HospitalInspections.org

Based on review of contracts, medical staff credential files, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the delineation of privileges for 2 of 2 distant-site physicians reviewed, who provided teleradiology services to patients at the CAH. (Practitioners DD and EE)

The Director of Radiologist reported Practitioner DD last read radiology exams for the CAH on 6/18/18 and Practitioner EE last read radiology exams for the CAH on 6/15/18.

Failure to delineate privileges for the teleradiology distant-site physicians could allow the teleradiologist to read exams they are not qualified to read and could potentially result in the misdiagnosis of patients at the CAH and cause further injury to the patient and/or death.

Findings include:

1. Review of a contract titled "Physician Credentialing and Privileging Agreement", signed by the CAH's Chief Executive Officer (CEO) on 8/15/17 and approved by the CAH's Board of Trustees on 9/25/27, revealed in part ". . .[Telemedicine Entity] has supplied HCF [Shenandoah Medical Center] with Schedule 1, a list identifying each Physician and the scope of privileges granted by [Telemedicine Entity]. . . ."

2. Review of medical staff credential files on 6/27/18 at 8:15 AM with the CEO and Staff N, Credentialing Coordinator, revealed the lack of delineated privileges for Practitioners DD and EE.

3. During an interview on 6/27/18 at 8:15 AM, the CEO and Staff N, Credentialing Coordinator, verified the lack of delineated privileges for Practitioners DD and EE.

Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) staff failed to ensure emergency equipment and supplies commonly used in life saving procedures were readily available for treating emergency cases. Problem identified with 1 of 1 "Neonatal Resuscitation Program (NRP) Bag" (a bag that contains medications, supplies and equipment for emergency resuscitation of a newborn baby that was easily portable).

The Chief Nursing Officer identified 106 deliveries in 2017.

Failure to ensure the "NRP Bag" was fully stocked and ready for use at the time of delivery or in the event of an emergency may result in lack of lifesaving supplies and equipment needed to resuscitate (to revive from apparent death) a newborn infant potentially resulting in significant injury and or death.

Findings include:

1. During an observation on 6/18/2018 at 3:08 PM with staff revealed a zipped a side compartment of the "NRP Bag" with an opened, empty sterile package. The package had contained a stylet (a thin wire inserted into a catheter or small tube to maintain rigidity). A second opened, no longer sterile package, contained a 2.5 endotracheal (ET) tube (an endotracheal tube is a catheter that is inserted into the trachaea for the primary purpose of establishing and maintaining an open airway) with a stylet inserted into the ET tube. A third opened, no longer sterile package, contained a 2.0 ET tube.

Endotracheal intubation requires sterile supplies in unopened intact packaging to prevent the potential introduction of microorganisms into the airway and lungs that could lead to infection.

2. Review of the hospitals policies revealed the hospital lacked a policy on the use and maintenance of the "NRP Bag".

3. During an interview on 6/18/2018 at 3:08 PM Staff B, Nurse Manager Med/Surg and Obstetrics stated the "NRP Bag" is taken on emergency ambulance transfers that have the potential for delivery of a newborn and was utilized within the hospital in emergency cases that involve a potential delivery of a baby. Staff B verified the "NRP Bag" was ready for use and these opened supplies should not be present as they were unusable in the opened and no longer sterile condition. Staff B stated it was the responsibility of the OB Nursing Staff to keep the "NRP Bag" in a state of readiness. Staff B verified the hospital does not have a policy on the use and maintenance of the "NRP Bag".

Based on review of the blood bank agreement and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH's medical staff and the person responsible for the operation of the CAH approved the current blood bank agreement. The Laboratory administrative staff reported the laboratory had 10 units of blood products available for patients at the time of the survey.

Failure to ensure a current blood bank agreement was approved by the CAH's medical staff and the person responsible for the operation of the CAH could potentially interrupt the availability of blood products needed for emergencies resulting in patient harm and/or death.

Findings include:

1. Review of the "American Red Cross Blood Services Agreement", dated September 13, 2013, lacked approval by
the CAH's medical staff and the person responsible for the operation of the CAH.

2. During an interview on 6/19/18 at 1:10 PM, Staff O, Laboratory Director, acknowledged the current Blood Bank Agreement dated September 13, 2013 lacked approval by the CAH's medical staff and the person responsible for the operation of the CAH.

Based on document review and interviews the facility's administrative staff failed to maintain a list of safety checks on equipment throughout the hospital.

Failure to maintain a list of equipment that is used by the facility has resulted in the facility not being able to determine what equipment is present at the facility and if it has had a safety check done on it. This failure could potentially result in a patient being harmed by faulty equipment that has not been tested for safety.

Findings Include:

A. Review of document titled Equipment Inventory Report, Report Run Date: 6/18/2018, Report ID:OAIN001, from Universal Hospital Services (UHS) for Shenandoah Memorial Hospital revealed in part: "Total Equipment count: 362." Of the items that came into contact with patients; 14 were not covered and 16 items were late for safety checks.

B. Review of document titled BIOMED360 AGREEMENT, Agreement #: UHS-14733, dated 4/7/2017 revealed in part: " ...MANAGEMENT SERVICES ...UHS will maintain the following data: ...Equipment Log. BIOMED will maintain an equipment log that is a listing of Equipment and includes the make, model and serial number of each unit of Equipment and the department to which it is assigned ...Preventative Maintenance/ Safety Test Records. BIOMED will complete and maintain an electronic record of safety test or preventative maintenance procedures for all Equipment ...Exclusions The following are not covered Services or Equipment and are excluded under this Exhibit: ...Service required because of installation, relocation or certification surveys ...Service required under a manufacturer's warranty."

C. Review of policy #674 titled MM- Service & Maintenance Agreements, Date effective 4/16/2015 revealed in part: "It may be determined that contract service ...The Director of Environmental Services will negotiate all service contracts ...Contract vendor performance shall be monitored and evaluated on an ongoing basis ...Compensation certificates shall be acquired from each vendor which is under contract to do work in the facility ..."

D. During an interview on 6/26/2018 at 8:00 AM with Director of Materials Management revealed the department does not maintain a list of the equipment in the hospital, including patient care equipment. Director of Material Management confirmed it was his responsibility to maintain a list of the safety checks on equipment, including equipment used for patient care.

E. During an interview on 6/26/2018 at 1:45 PM the Chief Financial Officer (CFO) reported some of the equipment on the Equipment Inventory Report has been put into storage and is not present at the hospital. The CFO confirmed the responsibility of maintaining a current list of equipment and safety checks on said equipment falls on the Director of Materials Management, who is under the direction of the CFO.

F. During an interview on 7/9/2018 at 0810 AM the BIOMED representative revealed the responsibility to maintain a list of equipment to be inspected falls on the facility and the BIOMED company.

G. During an interview on 6/26/2018 at 9:40 AM the CIO confirmed he was not aware of any documentation to provide referring to the equipment not covered by the BIOMED company. He confirmed he had no way of showing that the equipment was safe for patient use.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician periodically reviewed the CAH patient records, cared for by the mid-level practitioner, in conjunction with the mid-level practitioner for 2 of 2 mid-level practitioners. (Staff Q and T)

The Chief Nursing Officer reported the number of patients cared for by the mid-level practitioners from January 2018 through May 2018 as follows:
- Practitioner Q - 16 inpatients
- Practitioner T - 14 inpatients

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "Physician and Mid-Level Responsibilities", dated June 1, 2018, revealed the following in part, ". . .The physician, in conjunction with the mid-level practitioner, reviews the patient records, provides medical orders and provides medical care services to the patients of the Shenandoah Medical Center. The physician reviews the medical records to ensure patients receive appropriate diagnostics, care and treatments according to standards of care. . . Health Information Director shall select the required number of charts and physicians and mid-level practitioners shall jointly review and discuss the care provided. . . ."

2. Review of documentation revealed the lack of documentation the physician reviewed the CAH patient records, cared for by the mid-level practitioner, periodically, in conjunction with the mid-level practitioner.

3. During an interview on 6/25/18 at 10:00 AM, Staff T, Advanced Registered Nurse Practitioner (ARNP), stated the collaborating physician was supposed to pull so many charts quarterly, then sit down with the ARNP and review the charts. Staff T stated she was unsure of any documentation of the chart review.

During an interview on 6/27/18 at 9:40 AM, Staff R, Chief Nursing Officer (CNO), stated there was not any documentation of patient medical records of patients cared for by the ARNP by the physician.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the mid-level practitioner participated with the physician in the periodic review the CAH patient records, cared for by the mid-level practitioner, for 2 of 2 mid-level practitioners. (Staff Q and T)

The Chief Nursing Officer (CNO) reported the number of patients cared for by the mid-level practitioners from January 2018 through May 2018 as follows:

- Practitioner Q - 16 inpatients
- Practitioner T - 14 inpatients

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "Physician and Mid-Level Responsibilities", dated June 1, 2018, revealed the following in part, ". . .The physician, in conjunction with the mid-level practitioner, reviews the patient records, provides medical orders and provides medical care services to the patients of the Shenandoah Medical Center. The physician reviews the medical records to ensure patients receive appropriate diagnostics, care and treatments according to standards of care. . . Health Information Director shall select the required number of charts and physicians and mid-level practitioners shall jointly review and discuss the care provided. . . The mid-level practitioner will participate with the physician in a periodic review of patient medical records. . . ."

2. Review of documentation revealed the lack of documentation the physician reviewed the CAH patient records, cared for by the mid-level practitioner, periodically, in conjunction with the mid-level practitioner.

3. During an interview on 6/25/18 at 10:00 AM, Staff T, Advanced Registered Nurse Practitioner (ARNP), stated the collaborating physician was supposed to pull so many charts quarterly, then sit down with the ARNP and review the charts. Staff T stated she was unsure of any documentation of the chart review.

During an interview on 6/27/18 at 9:40 AM, Staff R, CNO, stated there was not any documentation of patient medical records of patients cared for by the ARNP by the physician.

Based on policy and patient medical record review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the Advanced Registered Nurse Practitioner (ARNP) notified a physician when the ARNP admitted 2 of 2 patients in the last six months in accordance with the regulations. (Patient #1 and 9) Administrative staff identified a census of 4 patients at the beginning of the survey.

The Chief Nursing Officer (CNO) reported the number of patients cared for by the mid-level practitioners from January 2018 through May 2018 as follows:

- Practitioner Q - 16 inpatients
- Practitioner T - 14 inpatients

Failure to notify the physician of a patient admitted by an ARNP resulted in the lack of the physician's ability to provide medical direction, consultative services, and could potentially result in missed diagnosis, treatment, and care of the patient.

Findings include:

1. Review of CAH policy titled "Physician and Mid-Level Responsibilities", dated June 1, 2018, revealed in part, ". . . POLICY: Responsibilities of the physician and mid-level practitioner include the provision for medical direction for hospital health care activities and consultation for the medical supervision of the health care staff. . . ."

Review of CAH policy titled "Med/Surg - Acute to Skilled Transfer", dated 11/21/2017, revealed in part, ". . . The physician shall write an order to transfer the patient to skilled care status. . . ."

The policies failed to require the mid-level practitioner to notify a physician when the mid-level practitioner admitted a patient in accordance with the regulations.

2. Review of patient medical record for Patient # 1, admitted to skilled care on 6/14/18 by by Staff Q, ARNP lacked documentation of physician notification when the mid-level practitioner admitted the patient to the hospital.

Review of patient medical record for Patient # 9, admitted to the hospital 5/17/18 by by Staff Q, ARNP lacked documentation of physician notification when the mid-level practitioner admitted the patient to the hospital.

3. During an interview on 6/19/18 at 3:30 PM, Staff B, Nurse Manager Medical/Surgical and Obstetrics, stated she was not aware of the requirement or documentation that an ARNP notified a physician of the admission of a patient.

During an interview on 6/25/18 at 10:00 AM, Staff T, ARNP - Hospitalist, stated she does not notify a physician of a patient admission to the hospital because the physician usually referred the patient to the ARNP for admission to the hospital. Staff T stated if a patient was referred to the ARNP for admission to the hospital by another ARNP, a physician would not be notified of the patient's admission to the hospital.

During an interview on 6/25/18 at 12:15 PM, Staff S, ARNP - Clinic and Urgent Care, stated she does not notify a physician of referral of a patient for admission to the hospital . The ARNP - Hospitalist admits the patient to the hospital.

During an interview on 6/27/18 at 10:20 AM, Staff R, CNO verified the CAH did not have a policy that addressed the requirement for the mid-level provider to notify a physician when the mid-level practitioner admitted a patient to the hospital. Staff R verified patient medical record for Patient #9 lacked documentation of physician notification when the mid-level practitioner admitted the patient to the hospital.

Based on review of policies/procedures, meeting minutes, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the required group of professionals, including a physician and a mid-level practitioner, reviewed all patient care policies for 21 of 21 patient care departments. (Nursing - Medical/Surgical and Obstetrics), Quality, Emergency Department, Surgery, Imaging, Dietary, Diabetic Education, Laboratory, Pharmacy, Anesthesia, Respiratory Therapy/Sleep Study, Social Services, Rehab/Wellness - Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac/Pulmonary Rehab, Infection Control, Infusion Center, Specialty Clinic, Health Information Management, Maintenance/Safety, Housekeeping/Laundry, and Materials Management). Administrative staff identified a census of 4 patients at the beginning of the survey.

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

Findings include:

1. Review of CAH policy titled "CAH Policy Procedure Development & Review", dated 5/15/18, revealed in part, ". . . All policies and procedures of Shenandoah Medical Center and affiliated clinics related to patient care shall be developed, executed, and reviewed annually by the Critical Access Hospital Committee. . . ."

2. Review of "Minutes for Critical Access Hospital Professional Advisory Committee" dated June 12, 2017; August 14, 2017; November 13, 2017; January 8, 2018; and May 7, 2018 revealed new or changed policies for Nursing - Medical/Surgical and Obstetrics, Quality and Emergency Department. A physician and mid-level practitioner attended the above stated Critical Access Hospital Professional Advisory Committee meetings.

The Minutes for Critical Access Hospital Professional Advisory Committee lacked annual approval of all patient care policies for Nursing - Medical/Surgical and Obstetrics), Quality, Emergency Department, Surgery, Imaging, Dietary, Diabetic Education, Laboratory, Pharmacy, Anesthesia, Respiratory Therapy/Sleep Study, Social Services, Rehab/Wellness - Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac/Pulmonary Rehab, Infection Control, Infusion Center, Specialty Clinic, Health Information Management, Maintenance/Safety, Housekeeping/Laundry, and Materials Management.

3. During an interview on 6/21/18 at 10:30 AM, Staff R, Chief Nursing Officer, verified the Critical Access Hospital Professional Advisory Committee only review new policies and policies that have revisions.

4. During an interview on 6/25/18 at 12:15 PM, Staff S, Advanced Registered Nurse Practitioner (ARNP), stated she attends the Critical Access Hospital Professional Advisory Committee for annual policy/procedure review. Staff S stated the Department Heads bring policies that need approval to the committee but they are only policies that are changed or new policies. Staff S stated the rest of the policies are reviewed by the Department Heads and do not go to the Critical Access Hospital Professional Advisory Committee.

Based on observation, review of policy, and staff interview the Critical Access Hospital's (CAH) Administrative staff failed to ensure medications were securely stored in one of one obstetrical area not readily accessible to unauthorized persons.

The Chief Nursing Officer (CNO) identified 106 deliveries in 2017. The hospital has 2 Labor, Delivery, Recovery, and Postpartum rooms (LDRP's).

Failure to ensure medications are secure from unauthorized access allows individuals to obtain medications that could lead to unauthorized use resulting in potential injury and/or death and the potential of missing critical medications in an emergency situation resulting in potential injury and/or death.

Findings include:

1. During an observation on 6/18/2018 at 3:00 PM an unsecured door located within LDRP patient room 294 was noted to access an obstetrical equipment and supply room. A second door at the opposite end of the supply room accessed the other LDRP patient room. The equipment and supply room held the emergency "Neonatal Resuscitation Program (NRP) Bag" which contained emergency medications for the resuscitation of newborn infants. Located on a wall in the supply room were bins which contained additional supplies such multiple 10 ml sterile saline filled syringes and sterile IV needles.

2. Review of policy # 8799 titled "Medication Administration" dated effective 5/30/2018 revealed in part..."5. Storage of Medications: Medications shall be stored in the pharmacy or the automated dispensing cabinet. Medications shall not be stored in the patient's room or pod...",

3. During an interview on 6/18/2018 at 3:00 PM Staff B, Nurse Manager Med/Surg and Obstetrics, verified the supply room contained medications and was easily accessible by anyone, including visitors, from within the patient's room. Staff B also confirmed the supply room doors were not secured to prevent unauthorized access and the room was not visually monitored by staff to prevent unauthorized access.

30076


I. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to maintain kitchen equipment, used for patient food preparation, in a sanitary manner. The administrative staff identified a census of 4 patients. The Foodservice Director reported the dietary staff provided approximately 9 to 18 patient meals daily.

Failure to maintain food preparation equipment in a sanitary manner could potentially result in the contamination of patient food and lead to foodborne illness.

Findings include:

1. Observation on 6/18/18, at 12:00 PM, revealed the kitchen had 2 cutting boards currently in use and 8 stored as clean and ready for use. A medium white cutting board, in use by the toaster, had a worn, marred surface with stains on both sides. A large green cutting board, in use near the trayline, had a worn, marred surface with stains on both sides. Cutting boards stored as clean, included 1 large red, 2 small and 1 large white, 1 medium yellow, 1 large blue, 1 large yellow and 1 large tan all of which had worn, marred surfaces with stains on both sides.

2. During an interview on 6/18/18, at 12:45 PM, Staff A, Foodservice Director, acknowledged the condition of the cutting boards as worn and confirmed they should be replaced.

3. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires food preparation surfaces to be maintained in an intact manner and equipment such as cutting boards, subject to scratching and scoring, should be discarded or resurfaced if they can no longer be effectively cleaned and sanitized.


38211


II. Based on document review, observation and staff interviews the hospital failed to ensure housekeeping staff followed policies on the cleaning of patient rooms.

Failure of facility housekeeping staff performing appropriate patient room cleaning and disinfecting could result in new patients contracting disease or infections from past patients.

Findings Include:

1. Review of document titled Clean on the Go Super HDQL 10 Maximum Economy Neutral Disinfectant revealed in part: " Maximum economy: ½ ounce per gallon of concentrate provides total cleaning, disinfection and deodorization in one labor saving, cost effective step ...recommended for use on floors, wall, stainless steel, plastic and other hard nonporous surfaces."

2. Review of document titled Clean by Peroxy all purpose Hydrogen Peroxide cleaner revealed in part: All you need: Pale blue in color ...all-you-need, all-purpose cleaner ...most surfaces and surface soils ...

3. During an observation on 6/20/2018 at 2:35 PM in patient room 218, Housekeeping Staff I and Housekeeping Staff H performed a total room cleaning. Staff I used Clean by Peroxy 15 all purpose hydrogen peroxide cleaner to wipe down all surfaces in the room and mop part of the patient room floor,the bathroom, and then mopped their way out of the patient room floor. At 2:45 PM Staff I wiped off a Neo Blue Phototherapy Radiometer (device used to regulate blanket used for babies with jaundice, a yellowing of the skin due to a blood abnormality) and placed it on the un-wiped bed.

4. During a group interview on 6/20/2018 at 3:00 PM both Staff H and Staff lacked knowledge of wet times (time it takes for a product to disinfect a surface) of the product being used to clean the floors and wipe hard surfaces.

5. During a group interview on 6/20/2018 at 3:00 PM both Staff H and Staff lacked knowledge of the frequency of the changing of the toilet brush that is dedicated to the patient bathroom.

6. During an observation on 6/20/2018 at 3:18 PM Staff I failed to replace the toilet brush and holder that had been used for the previous patient.

7. During an interview on 6/20/2018 at 3:18 PM Staff I revealed the housekeeping staff have been instructed to alternate mopping the floors with Clean on the go Clean by Peroxy 15 and Super HDQ Neutral Disinfectant. Staff I reported one of the two products disinfects more than the other. When asked what the wet time was for the HDQ, Staff I did not know.

8. During an interview on 6/25/2018 at 4:00 PM the Housekeeping Manager revealed she expects staff to replace the toilet brush when a patient has been discharged and that staff are to disinfect the bathroom and mop with Peroxy 15 solution if the patient was not an isolation patient, as this solution is recommended for the floors to ensure they last longer.

9. During review of policy #1023, titled PATIENT ROOM OCCUPIED CLEANING, date effective: 6/12/2013 states in part; "To maintain a safe, aseptic and attractive environment for patient care ...Wash all furniture and fixtures with disinfectant solution ...Change disinfectant solution in pails and buckets after every three rooms ..."

III. Based on policy review, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to establish a consistent system to identify and prevent transmission of infections and communicable diseases and follow the established system for employees for 2 of 3 volunteer health files selected for review (Staff U and V). Administrative staff identified a census of 4 patients at the beginning of the survey.

Failure to identify infections and communicable diseases could potentially result in causing harm to patients through exposure and transmission of communicable diseases.

Findings include:

1. Review of CAH policy titled "HR - Employee Health", dated 8/1/2016, revealed in part, ". . . Policy: The purpose of this policy is to protect both patients and employees from illnesses which could be transmitted while on the job. . . Scope: This policy applies to all current SMC employees, contracted staff, job applicants who have accepted a contingent offer of employment, students and vendors. . . Procedure: . . All new employees prior to being hired need to fulfill the following requirements: Physical Assessment. . . ."

2. Review of volunteer health information for Staff U, Volunteer, revealed a start date of 3/1/2017 and the lack of a health exam prior to beginning volunteer time.

Review of volunteer health information for Staff V, Volunteer, revealed a start date of 6/14/2017 and the lack of a health exam prior to beginning volunteer time.

3. During an interview on 6/27/18 at 8:50 AM, the Chief Human Resources Officer confirmed the 2 identified volunteers lacked a health exam prior to beginning volunteer time.

IV. Based on interviews and documentation review the facility's administrative staff failed to ensure Physical Therapy/ Occupational Therapy staff used cleaning materials appropriately.

Failure of PT/OT staff to ensure the Hard Surface Wipes are being used appropriately could potentially result in patients and clients receiving skin rashes and cracking of the skin that could result in infections.

Findings include:

1. During an observation on 6/6/2018 at 9:45 AM in the Wellness Center, PT/ OT(Physical Therapy/ Occupational Therapy Department) a client got off of a treadmill and used a Spartan Hard Disinfecting Wipe to wipe the treadmill down. The client then rubbed their hands vigorously with the wipe and left the facility without washing their hands.

2. During an interview on 6/6/19/2018 at 9:45 AM in the Wellness Center PT/OT the Wellness Service Director revealed patients and clients are taught to use Spartan Hard Surface Disinfecting Wipes to wipe machines down after each use.

3. During an interview on 6/19/2018 at 10:30 AM Exercise Physiologist L reported she teaches patients how to use the equipment and to clean with Spartan Hard Surface Disinfecting Wipes. She then revealed she did not know the wet time for the wipes to be effective. She also said she has not taken the time to make sure people wash their hands after use.

4. During an interview on 6/21/2018 at 9:00 AM Chief Nursing Officer said she expected the Wellness Center to use Sani-Wipes instead of Hard Surface Wipes; as Sani-Wipes are approved for use for general public. She then said she would expect that staff would wear gloves if they are handling the Hard Surface Wipes.

5. Review of document titled Spartan Chemical Company, Inc. Material Safety Data Sheet revealed in part, "Product name ...NABC HARD SURFACE DISINFECTING WIPES ... Product Division: Janitorial ...Avoid frequent or prolonged skin contact. Wash thoroughly with soap and water after handling ....SPECIAL PROTECTIVE INFORMATION ...Rubber or other impervious gloves are recommended for frequent or prolonged contact."
.

Based on review of documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to maintain complete list of contracted services that described the nature and scope of the services provided. The CAH identified a list of 6 contracted services.

Lack of a complete list of contracted services including the delineation of the nature and scope of contracted services could potentially result in failure of compliance of the contracted services' responsibilities.

Findings include:

1. Review of the list of contracted services requested revealed current contracts/agreements for the MRI, PET/CT, Stereo-tactic Biopsy, Pathology, Radiology, Biomed.

2. Review of the list of contracted services revealed the list failed to include contracts/agreements for the Blood Banking Agreement, Teleradiology, Agreement for Dental Care, Emergency Water, and Emergency Fuel.

3. Review of the list of contracted services revealed the list lacked delineation of the nature and scope of services each contracted entity would provide.

4. During an interview on 6/25/18 at 11:55 AM, Staff N acknowledged the list of contracted services failed to include all services furnished under arrangements or agreements and lacked a description of the nature and scope of the services provided.

Based on observation, interview and document review the facility's administrative staff failed to ensure the Operating Room (OR) staff followed hospital procedure for medication administration.

Failure of operating room staff to clean the rubber septum on the top of the medication vials could potentially introduce foreign bacteria and germs into the blood stream of surgical patients; leading to infection.

Findings Include:

1. During an observation on 6/20/2018 at 8:00 AM during a surgical procedure on Patient 4, Certified Registered Nurse Anesthetist (CRNA) Staff F, uncapped Robinul(reduces saliva production and stomach acids), Lidocaine(numbing agent) Propafol(general anesthetic), Ephedrine(used to control blood pressures during surgery) and then at 8:46 AM another vial of Propafol. CRNA F removed the caps from the vials and immediately inserted needles to remove medications without wiping the septum of the vial first.

2. . During an interview on 6/26/2018 at 11:05 AM with CRNA F confirmed he did not wipe the tops of the vials of 5 medications during a procedure on Patient 4 on 6/20/2018.

3. During an interview on 6/20/2018 at 3:40 PM in the OR recovery area, Registered Nurse (RN) H revealed it was her understanding if a vial is new it does not have the need to be cleansed with alcohol. Her practice is to pop the top and remove the medicine from the vial.

4. During an interview on 6/25/2018 at 3:50 PM with OR Nurse Manager reported it is her expectation that her staff use an alcohol wipe on the top of all vials opened before withdrawal of medication.

5. Review of the facility's medication administration reference; Elsevier Medication Administration: Injection Preparation from Ampules and Vials Clinical Review: Donna Grochow, MSN, RNC-NIC, WCC, May 2017 revealed in part: "Preparing Medication from a Vial containing a Solution 1. Remove the cap covering the top of an unused vial to expose the rubber seal. 2. Firmly and briskly wipe the surface of the rubber seal with an alcohol swab, being sure to apply friction and allow it to dry. 3. Draw up the medication into the syringe ..."

I. Based on review of records, policy, and staff interviews the Critical Access Hospital's (CAH) Administrative staff failed to ensure each patient that received anesthesia services had a properly executed informed consent for 5 of 5 consents reviewed in surgery and obstetrics. (Patients # 25, 26, 27, 28, 29)

The Chief Nursing Officer (CNO) identified approximately 95 surgical cases a month. The CNO also identified 63 of the 106 patients delivered in 2017 received epidural anesthesia.

Failure to inform all patients who received anesthesia of the options and consequences needed in order to make an informed consent to a procedure or treatment could potentially result in the patient having received an unwanted procedure.

Findings include:

1. Review of records revealed:

a. 2 of 5 anesthesia consent forms were signed by the patient prior to the Certified Registered Nurse Anesthetist (CRNA) provider consulted with the patient. ( Patient #25, 26)

Patient # 25's anesthesia consent signed by patient #25 and witness on 6/17/2018 at 0140 AM. CRNA Provider P signed consent form at 6/17/2018 at 0230 AM. Provider P Anesthesia Record remarks reveal "6/17/2018 0230 Pt. assessment complete. Discussed risks/benefits with Pt. Obtained consent."

Patient #26 anesthesia consent signed by Patient #26 and the witness on 5/3/2018 at 9:00 AM. The consent lacked a signature of the Anestehsia Provider. Anesthesia Record remarks reveal CRNA Provider P documented on 5/4/2018 " 0854 Pt assessment complete. Discussed risks/benefits of procedure with pt. Consent obtained."

b. 5 of 5 anesthesia consent forms contained 2 blanks spaces where the patient's name and the name of the practioner performing the procedure was to be documented. (Patients #25, 26, 27, 28, 29)

c. 5 of 5 anesthesia consent forms lacked identification of the type of anesthesia to be performed. Consent for Anesthesia Services forms contain a statement in part: " I hereby consent to the anesthesia services checked above..." (Patients #25, 26, 27, 28, 29)

d. 2 of 5 anesthesia consent forms lacked a date and time that the patient and/or legal guardian signed the consent. (Patients # 28, 29)

2. Review of policy # 2359 titled "ADM - Informed Consent" effective 04/01/2018 revealed in part..." 1. Every patient has the right to informed consent. This means the patient has the right to receive a complete explanation of the proposed.....procedure....before deciding whether to concent to having the proposed .......procedure done." " All parts of the consent are completed and/or marked out. " "The responsibility of informed consent with the patient is the....anesthesia provider.... ensuring that all ...elements of the informed consent discussion are documented." "The Provider, the Patient and the Witness shall sign, date and time the consent."

3. During and interview on 6/27/2018 at 9:40 AM, CRNA Provider P revealed that when the Obstetrical staff have a patient who desires epidural (anesthetic medication injected into the epidural space around the spinal cord) anesthesia for pain control sign the Anesthesia Consent form when they are admitted to the hospital, prior to the CRNA having consulted with the patient. CRNA P verbalized she discussed the type of anestehsia to be performed and the risks and benefits of each and acknowledged that this was not docuented on the consent form. CRNA P verified Patient #25's consent form lacked required elements of documentation for an informed consent.

4. During an interview on 6/27/2018 at 9:55 AM, the Chief Nursing Officer (CNO) verbalized she was not aware anesthesia consent forms were being signed by obstetrical patients on admission and prior to having consulted with the CRNA.

5. During an interview on 6/27/2018 at 10:10 AM, staff B, Nurse Manager Med/Surg and Obstetrics, reported Anesthesia Consent forms are in OB Admission packets and that nurses must "get all the paperwork signed when they ( OB patient) come in." Staff B verified this is in violation of hospital policy and when signed in this manner it is not an informed consent.


II. . Based on document review the facility's administrative staff failed to ensure Cardiac Therapy and Pulmonary Therapy staff followed policy and confirmed completion of documentation in the Cardiac/ Pulmonary Rehabilitation records. Review of open patient records on 6/19/2018 in the Cardiac/ Pulmonary Rehabilitation Department revealed incomplete documentation in 4 of 6 record reviews.

Failure to ensure completion of documentation has resulted in the facility not being able to display dates of informed consent and orders being completed.

Findings Include:

1. Review of Cardiac Rehabilitation policy # 1987 titled CR-Policy Informed Consent, Date Effective 1/18/2018 revealed in part: "To establish guidelines that ensure the participant is thoroughly informed and educated regarding participation within the cardiac rehabilitation program and voluntarily agrees and/ or consents to participate ...The consent forma shall include ...Dated signature of the participant, professional staff member ... Both parties will sign and date the form in agreement, to what it states ..."

2. Review of Patient #5's medical record revealed no order for pulmonary therapy services in the chart. Pulmonary Rehabilitation has been provided to Patient #5 since 2/9/2018.

3. Review of Patient #8's medical record revealed no date in the patient rights portion. Patient #8 started pulmonary therapy on 4/11/2018.

4. Review of Patient #7's medical record revealed no date in the patient rights portion. Patient #7 started pulmonary therapy on 4/25/2018.

5. Review of Patient #6's medical record revealed no date on the order for cardiac therapy services in the chart. The patient consent and patient rights forms were not dated. Patient #6 started cardiac therapy on 6/12/2018.

6. During an interview on 7/9/2018 at 11:45 AM CNO revealed the facility uses the Cardiac Rehabilitation policy for both Cardiac and Pulmonary patients as they are completed in the same area by the same staff.

Based on observation, policy/procedure review, and staff interview, the Critical Access Hospital (CAH) staff failed to secure and protect patient information from unauthorized users in the Diabetic Education office ( 1 of 4 areas where paper patient medical records were stored).

Failure to secure patient medical records against unauthorized access could result in identity theft and/or unauthorized disclosure of personal medical information.

Findings include:

1. Observation during tour of the Diabetic Education office on 6/20/18 at 10:40 AM with Staff G, Director of Diabetic Education, revealed one unlocked drawer that contained 43 current patient medical records and approximately 60 old patient medical records.

2. During an interview, at the time of the observation, Staff G verified that housekeeping cleaned the Diabetes Education office after hours and when Diabetes Education staff were not present and the drawer that contained patient medical records was unlocked.

3. Review of CAH policies/procedures revealed the lack of a policy related to the security of paper patient medical records.

4. During an interview on 6/20/18 at 3:20 PM, the Supervisor of Medical Records confirmed the lack of a policy related to the security of paper patient medical records.

I. Based on observation, and interview the facility's administrative staff failed to institute a policy directing the safe storage of medical supplies in the Operating Rooms (OR).

Failure to ensure safe storage of supplies in the OR could result in the inability to clean the OR appropriately and could potentially lead to the misplacement and misuse of supplies.

Findings Include:

1. During an observation on 6/20/2018 at 10:15 AM in a procedure room in the OR, the Anesthesia Pyxis Machine (machine that holds medicine and supplies) in the OR had packaged syringes open to the air.

2.. During an interview on 6/20/2018 at 10:15 AM, Certified Registered Nurse Anesthetist (CRNA) F reported that the syringes in all of the operating rooms are left open on the Anesthesia Pyxis Machines at all times for the ease of access for the anesthesia staff.

3. During an interview on 6/21/2018 at 9:00 AM, Chief Nursing Officer (CNO), responsible for infection control, stated the expectation is that all syringes should be secured in closed drawers when procedures are over, however there is no policy in place to direct staff to do so. Adapted from Perry and Potter 2018 revealed in part; " ...Preparing Medication from a Vial Containing a Solution ...1. Remove the cap ...2. Firmly and briskly wipe the surface of the rubber seal with an alcohol swab, being sure to apply friction, and allow it to dry. 3. Draw up the medication into the syringe ..."

4. Review of procedures used by the hospital for medication administration titled Medication Administration: Injection from Ampules and Vials,



II. Based on an interview the facility's administrative staff failed to have policies in place to direct staff to the storage of patient care items such as syringes in the operating rooms, cleaning of the anesthesia cart.

1. During an interview on 6/26/2018 at 4:50 PM, CNO reported there was not a policy in place to direct staff to the storage of syringes in the OR suites or a policy for the anesthesia cart cleaning process.

III. Based on an interview the facility's administrative staff failed to have a policy in place to direct the pulmonary therapy staff to completion of patient medical records.

1. During an interview on 7/9/2018 at 11:45 AM, CNO reported there was not a policy in place for pulmonary therapy, only one for cardiac therapy to direct staff to completion of documentation.

I. Based on observation, review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to monitor hot water temperatures above 120 degrees to ensure patient safety from burns in the inpatient care area. Administrative staff identified a census of 4 patients at the beginning of the survey.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 1 second at 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees.

Findings include:

1. Observations during a tour of the nursing floor on 6/18/18 from 10:00 AM to 10:50 AM, accompanied by the Chief Executive Officer (CEO) and Staff R, Chief Nursing Officer (CNO), revealed the following hot water temperatures:

a. Room 204 - Intensive Care Unit (ICU): 129.0 degrees at 10:10 AM.
b. Room 207: 129.2 degrees at 10:15 AM.
c. Room 215: 127.4 degrees at 10:20 AM.
d. Room 228: 127.4 degrees at 10:25 AM.
e. Room 294 - Obstetrics: 131.0 degrees at 10:50 AM

The following hot water temperature was confirmed by the maintenance staff using their thermometer at 10:30 AM.

Room 204 - ICU: Surveyor thermometer 131.1 degrees, Maintenance staff thermometer 129.6 degrees.

2. Review of CAH policy titled "Domestic water heater maintenance (Hospital)", dated June 16, 2017, revealed in part "Policy:. . . It is important that domestic water temperatures be maintained to supply water to all areas between 110 and 120 degrees F. Temperatures above 120 degrees may cause severe burns. . . Procedure: Daily. Inspect water heater for proper operation and log water temperature this shall be no greater than 120 degrees Fahrenheit or 49 degrees Celsius. Water temperatures will be taken at 4 locations throughout the facility as listed below: A. Patient area. . . ."

3. Review of documentation revealed there was not a log or any documentation that the maintenance staff checked the hot water temperatures in the hospital patient rooms.

4. During an interview on 6/18/18 at 10:30 AM, Staff C, Maintenance Worker, and Staff D, Maintenance Supervisor verified the water temperature in the patient area was above 120 degrees and the goal for the hot water temperature was to be at 120 degrees. Staff C and Staff D stated the maintenance staff did not check the hot water temperatures in the hospital patient rooms.

During an interview on 6/18/18 at 10:30 AM, Staff D and Staff R, Chief Nursing Officer (CNO), stated they were not aware of a policy that addressed the hot water temperature in the patient area.

During an interview on 6/18/18 at 11:05, Staff D stated the hot water coming out of the hot water heater was set at 130 and it was turned down to 120 degrees.

During an interview on 6/21/18 at 2:30 PM, Staff D stated the maintenance staff have not monitored the hot water temperatures in the five years he had been employed at the hospital.


II. Based on review of review of the Quality Plan, Quality activities, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to evaluate all patient care services provided for Nuclear Medicine, Specialty Clinics, contracted services to include Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI), Stereotactic Biopsy, and Teleradiology. The CAH administrative staff reported a census of 4 patients at the beginning of the survey.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.
Findings include:

1. Review of the "2018 Quality, Risk Management and Patient Safety Operational Plan" revealed in part ". . .The goal of the quality program is to evaluate all patient care services and other services affecting patient health and safety. . . ."

2. Review of the Quality Assurance Committee Meeting minutes from June 12, 2017 through June 4, 2018 lacked documentation that showed CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Nuclear Medicine, Specialty Clinics, contracted services to include PET, MRI, Stereotactic Biopsy, and Teleradiology.

3. During an interview on 6/27/18 at 9:50 PM, Staff R, Chief Nursing Officer (CNO), acknowledged the lack of participation in the quality assurance process to include ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Nuclear Medicine, Specialty Clinics, contracted services to include PET, MRI, Stereotactic Biopsy, and Teleradiology.

4. During an interview on 6/19/18 at 9:15 AM, Staff FF, Director of Radiology, stated the mobile contracted services - PET, MRI, Stereotactic Biopsy - send quality information to the CAH and Staff FF maintains the information in the Radiology office and did not report the information to the CAH's quality committee.

5. During an interview on 6/20/18 at 11:05 AM, Staff GG, Nuclear Medicine Technologist, stated he did not report anything to the CAH's quality committee.

Based on review policies/procedures, medical staff credential files, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure all practitioners that provided care and services to the CAH patients had external peer review results available prior to reappointment to the medical staff for 7 of 10 applicable practitioners. (Practitioners W, X, Y, Z, AA, BB, CC)

CAH administrative staff verified the following physicians had provided services to patients of the CAH during the last credentialing period as follows:
Practitioner W, surgeon, provided care to 286 inpatients and 681 outpatients in the two years prior to reappointment.

Practitioner X, orthopedic surgeon, provided care to 187 inpatients and 189 outpatients in the two years prior to reappointment.

Practitioner Y, Obstetrician/Gynecologist, provided care to 141 inpatients and 81 outpatients in the two years prior to reappointment.

Practitioner Z, Emergency Medicine, provided care to 61 inpatients and 2060 outpatients in the two years prior to reappointment.

Practitioner AA, Gastroenterologist, provided care to 134 outpatients in the two years prior to reappointment.

Practitioner BB, Urologist, provided care to 330 outpatients in the two years prior to reappointment.

Practitioner CC, Cardiologist, provided care to 1213 outpatients in the two years prior to reappointment.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy titled "Credentialing Peer Review", dated June 15, 2018, revealed in part, ". . .Shenandoah Medical Center (SMC) shall work cooperatively with Alegent Health Critical Access Hospital Network to establish and provide a collaborative approach for SMC to objectively and systematically monitor and evaluate the appropriateness of diagnosis and treatment, quality of patient care, and clinical outcomes. The quality monitoring data shall be utilized as one of the aspects of the credentialing process for physicians and independent licensed practitioners. . . . Results of peer review will be considered at the end of each physician's probationary period and prior to reappointment to the Medical Staff. . . ."

Review of the CAH's network agreement, dated November 9, 2007, revealed in part, ". . .Peer review assistance will be provided through participation in the Alegent Health CAH Network Peer Review Program. . . ."

2. Review of medical staff credential files revealed the following physician files lacked external peer review results available prior to reappointment to the medical staff for the following:

a. Practitioner W was recommended for reappointment by the Medical Staff on 6/20/2018 pending peer review results. Practitioner W was approved for reappointment by the Board of Directors without comment and medical staff final recommendation on 6/25/2018.

b. Practitioner X was recommended for reappointment by the Medical Staff on 11/15/2017. Practitioner X was approved for reappointment by the Board of Directors on 11/27/2017.

c. Practitioner Y was recommended for reappointment by the Medical Staff on 7/19/2017. Practitioner Y was approved for reappointment by the Board of Directors on 7/24/2017.

Practitioner Z was recommended for reappointment by the Medical Staff on 4/18/2018. Practitioner Z was approved for reappointment by the Board of Directors on 4/23/2018.

Practitioner AA was recommended for reappointment by the Medical Staff on 8/16/2017. Practitioner AA was approved for reappointment by the Board of Directors on 8/28/2017.

Practitioner BB was recommended for reappointment by the Medical Staff on 1/17/2018. Practitioner BB was approved for reappointment by the Board of Directors on 1/22/2018.

Practitioner CC was recommended for reappointment by the Medical Staff on 8/16/2017. Practitioner CC was approved for reappointment by the Board of Directors on 8/28/2017.

3. During an interview on 6/26/18 at 1:15 PM, Staff N, Credentialing Coordinator, verified the lack of external peer review results available prior to reappointment to the medical staff for Practitioners W, X, Y, Z, AA, BB, CC.

During an interview on 6/27/18 at 8:15 AM, the Chief Executive Officer (CEO) and Staff N acknowledged the lack of external peer review results available prior to reappointment for all physicians.

Based on review of policies, 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 3 of 4 medical records (Patients # 1, #2, and #3).

The Chief Nursing Officer identified a census of one swing bed patient at the beginning of the suvey.

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 Policy # 1650 titled "Med/Surg - Rehab Services, SWB", dated 5/12/2014 states in part...."Rehabilitation Services are provided only upon the written order of the patient's attending physician."

Review of Policy # 2026 titled "Med/Surg - Acute to Skilled Transfer", dated 11/21/2017 states in part ......" The new chart shall contain....a set of skilled care orders from the physician."


2. Review of Patient #1's open medical record revealed Patient #1 was admitted for swing bed services on 6/14/2018 at 3:24 PM with diagnosis of decreased strength, endurance and mobility following a Coronary Artery Bypass Grafting (CABG) procedure, a type of surgery that improves the blood flow to the heart.

An electronic order entry dated 14-June-2018 at 4:21 PM revealed Practitioner Q, Advanced Registered Nurse Practitioner (ARNP) ordered Physical Therapy Evaluation & Treatment.

An electronic order entry dated 14 -June-2018 at 4:22 PM revealed Practitioner Q, ARNP ordered Occupational Therapy Evaluation & Treatment.

Review of Patient #2's closed medical record revealed Patient #2 was admitted for swing bed services on 2/21/2018 at 1:52 PM with a diagnosis of decreased strength following placement of a nerve stimulator at a tertiary medical center.

An electronic order entry placed 21-Feb-2018 at 3:01 PM revealed Practitioner Q, ARNP ordered Physical Therapy Evaluation & Treatment.

An electronic order entry placed 21-Feb-2018 at 3:01 PM revealed Practitioner Q, ARNP ordered Occupational Therapy Evaluation & Treatment.

Review of Patient # 3's closed medical record revealed Patient # 3 was admitted to swing bed services on 9/28/2017 at 3:51 PM for rehab services following spinal surgery for chronic osteomyelitis (infection of the bone) of the lumbar spine.

An electronic order entry placed 28-Sept-2017 4:10 PM revealed Practitioner T, ARNP ordered Physical Therapy Evaluation & Treatment.

An electronic order entry placed 30-Sept-2017 8:17 AM revealed Practitioner T, ARNP ordered Occupational Therapy Evaluation & Treatment.

3. During an interview on 6/19/2018 at 3:20 PM, Staff B Nurse Manager Med/Surg & OB, stated ARNP's order physical and occupational therapy for swing bed patients and was within the ARNP professional licensure to do this.

4. During an interview on 6/25/2018 at 12:15 PM, Practitioner T, ARNP, stated ARNP's manage skilled patients and ARNP's write orders for physical therapy and occupational therapy for skilled patients.

Based on policy and document review, and staff interviews, the Critical Access Hospital (CAH) failed to ensure all inpatients (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 patients directly admitted from the clinic, walk-in obstetric patients, or from the nursing home. The facility had 1 Patient's Rights policy. The facility identified a current census of 4 inpatients at the beginning of the survey.

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 CAH policy titled "Visitation Policy", dated 6/14/18, revealed in part, "To ensure that all visitors of patients of Shenandoah Medical Center (SMC) enjoy equal visitation privileges consistent with patient preferences to the facilities justified clinical restrictions. . . Prior to care being provided, the facility will inform each patient or surrogate decision maker, (or Support Person, where appropriate), of their rights and responsibilities related to visitation. . . Subject to his or her consent, the right to receive visitors her or he designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend and her or he right to withdraw or deny such consent at any time. . . ."

2. Review of admission packet revealed a 'Welcome Letter' that revealed in part, ". . . Visiting Hours. . . ."

The Welcome Letter included in admission packets provided to the patients at the time of admission failed to provide all patients with the current visitation rights.

3. Review of documentation provided by Staff R, Chief Nursing Officer (CNO), of patients directly admitted from the clinic, walk-in obstetric (OB) patients, and nursing home (NH) patients revealed the number and sample of admitted patients that failed to receive the current visitation rights as follows:

- January 2018 - 8 of 18 patients did not receive current visitation rights (Patients #10 - OB, 11 - Clinic, 12 - OB)
- February 2018 - 7 of 12 patients did not receive current visitation rights (Patients #13 - NH, 14 - Clinic, 15 - OB)
- March 2018 - 9 of 19 patients did not receive current visitation rights (Patients #16 - NH, 17 - OB, 18 - Clinic)
- April 2018 - 7 of 18 patients did not receive current visitation rights (Patients #19 - OB, 20 - OB, 21 - OB)
- May 2018 - 11 of 25 patients did not receive current visitation rights (Patients #9 - Clinic, 22 - OB, 23 - Clinic, 24 - OB).

4. During an interview on 6/19/18 at 4:20 PM, Staff R, Chief Nursing Officer (CNO), and Staff B, Nurse Manager Medical/Surgical and Obstetrics, stated the Welcome Letter was in the admission packet and was provided to inpatients at the time of admissions. Staff R and Staff B verified the welcome letter failed to include the current visitation rights.

Staff R, CNO, verified that direct admit patients from the clinic, walk-in obstetrics patients, and patients admitted from a nursing home did not receive the current visitation rights.