Therapy treatments - 2,270 per year
- Emergency Room visits - 2,871 per year
- Surgery procedures - 1,076 per year
- Laboratory procedures - 55,098 per year
- Radiology procedures - 8,236 per year

Findings include:

1. Review of CAH policy titled "Patient's Rights", revised 1/2014, revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 3/4/15 at 8:00 AM, Staff F, Chief Nursing Officer, acknowledged the Patient Rights policy lacked the current patient visitation rights information as required by the regulations.

Based on document review, observations, 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, a 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 19 patients - 10 acute patients, 6 swing bed patients, 1 hospice patient, and 2 observation patients.

The CAH staff identified an average number of patients served in the following areas:
- Average daily inpatient (acute and swing bed) census - 7
- Physical Therapy patient visits - 3,475 per year
- Occupational Therapy patient visits - 634 per year
- Speech Therapy patient visits - 50 per year
- Cardiac Rehabilitation patients - 61 per year
- Respiratory Therapy treatments - 2,270 per year
- Emergency Room visits - 2,871 per year
- Surgery procedures - 1,076 per year
- Laboratory procedures - 55,098 per year
- Radiology procedures - 8,236 per year

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 present when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of undated patient handout, "Your Patient Rights", revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 3/4/15 at 8:00 AM, Staff F, Chief Nursing Officer, acknowledged the Patient Rights patient handout lacked the current patient visitation rights information as required by the regulations.