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Based on observation, document review, and staff interview, the acute care hospital failed to ensure staff at 1 of 1 provider based clinics (Avera Medical Group Spencer) informed patients of their patient rights, responsibilities, and visitation rights, at the time of the patient's registration. Failure to ensure staff at 1 of 1 provider based clinics informed patients of their patient rights, responsibilities, and visitation rights, could potentially result in patient's inability to exercise their rights and responsibility to assist in the provision of the highest possible quality of care. The hospital administrative staff identified the clinic served approximately 200 patients per day.

Findings include:

1. Observation on 3/26/19 at 3:30 PM AM, during a tour of the Avera Medical Group Spencer Clinic, showed the patient registration area lacked documented evidence of the hospital's Patient Rights and Responsibilities information provided to patients who received care and services at the clinic. Further observation showed the patient admission waiting area lacked postings of the Patient Rights and Responsibilities for patients to review.

2. During an interview at the time of the observation, Patient Services Representative D acknowledged she was unaware she needed to inform patients of their patient rights and responsibility prior to the patient receiving services at the clinic. Patient Services Representative D confirmed the clinic lacked written documents regarding patient rights and responsibilities to provide to the patients for review and/or postings of patient rights and responsibilities at the clinic.

The Clinic Manager acknowledged the clinic lacked written documents regarding patient rights and responsibilities to provide to patients and/or posting of patient rights and responsibilities to review prior to the patient receiving services at the clinic.

3. During an interview on 3/27/2019 at approximately 9:00 AM, the Vice President of Patient Care Services acknowledged the clinic lacked Patient Rights and Responsibilities postings and materials for patients to review prior to receiving services at the Avera Medical Group Spencer Clinic. Additionally the the Vice President of Patient Care Services acknowledged the clinic staff failed to follow hospital policy to educate and inform patients of their patient rights and responsibilities at the time of admission for services at the therapy clinic.

Based on policy and procedure review, patient medical record review, and staff interview, the Hospital administrative staff failed to ensure Behavioral Health Unit (BHU) nursing staff updated the patient care plan in 1 of 2 BHU medical records where the patient was placed in restraint and seclusion to control violent or self destructive behavior (Patient #8). The BHU administrative staff reported a census of 6 patients at the beginning of the survey. Failure to update a patient's care plan after the use of seclusion and/or restraints could potentially fail to provide the patient's caretakers with information on methods or techniques to assist the patient and potentially avoid the use of seclusion or restraints.

Findings include:

1. Review of the undated policy and procedure, "Restraint or Seclusion Policy," revealed in part, "...Complete documentation [in the] Plan of Care...."

2. Review of Patient #8's medical record revealed the hospital staff placed Patient #8 in restraint and seclusion on 3/8/19 at 9:14 AM to control Patient #8's violent behavior. Patient #8's medical record lacked evidence the BHU nursing staff modified or updated Patient #8's plan of care after they used restraints and seclusion to control Patient #8's violent or self-destructive behavior.

3. During interview on 3/28/19 at 10:15 AM, the Director of Behavioral Health Services acknowledged the medical record for Patient #8 lacked evidence the nursing staff modified or updated the patient's plan of care after the staff used seclusion and restraint to control the patient's violent behavior. The Director of Behavioral Health Services acknowledged that nursing staff failed to follow established hospital policies and procedures.

Based on document review and staff interview, the hospital's administrative staff failed to develop and implement a written policy or procedure regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights, and the reasons for the clinical restriction or limitation. Failure to develop and implement a written policy could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The hospital administrative staff identified a census of 32 patients on entrance.

Findings include:

1. Review of the hospital's policy index on 3/27/19 at approximately 4:45 PM revealed the hospital lacked a policy related to patient visitation rights.

2. During an interview on 3/28/19 at 9:30 AM, the Behavioral Health Director acknowledged the hospital failed to develop and implement a Patient Right's policy that addressed patient visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients.

Based on document review and staff interview, the hospital's administrative staff failed to update the visitation rights information to ensure staff informed all patients (or support persons where appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities. The acute care hospital's administrative staff identified a census of 32 patients on entrance.

Findings include:

1. Review of hospital's patient right's information revealed the hospital staff failed to include langugae that informed patients (or support person where appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients.

2. During an interview on 3/28/19 at 9:30 AM, the Behavioral Health Director acknowledged the hospital's patient right's brochures lacked the required language regarding visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients.

Based on observation, policy and procedure review, and staff interviews, the Hospital staff failed to secure and protect patient information from unauthorized users in 2 of 3 storage areas for paper medical records (Therapies and the Avera Medical Group Spencer). Therapy staff identified approximately 64 outpatient visits per day by physical therapy staff, 25 outpatient visits per day by occupational therapy staff, and 8 outpatient visits per day by speech therapy staff. The hospital administrative staff identified the clinic served approximately 200 patients per day. 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. Observations during tour of the Therapy area on 3/25/19 at 2:45 PM with the Director of Rehabilitation Services revealed the following:

a. Physical Therapy Office - 1 three drawer locked file cabinet that contained approximately 75 current patient paper medical records and approximately 26 discharged patient paper medical records. The key to the locked file cabinet was visible on the outside of an adjacent cabinet. The patient paper medical records contained patient personal and medical information.

b. Occupational Therapy Office - 1 two drawer file cabinet that contained approximately 50 current patient paper medical records. The key to the locked file cabinet was visible on top of an open square tubing behind the file cabinet. The patient paper medical records contained patient personal and medical information.

c. Speech Therapy Office - 1 two drawer file cabinet that contained approximately 50 current patient paper medical records. The key to the locked file cabinet was visible in an unsecured drawer. The patient paper medical records contained patient personal and medical information.

2. During an interview, at the time of the observation, the Director of Rehabilitation Services verified that housekeeping cleaned the therapy offices after hours, when therapy staff were not present. The Director of Rehabilitation Services acknowledged the locked drawers contained patient medical records, but anyone present in the therapy offices could see the keys.

3. Review of the undated policy, "Protection and Availability of Medical Records Policy," revealed in part, "...Access to medical records is restricted to authorized personnel and medical staff...."


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4. Observations on 3/26/19 at 3:30 PM, during a tour of the Avera Medical Group - Spencer medical records office revealed the area stored old paper patient medical records, generated from 2008 to 2011. The medical records office contained approximately 29,000 total clinic patient records.

5. During an interview at the time of the observation, the Clinic Manager verified that housekeeping staff cleaned the Avera Medical Group medical records office after hours, which resulted in the medical records staff's inability to supervise the housekeeping staff. and when the medical records staff were not present.

6. During an interview on 3/2719 at 9:00 AM, the Clinic Manager confirmed the Avera Medical Group-Spencer followed the medical record policies of Spencer Hospital .

I. Based on observation, document review, and staff interviews, the Hospital therapy staff lacked a system to ensure the staff checked the water temperature and ensured the temperature was in an acceptable range for 1 of 2 hydrocollators in the therapy area. The therapy administrative staff could not identify how many times therapy staff used a hot pack from the hydrocollator located in the occupational therapy care area. Therapy staff identified approximately 25 outpatient visits per day by occupational therapy staff. A Hydrocollator is a stainless-steel thermostatically controlled liquid heating device designed to heat silicone packs in water. The staff remove the packs from the water, wrap the pack in several layers of towels, and apply the packs to the patient's affected area to relieve acute pain. Failure to monitor water temperature in the hydrocollator could potentially cause serious burns to patients during hot pack therapy.

Findings include:

1. Observation during tour of the therapy area on 3/25/19 at 2:45 PM with the Director of Rehabilitation Services, revealed 2 Hydrocollator units (a liquid heating device used in physical therapy to heat and store hot packs for therapeutic use of moist hot packs on patients) that contained approximately 2 small and 4 large hot packs immersed in hot water.

2. Review of the undated Therapy policy, "Thermal Modalities - Cold Packs and Moist Heat Packs," revealed in part, "...Water temperature on hydrocollator master heating units should not exceed 165 degrees F. Temperatures greater that this should be reported to the department director...."

3. Review of document, "Cleaning Chart for Equipment," revealed the water temperature in the occupational therapy hydrocollator registered 180 degrees F from 1/2/2019 to 3/25/2019.

4. During an interview on 3/25/19 at 3:50 PM, Therapy Office Staff E confirmed the staff checked the hydrocollator temperature daily and record the temperature on the computer. Therapy Office Staff E verified the temperature of the water in the Occupational Therapy hydrocollator exceeded the acceptable range in accordance with the facility policy and the staff failed to report the hydrocollator temperature as being outside the acceptable range.


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II. Based on observations, documentation, and staff interviews, the acute care hospital staff failed to document the date staff opened 2 of 2 bottles of Accu-Check testing controls, in accordance with the manufacturer's requirements. The 2 undated bottles of Accu-Chek testing controls were used to test 4 Accu-Chek Performa Blood Glucose monitors located in each of the 4 Spencer Hospital ambulances. Failure to document the date the staff opened the high and low glucometer controls could potentially allow the staff to use the high and low glucometer controls after the manufacturer's shortened expiration date, potentially resulting in inaccurate test results, which could lead to patients receiving inappropriate treatment. The facility staff could not identify the number of glucometer checks performed in its ambulances and identified approximately 1400 EMS calls per year.

Findings include:

1. Observation on 3/25/19 at 2:30 PM, during tour of the Ambulance area, with the Director of the Emergency Department and Ambulance and Paramedic C, revealed 1 opened bottle of high glucometer control solution and 1 opened bottle of low glucometer control solution available for use. The high and low bottles of control solutions lacked documented evidence of the date the staff first opened the bottles.

2. Review of the manufacturer's instructions for the Accu-Chek Performa high and low controls revealed in part, "Write the date the bottle was opened on the bottle label ... control solution is stable for 3 months that date..."

3. Review of the policy, "SPENCER HOSPITAL ACCU-CHEK PERFORMA POLICY," provided by the Director of the Emergency Department and Ambulance on 3/26/19, revealed in part, "If opening a new glucose control, hand-write the current date..."

4. During an interview at the time of the tour of the Ambulance area, Paramedic C acknowledged the Glucometer high control solution and low control solution bottles lacked the date the staff opened the bottles, and failed to reflect the shortened expiration date, as required by the manufacturer. Paramedic C identified the EMS staff used the 2 control bottles to test each of the 4 Accu-Check Performa Glucose Meters in the ambulances.

5. During an interview at the time of the tour of the Ambulance area, the Director of the Emergency Department and Ambulance acknowledged the Glucometer high control solution and low control solution bottles lacked the date the staff opened the bottles, and failed to reflect the shortened expiration date, as required by the manufacturer.




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III. Based on observation and staff interviews, Acute Care Hospital administrative staff failed to ensure staff removed outdated supplies from the inpatient units. Failure to remove outdated patient supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, the date after which the the manufacturer no longer guarantees the product is sterile and safe for patient use. The acute care hospital's administrative staff identified a census of 32 patients on entrance.

Findings include:

1. Observations on 3/25/19 at 1:45 PM, during a tour of the Inpatient Units, revealed the following expired supplies:

a. 2 West, Room 2505, 1 of 1 respiratory bottle of water (used to humidify oxygen delivered to patients) expired 11/8/18

b. 2 West, Room 2503, 1 of 1 sterile bacteriostatic surgical lubricant, 5 grams, expired 1/2019

c. 2 West, Supply Room, 1 of 1 Hydrogen Peroxide, expired 8/2019 (undated open bottle); 1 of 3 Medchoice
Lubricating Jelly, expired 12/25/18; 1 of 2 anaerobic specimen collection vacutainers, expired 12/2018; and 2 of 2 4.0 milliliter green top lab tube, both expired 1/31/19

d. 3 West, Nourishment Room, 4 of 4 infant nipples and rings, all expired 2/1/19

e. 3 West, Supply Room, 4 of 5 Gastroccult gastric test for occult (not visibly apparent) blood and pH, all expired 3/8/18

f. 3 West, Emergency Cart, 2 of 3 Nasopharyngeal airways, 8.5 millimeters, expired 6/2018 and 9/2018; 1 of 1 Yankauer suction catheter, expired 10/2018; 1 of 2 Medchoice Lubricating Jelly, expired 10/5/18; and 3 of 3 BD 1 milliliter syringes, all expired 8/2018

2. During an interview at the time of the tour, Director, Medical/Surgical and Skilled, acknowledged nursing staff failed to remove the expired supplies from the inpatient areas.

3. Observations on 3/25/19 at approximately 3:45 PM, during a tour of the Intensive Care Unit (ICU), revealed the following expired supplies:

a. Emergency Cart, 1 of 1 Pediatric Electrode set, expired 3/17/19

b. Med Room, 1 of 1 Adult Lumbar Puncture Kit, 22 gauge, expired 3/3/19

4. During an interview at the time of the tour, Director, ICU, acknowledged the nursing staff failed to remove the expired supplies from the ICU inpatient area.

I. Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure 13 out of 24 observed surgeons, anesthesia providers, and other OR staff, wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 5,200 surgical procedures per year.

Findings include:

1. During an interview on 3/27/19 at approximately 10:50 AM, the OR Director revealed the hospital followed the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines for surgical attire.

2. Review of the AORN Guideline for Surgical Attire, copyright 2018, revealed in part, "A clean surgical head covering or hood that confines all hair and completely covers the ears, scalp skin, sideburns and nape of the neck should be worn." "Hair and skin can harbor bacteria that can be dispersed into the environment. The collective body of evidence supports covering the hair and ears while in the [operating rooms.]"

3. Review of the hospital's Perioperative Services Infection Control Policy, undated, revealed in part: "All hair must be covered while in the semi-restricted and restricted areas of perioperative services."

4. Observations on 3/37/19 at approximately 8:00 AM, during a tour of the operating rooms, revealed the following:

a. Observations from outside Operating Room #1 revealed 7 staff engaged in an orthopedic surgery. Five of the seven staff (including the Surgeon, Physician Assistant (PA), Certified Registered Nurse Anesthetist (CRNA) student, Surgical Technician, and an Orthopedic Device Representative) wore a skull cap. The skull cap consisted of a cap covering the Surgeon's forehead and central part of Surgeon's hair. The skull cap did not cover the lower approximately one inch of Surgeon's hair on the side of Surgeon's head and the back of Surgeon's hair.
The skull cap consisted of a cap covering PA's forehead and central part of PA's hair. The skull cap did not cover the lower approximately one inch of PA's hair on the side of PA's head and the back of PA's hair. The skull cap consisted of a cap covering CRNA student's forehead and central part of CRNA student's hair. The skull cap did not cover the lower approximately one inch of CRNA student's hair on the side of CRNA student's head and the back of CRNA student's hair. The skull cap consisted of a cap covering Surgical Tech's forehead and central part of Surgical Technician's hair. The skull cap did not cover the lower approximately one inch of Surgical Technician's hair on the side of Surgical Technician's head and the back of Surgical Technician's hair. The skull cap consisted of a cap covering Orthopedic Device Representative's forehead and central part of Orthopedic Device Representative's hair. The skull cap did not cover the lower approximately one inch of Orthopedic Device Representative's hair on the side of head and the back of Orthopedic Device Representative's hair.

b. Observations from outside Operating Room #2 revealed 6 staff engaged in orthopedic surgery. Three of the 6 staff (including the Surgeon and 2 Orthopedic Device representatives) wore a skull cap. The skull cap consisted of a cap covering the Surgeon's forehead and central part of Surgeon's hair. The skull cap did not cover the lower approximately one inch of Surgeon's hair on the side of Surgeon's head and the back of Surgeon's hair. The skull cap consisted of a cap covering both Orthopedic Device Representative's foreheads and central part of both Orthopedic Device Representative's hair. The skull cap did not cover the lower approximately one inch of both Orthopedic Device Representative's hair on the side of head and the back of both Orthopedic Device Representative's hair.

c. Observations from outside Operating Room #4 revealed 5 staff engaged in surgery. Three of the 5 staff (including the Surgeon, CRNA, and a Surgical Tech) wore a skull cap. The skull cap consisted of a cap covering the Surgeon's forehead and central part of Surgeon's hair. The skull cap did not cover the lower approximately one inch of Surgeon's hair on the side of Surgeon's head and the back of Surgeon's hair. The skull cap consisted of a cap covering CRNA's forehead and central part of CRNA's hair. The skull cap did not cover the lower approximately one inch of CRNA's hair on the side of CRNA's head and the back of CRNA's hair. The skull cap consisted of a cap covering Surgical Tech's forehead and central part of Surgical Technician's hair. The skull cap did not cover the lower approximately one inch of Surgical Technician's hair on the side of Surgical Technician's head and the back of Surgical Technician's hair.

5. During an interview on 3/37/19 at the time of the tour, OR Director acknowledged the surgeons, anesthesiologists, and other staff in the ORs wear skull caps that do not completely cover their hair.

6. Observations in OR #3 at approximately 8:25 AM, revealed Patient #7 underwent a laparoscopic cholecystectomy (removal of the gallbladder with a small tube). Six staff participated in the surgical procedure. Two of the 6 staff wore skull caps (including the Surgeon and the Medical Student). The Surgeon wore a skull cap. The skull cap consisted of a cap covering the Surgeon's forehead and central part of Surgeon's hair. The skull cap did not cover the lower approximately one inch of Surgeon's hair on the side of Surgeon's head and the back of Surgeon's hair. The Medical Student wore a skull cap. The skull cap consisted of a cap covering the Medical Student's forehead and central part of the Medical Student's hair. The skull cap did not cover the lower approximately one inch of the Medical Student's hair on the side of the Medical Student's head and the back of the Medical Student's hair.


II. Based on observation, document review, and staff interview, the hospital's administrative staff failed to ensure 1 out 1 observed CRNA students and 1 of 1 observed Surgical Technicians wore head coverings that fully covered their earrings. Failure to wear head coverings that fully cover earrings could potentially result in bacteria, fungi, or viruses on the surgical staff members' jewelry entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 5,200 surgical procedures per year.

Findings include:

1. During an interview on 3/27/19 at approximately 10:50 AM, the OR Director revealed the hospital followed the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines for surgical attire.

2. Review of the AORN Guideline for Surgical Attire, copyright 2018, revealed in part, "Jewelry (eg, earrings, necklaces, bracelets, rings) that cannot be contained or confined within the scrub attire should not be worn in the semi-restricted or restricted areas."

3. Review of the hospital's Perioperative Services Infection Control Policy, undated, revealed the hospital lacked a requirement for the surgical staff in the operating rooms to contain jewelry within the scrub attire.

4. Observations in OR #3 at approximately 8:25 AM, revealed Patient #7 underwent a laparoscopic cholecystectomy (removal of the gallbladder with a small tube). CRNA student wore a cap that did not cover CRNA student's ears and earrings. The CRNA student had 2 exposed stud earrings in the CRNA student's left earlobe, and 2 stud earrings in the right ear lobe. The Surgical Technician wore a cap that did not cover the Surgical Technician's ears and earrings. Surgical Technician had 2 exposed stud earrings in Surgical Technician's left earlobe, and 2 stud earrings in the right ear lobe.

5. During an interview on 3/27/19 at approximately 10:50 AM, the OR Director acknowledged the staff in the OR sometimes wear earrings that are exposed outside their scrub attire.

Based on document review and staff interview, the hospital's surgical staff failed to ensure a physician updated the history and physical for surgical patients prior to surgery in accordance with the hospital's policy for 1 of 3 surgical patient medical records reviewed (Patient #9). The surgical staff identified approximately 430 surgical cases per month. Failure of the physician to update the history and physical prior to surgery could potentially result in unrecognized changes in the patient's condition that would affect the patient's treatment and could increase the risk of patient harm or death.

Findings include:

1. Review of policy "History and Physicals on the Surgical Patient," dated 4/24/2018, revealed in part, "...When an H&P [History and Physical] is completed within 30 days before admission or registration, there shall be an updated medical record entry documenting an examination for any changes in the patient's condition within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services...."

2. Review of Patient #9's medical record revealed the following:
a. An H&P dated 12/19/18
b. Had a left total knee replacement on 1/7/2019
c. An uncompleted History and Physical Update form signed by Physician F.

The History and Physical Update form lacked documentation the History and Physical was reviewed, the patient was examined and if any changes had occurred since the History and Physical was completed with a date or time.

3. During an interview on 3/28/19 at 11:00 AM, at the time of closed patient medical record review, the Registered Nurse Clinical Analyst verified the History and Physical Update form lacked documentation the surgeon reviewed the History and Physical, the surgeon examined the patient, the surgeon documented if the patient had any changes which occurred since the patient had the History and Physical created, along with the date and time the surgeon updated the History and Physical.

Based on review of swing bed patient rights and staff interviews, the Acute Care Hospital staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights to include the right to:

a. share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,

b. inform each Medicaid-eligible resident, in writing, at the time of admission to the facility and when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged, those items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services, and inform each Medicaid-eligible resident when changes are made to the items and services.

The CAH administrative staff identified a census of 4 swing bed patients at the beginning of the survey and admitted 46 swing bed patients in 2018. 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, potentially resulting in the patients failing to exercise their rights if they so desired.

Findings include:

1. Review of the "Skilled Nursing Care Admission Agreement," revised 7/2018, revealed it lacked the following swing bed patient rights:

a. to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,

b. inform each Medicaid-eligible resident, in writing, at the time of admission to the facility and when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged, those items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services, and inform each Medicaid-eligible resident when changes are made to the items and services.

2. During an interview on 3/27/2019 at approximately 4:00 PM, the Director of Med/Surg Nursing confirmed the hospital staff failed to inform the swing bed patients of the above listed swing bed patient's rights.

Based on document review and staff interview, the acute care hospital failed to maintain a dental services contract for skilled patients in swing beds. The administrative staff identified a census of 4 skilled patients at the time of the entrance. Failure to ensure the hospital offered dental services to swing bed patients could potentially result in the swing bed patients needing dental services and the hospital staff failing to ensure the patients received dental care.

Findings include:

1. During an interview on 3/27/19, 10:05 AM, the Director of Med/Surg reported skilled patients in swing beds could receive dental services from either their personal dentist or another local dentist. The Director of Med/Surg lacked knowledge of a written agreement or contract with a dentist to provide dental services to swing bed patients.

2. Review of a list of Contracted Services provided by hospital administrative staff revealed the list lacked a contract with a dentist for dental services.

3. Review of the "DENTAL SERVICES POLICY FOR SWING BED," provided on 3/27/19 by the Director of Med/Surg, revealed in part, "Whenever possible, the patients own dentist... arrangements made for care to be received by him/her,...if not possible with own dentist...contact another local dentist to provide the care.." The policy lacks identification of a dentist for the provision of routine or emergency dental services to the hospital's swing bed patients, if the patient lacked a local dentist.

3. During an interview on 3/27/19 at 3:00 PM, the Vice President of Patient Care Services, acknowledged the hospital lacked a written agreement or contract with a dentist to provide routine and emergency dental services for its swing bed patients, or a dentist on the hospital's medical staff which could provide dental services to the hospital's swing bed patients.