HospitalInspections.org

Based on record review and interview the facility failed to provide a contract for radiology telemedicine services. Failure to provide a contract for radiology services may lead to disruption in the facility's ability to provide continuous radiology services and put all patients at risk for not receiving consistent care.

Findings include:

- Contract review on 1/19/17 at 10:00 AM revealed the facility failed to have a current contract or agreement for telemedicine radiology services provided by Telerad, Inc.

Interview with Director of Quality and Radiology Staff DD acknowledged "the radiologists are employed by Telerad but are credentialed through our facility and are on site 2-3 days per week and also provide 24/7 coverage."

Interview with CEO Staff BB confirmed the facility has no contract for the radiology services and stated " I checked with them and they have no contracts with any of the facilities they provide services to. "

Based on observations, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the Emergency Department and Medical Surgery Department maintained proper checks on equipment for two of three Emergency Crash Carts (Emergency Department and Medical Surgery). This deficient practice had the potential to place all patients at risk for inadequate care and possible harm.

Findings Include:

- Emergency Department Crash Cart observed on 1/17/2017 at 12:35 PM revealed the staff failed to check the Defibrillation/Crash Cart for 5 shifts for the month of January; January 10th at 7am and 7pm, January 11th at 7pm and January 16th at 7am and 7pm.

- Medical Surgical Department Crash Cart observed on 1/17/2017 at 12:20 PM revealed the staff failed to check the Defibrillation/Crash Cart for 3 shifts for the month of January; January 5th at 7pm and January16th at 7am and 7pm.

Manager of Emergency Department and Medical Surgical Department Staff D interviewed on 1/17/2017 at 12:40 PM acknowledged the Defibrillation/Crash Cart log book was not filled out properly per policy. Staff D stated the Charge Nurse of each shift is responsible to check the Emergency Crash Carts.

- Policy titled "Stocking the Crash Carts" reviewed on 1/17/2017 directed staff to "...Crash carts and defibrillators will be checked every shift... "

Based on observations, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure all supplies are maintained to safely meet patients' needs for the day-to-day operations for one of one Emergency Department (ED) room, one of two Labor and Delivery rooms, two of two Emergency Department Crash carts, one of one Medical Surgical Emergency Crash cart, one of one central supply room, one of one nursing station pharmacy room, one of one OR clean supply room and one of one Operating Room. This deficient practice or the failure of the facility to dispose of expired supplies placed all patients at risk for receiving ineffective supplies.

Findings include:

- Emergency Department Room observed on 1/17/2017 at 3:10 PM revealed the following outdated supplies:
1) Two silk braided sutures (stitches holding together the edges of a wound or surgical incision) in chest tube kit (to drain fluid, blood or air from around the lungs, heart or esophagus) with expiration date of 1/2016.
2) Two Cholora prep kits (disinfect skin) in chest tube kit with expiration date of 1/2016.
3) Two Povidone Iodine (to treat and prevent infection) cleansing scrub swab stick in chest tube kit with expiration date of 9/2015.
4) Two Vaseline Petroleum jelly in chest tube kit with expiration dates of 3/2016 and 4/2016.
5) 23 Fluorets Sodium ophthalmic strips (Staining the anterior of the eye during eye examination) in locked cabinet with expiration date of 4/2010.

Emergency Department Manager Staff D interviewed on 1/17/2017 at 4:00 PM acknowledged the supplies were expired and should have been disposed.

- Labor and Delivery room one observed on 1/17/2017 at 11:50 AM revealed the following outdated supplies:
1) Three Safety Glide needle 23gauge x 1 inch with expiration dates of 3/2015 and 9/2015.
2) One open box large neoprene medical examination gloves with expiration date of 11/2016.

Emergency Department Manager Staff D interviewed on 1/17/2017 at 11:50 AM acknowledged the supplies were expired and should have been disposed.


- ED Broselow Crash Cart (color-coded tape measure of a child's height as measured by the tape to their weight to provide medical instructions including medication dosages, size of equipment and level of shock voltage when using a defibrillator-to treat threatening cardiac dysrhythmias to the heart) observed on 1/17/2017 at 12:40 PM revealed the following outdated supplies:
1) One Intubating stylet (help reduce friction between stylet and endotracheal tube for easy endotracheal tube insertion and removal) with expiration date of 10/2016.
2) One Cuffed Tracheal tube (an airway catheter used to provide an airway through the trachea and at the same time to prevent aspiration of foreign material into the bronchus-airway conducts air into the lungs) 6.5mm with expiration date of 10/2016.
3) Two Cuffed Tracheal tube 5.5mm with expiration date of 10/2016.
4) One Cuffed Tracheal tube 6.0mm with expiration date of 10/2016.


- Emergency Department Crash cart observed on 1/17/2017 at 12:50 PM revealed the following outdated supplies:
1) One Pediatric Colorimetric CO2 Detector (to verify proper endotracheal tube placement) with expiration date of 12/2016.
2) Two EZ stabilizer dressing (a complete solution for immediate vascular access for life-threatening emergencies) with expiration date of 7/2016 and 11/2016.
3) One Pediatric ECG electrodes Radiotrasparent packet (one piece disposable heart monitoring system that minimizes patient set up time and reduce of cross contamination) with expiration date of 10/25/2016.
4) One Sterile Blunt Fill filter needle (curved needle with the eye at the point) 18 gauge x 1 ½ inch in Intubation red box with expiration of 4/2016.
5) One Lubricating Jelly packet in Intubation red box with expiration date of 4/2016.

Emergency Department Manager Staff D interviewed on 1/17/2017 at 1:00 PM acknowledged the supplies were expired and should have been disposed.

- Medical Surgical Emergency Crash cart observed on 1/17/2017 at 12:20 PM revealed the following outdated supplies:
1) One Povidone Iodine swab stick with expiration date of 11/2015.
2) Two 3gram Lubricating jelly packets with expiration date of 6/2016.
3) One sterile Blunt Fill needle 18 gauge x 1 ½ inch needle with expiration date of 3/2016.
4) One Sterile Blunt Fill needle 18 gauge x 1 ½ inch needle in chest pain container with expiration date of 10/2015.
5) One Quick Combo Pediatric ECG electrodes Radiotransparent packet with expiration date of 10/25/2016.
6) Three Red Dot Monitoring electrode packets with expiration date of 2015.

Emergency Department Manager Staff D interviewed on 1/17/2017 at 12:35 PM acknowledged the supplies were expired and should have been disposed. Staff D indicated Staff E is responsible for the outdated supplies and to monitor the supplies monthly.

Ward Secretary Staff E interviewed on 1/17/2017 at 12:35 indicated they do watch out for the expired supplies. Staff acknowledged the supplies were expired and should have been disposed.


Observation on 1/17/17 Central Supply revealed the following expired supplies:
- Un-cuffed tracheal tube size 2.5mm/3.6mm (a tube used in non-ventilated patients that have no difficulty swallowing and have no danger of aspiration (a condition in which food liquids, saliva, or vomit is breathed into the airways), 1 expired 9/16.
- Cuffed tracheal tubes size 3.0mm/4.2mm, 4 expired 11/16.
- Cuffed tracheal tubes size 3.0mm/4.2mm, 3 expired 12/16.
- Salem Sump size 10 F (a tube useful for irrigating the stomach but is most often used for drawing out fluid and gas from the stomach), 2 expired 6/16.

Interview on 1/17/17 at 1:35 PM, Staff A verified the expired supplies in the Central Supply Room and discarded them immediately. The Central Supply has a good supply of these items with a long expiration date.


Observation on 1/17/17 pharmacy room by the nursing station revealed 3 swab sample packets that expired on 10/16.

Interview on 1/17/17 at 2:50 PM, Staff C verified the expired supplies and discarded them immediately and will replace them.


- Operating Room clean instrument supply room observed on 1/18/2017 at 1:25 PM revealed the following outdated supplies:
1) One Articulating Endoscopic Linear cutter reloads (design to clamp, staple, cut and release all with one hand to help enable a more precise approach) with expiration date of 5/2016.
2) One curved cutter stapler reload with expiration date of 8/2015.
3) Three 14 French 5cc balloon Foley catheter (to drain urine in bladder) with expiration dates of 12/2014, 10/2015 and 1/2016.
4) Four Stryker (product used for hip replacement) with expiration date of 11/2016.

- Operating Room observed on 1/18/2017 at 12:30 PM revealed white latex powdered surgical glove box opened on rack with expiration date of 9/2015.

Director of Surgery Staff I interviewed on 1/18/2017 at 1:25 PM acknowledged the supplies were expired and should have been disposed. Staff W stated they check the supplies every three months for outdates and it's everyone's responsibility.

- Policy review on 1/17/2017 revealed the Critical Access Hospital failed to provide a policy directing staff to monitor and to dispose expired supplies.

Based on observation, documentation review and staff interview Holton Community Hospital failed to maintain an infection control program that minimizes the risk of transmitting infections and communicable diseases by failing to : ensure outdated, unusable medications were removed and made unavailable for patient use (Refer to Tag CO276); ensure staff wore proper surgical attire (Refer to Tag CO278); ensure staff perform appropriate hand hygiene (Refer to Tag CO278); ensure staff documented Sterilized loads (Refer to Tag CO278); ensure staff performed Steam Plus Class 5 Integrator (indicator tablet placed in load (supplies) to ensure sterilization is done properly in autoclave-sterilizer) (Refer to Tag CO278); ensure Emergency Department Crash cart contained sterile items (Refer to CO278); ensure Medical Surgical Emergency Crash cart contained sterile items (Refer to CO278); ensure that there was separation between the clean and dirty sides in the Instrument cleaning room (Refer to Tag CO278); ensure staff separate patient food products from staff food (Refer to CO278); ensure staff cover clean linen when transporting (Refer to Tag CO278); ensure staff wore appropriate surgical attire in all semi restricted surgical areas (Refer to Tag CO278); ensure staff used the appropriate amount of detergent for cleaning endoscopes (Refer to Tag CO278).


The cumulative effect of these deficient practices placed all patients at risk for infection, contraction of communicable diseases and placed all patients at risk for receiving ineffective medications.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure outdated, unusable medications were removed and made unavailable for patient use in one of two Emergency (ED) Department Crash Carts and one of one Medical Surgical Emergency Crash Cart. This deficient practice to ensure that outdated medications are removed placed all patients at risk for receiving ineffective medications.

Findings Included:

- Emergency Department Broselow (color-coded tape measure of a child's height as measured by the tape to their weight to provide medical instructions including medication dosages, size of equipment and level of shock voltage when using a defibrillator-to treat threatening cardiac dysrhythmias to the heart) Crash Cart observed on 1/17/2017 at 1:00 PM revealed in the Green Acute Ischemic Stroke box two Sodium Chloride (used to treat acute alcohol intoxication) 0.9 % 10 cc (milliliter) filled injection syringe with expiration date of 11/2016.

- Medical Surgical Emergency Crash Cart observed on 1/17/2017 at 12:20 PM revealed two Bacteriostatic 0.9% Sodium Chloride 30 ml (milliliter) with expiration date of 12/1/2016.

ED Manager Staff D interviewed on 1/17/2017 at 1:00 PM acknowledged the medications were expired and should have been disposed.

- Policy titled "Management of Expired Medications" reviewed on 1/18/2017 directed staff "...Each department is responsible for checking all medications in their department within one week of the end of the month for any medication that is outdated. Expiration dates that contain only the month and year expire at the end of the stated month..." "...All medications that are expired shall be removed from the department, and given to the Pharmacy RN for disposal ..."

Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH's) Infection Control Officer failed to: ensure staff wore proper surgical attire in one of one Operating room procedure (Staff I, II, JJ, AA, R, and FF); perform appropriate hand hygiene (Staff AA and Staff O); ensure staff documented five of twenty-three Sterilized loads (12/19/2016 load 3, 12/22/2016 load 3, 12/23/2017 load 5, 1/9/2017 load 2, and 1/12/2017 load 2); ensure staff performed one of twenty-three Steam Plus Class 5 Integrator (1/23/2016); ensure one of one ED Emergency Crash cart contained sterile items; ensure one of one Medical Surgical Emergency Crash cart contained sterile items; ensure that there was separation between the clean and dirty sides in one of one instrument cleaning room; ensure staff performed proper handwashing in one of three observations (Staff X); ensure staff separate patient food products from staff food in one of one refrigerator; ensure staff cover clean linen when transporting (Staff KK); ensure appropriate surgical attire is worn in all semi restricted surgical areas (Staff O); and ensure staff used the appropriate amount of detergent for cleaning the endoscopes (instrument introduced into the body view its internal parts) (Staff FF). These deficient practices had the potential to expose all patients and healthcare workers to infectious diseases and expose all patients to bacterial contamination and cross contamination resulting in foodborne illness.

Findings Included:

- Operating Room observed on 1/19/2017 at 9:05 AM revealed Staff I, II, JJ, AA, R, and FF failed to follow their CAH policy and procedure to wear a mask in the restricted area during a Colonoscopy performed on patient #22.

Director of Surgery Staff I interviewed on 1/19/2016 at 9:30 AM. Surveyor asked Staff I if staff are to wear a mask while in the OR performing a procedure. Staff I indicated we do not have to because it is considered a dirty procedure but maybe we should if something splattered.

- Policy titled "...A single mask is worn in the restricted area to contain and filter droplets contain microorganisms expelled from the mouth and nasopharynx during breathing, talking, sneezing and coughing ... "


- Registered Nurse Staff AA observed on 1/19/2017 at 8:20 AM revealed Staff AA failed to perform hand hygiene when entering patient # 22's preoperative room and when exiting the room, immediately entering patient #21's preoperative room without performing hand hygiene.

Registered Nurse Staff AA interviewed on 1/19/2017 at 8:25 AM acknowledged they did not perform hand hygiene when entering and exiting patient #22's preoperative room and when entering patient #21's preoperative room. Staff AA indicated "ok" and nodded her head.

- Registered Nurse Staff O observed on 1/19/2017 at 8:40 AM revealed Staff O failed to perform hand hygiene when leaving patient # 23's preoperative room.

Registered Nurse Staff O interviewed on 1/19/2017 at 8:40 AM acknowledged they did not perform hand hygiene leaving patient # 23 preoperative room.

- Policy titled "Hand Hygiene" reviewed on 1/19/2017 directed staff "...Hand Sepsis Using Alcohol based Hand Rubs-indications for use before and after having direct contact with patients..." "...after contact with inanimate objects (including equipment) in the immediate vicinity of the patient..."


- Sterilization log book reviewed from 12/19/2016 through 1/18/2017 on 1/18/2017 at 1:15 PM revealed Steam plus Integrator Test Pack (information to assure supplies were sterilized properly) not filled out on 12/19/2016 load 3, 12/22/2016 load 3, 12/23/2017 load 5, 1/09/2017 load 2 and 1/12/2017 load 2.

- Sterilization log book reviewed on 1/18/2017 at 1:15 PM revealed Steam plus Class 5 Integrator (indicator tablet placed in load (supplies) to ensure sterilization is done properly in autoclave-sterilizer) was not in load 5 on 12/23/2016.

Director of Surgery Staff I interviewed on 1/18/2017 at 1:30 PM acknowledged the Steam Plus Integrator Test Pack and Steam plus Class 5 Integrator were not filled out/placed in loads per policy. Staff I stated it is their fault for not overseeing the Sterilizer log book and the staff.

- Policy titled "SPS Sterilizing Items for Use in the Getinge Sterilizer" reviewed on 1/18/2017 directed staff "...SPS Steam Plus Integrator Test Pack- This test pack consists of a Steam Plus Integrator inside a challenge pack for immediate load release of gravity and prevacuum sterilization cycles. For the highest level of sterility assurance, a Steam plus Sterilizer Test Pack should be run in every wrapped load in our sterilizer..."


- ED Emergency Crash Cart observed on 1/17/2017 at 12:40 PM revealed 10 empty syringes with sterile needles, blunt 18g x 1 ½ attached to the syringes in a Ziploc bag.

- Medical Surgical Emergency Crash Cart observed on 1/17/2017 at 12:20 PM revealed 8 empty syringes with sterile needles, blunt 18g x 1 ½, attached to the syringes in a Ziploc bag.

ED Manager Staff D interviewed on 1/17/2017 at 12:40 PM acknowledged the syringes had the sterile needles attached to the syringes. Once a sterile item is opened (i.e. syringe and/or the "sterile" needle) and not used within a reasonable time frame it is no longer sterile.

- Policy review on 1/17/2017 revealed the Critical Access Hospital failed to provide a policy directing staff to dispose of open sterile items, if not used, within a reasonable time.


- Instrument cleaning room observed on 1/18/2017 at 12:00 PM revealed clean and dirty instruments on the same side. When one enters the room to the left, there is a rack that is consider dirty; adjacent to the rack are the clean instruments that are drying: and to the right of the clean instruments is the hopper (a flushable basin used to discard contaminated body fluids-high risk for splattering;splashes). Staff FF was cleaning the instruments then took a container filled with contaminated liquid turned around and the dumped the fluid into the hopper.

Director of Surgery Staff I interviewed on 1/18/2017 at 12:30 PM acknowledged the dirty and clean sides are on the same side, and the dirty instrument rack is next to the clean open instruments.

CEO Staff BB interviewed on 1/19/2017 at 12:55 PM. Staff BB request one of the surveyors to go to the Instrument cleaning room to explain the close proximity of the clean and dirty side. Staff BB acknowledged the potential for contaminating the clean instruments.

- Policy review on 1/19/2017 revealed the Critical Access Hospital failed to provide a policy directing staff assure clean instruments are distant to the dirty instrument cleaning area.


- Observation on 01/17/17 at 11:45 in the facility laboratory revealed Medical Technologist Staff X failed to follow handwashing guidelines when drawing blood. Medical Technologist Staff X left gloves on after drawing lab specimen and walked the patient to the exit, opened the exit door with his/her dirty gloves, then returned to work station and carried the specimens to the computer.

Interview with Laboratory Supervisor Staff Y confirmed that all staff are educated and monitored for handwashing before and after applying and removing gloves and when handling lab specimens.

Review of policy titled Hand Hygiene" directed "...indications for use of alcohol based hand rubs... ...after removing gloves..."


- Observation on 1/18/17 at 10:00 AM revealed a refrigerator in the physical therapy department contained staff food items and bottled water.

Director of Rehabilitation Services Staff G verified the food in the refrigerator belonged to the staff and the bottled water is given to the patients. S/he acknowledged "I was unaware storing employee food with patient water was not acceptable practice."

- Policy review on 1/19/17 at 1:30 PM revealed facility failed to develop a policy for separation of employee food storage and patient food storage.


- Observation on 1/19/17 at 1:30 PM of Surgery Tech Staff KK pushing a cart of uncovered laundry in the facility hallway into the surgical suite.

Interview with Staff KK confirmed that the cart contained clean laundry and that it was not covered with a protective cover. Staff KK stated "sometimes the laundry is covered but the cover doesn't always fit the cart."

Interview with Director of Material Management Staff LL acknowledged the facility policy "is to transport the laundry with a protective cover over it. "

Review of policy "Storage, Collection, and Transportation of Linen" directed "...Clean linens will be transported to patient care by use of covered carts by Environmental Services Staff or the Department themselves..."


- Observation of RN Staff O on 1/17/17 at 11:15 during the tour of the surgical suite entered the semi restricted surgical area without scrubs or hair cover. A sign visible at the entrance of the semi restricted area directed staff that appropriate surgical attire is to be worn in the area including hair cover and shoe covers.

Interview with RN Staff O acknowledged the sign and stated "I am wearing hospital designated shoes so I don't have to have shoe covers. I probably should have my hair covered. When we have surgery we have scrubs to put on."

Review of policy "Attire In The OR" directed "...All personnel entering semi-restricted areas of the surgical suite shall be in operating room attire intended for use within the surgical suite (restricted area) as well... ...Semi-restricted areas include the sub sterile hallway outside of the OR and the sterilizing room..."

The Association of Surgical Technicians (AST) Standards of Practice for Surgical Attire, Surgical Scrub, Hand Hygiene and Hand Washing recommended "...The proper surgical attire should be worn in the semi-restricted and restricted areas of the healthcare facility surgery department... ...Surgical attire that should be worn in the semi-restricted and restricted areas of the surgery department includes the head cover, masks, scrub suit, warm-up jacket, and shoes ... "



- Instrument cleaning room observed on 1/19/2017 at 11:45 AM revealed Staff FF did not measure the detergent prior to pouring it into the filled sink containing water. Staff FF was preparing to clean an endoscope. Staff FF did not ensure the concentration of the detergent used for cleaning was adequate.


Surgical Technician Staff FF interviewed on 1/19/2017 at 11:45 AM stated they were taught by the previous Surgical Technician to pour the detergent into the water until it turns blue.
Director of Surgery Staff I interviewed on 1/19/2017 at 12:30 PM indicated they have been very busy and been meaning to observe the Surgical Technicians on performing the proper cleaning of Endoscopes. Staff I stated they need to get a better grip on her staff.


- Policy "Cleaning and Processing Flexible Endoscopes and Endoscope Accessories" reviewed on 1/19/2017 directed CAH Staff "...Flexible endoscopes will be cleaned and stored in accordance with the manufacturer's written instructions..."

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Based on interview, records review document review and policy and procedure review the Holton Community Hospital failed to have documentation of a history and physical (H & P) for 1 of 20 medical records reviewed (Patient #19) and failed to have a physician's signature within 30 days for 2 of 20 records reviewed (Patient #17 and #18). Failure to provide complete and accurate documentation of an H & P and to have an H & P signed within the 30 day timeframe put all patients at risk for unsafe care, incorrect procedures, surgeries, and receiving medication to which they may be allergic.

Findings include:

- Record review on 1/18/17 revealed Patient #19 failed to have documentation of an H & P. Patient #19 was admitted on 12/8/16 with a diagnosis of Gastrointestinal Bleed (GI). The patient arrived through the Emergency Department, was in observation and then admitted into the inpatient unit. Patient #19 received an x-ray, medications, labs and oxygen and was discharged back to their home on 12/13/16.

- Record review on 1/18/17 revealed Patient #17 failed to have a physician's signature on their H & P within 30 days. Patient # 17 was admitted on 9/30/16 with a diagnosis of End Stage Liver Disease, was seen in the Emergency Department, transferred to observation and then admitted as an inpatient. Patient #17 received medications and labs while an inpatient and was discharged back to their home on 10/3/16 with continued hospice services.

- Record review on 1/18/19 revealed Patient #18 failed to have a physician's signature on their H & P within 30 days. Patient # 18 was admitted 11/9/16 with a diagnosis of Pneumonia and received medications, labs, physical therapy, oxygen and a chest x-ray. Patient #18 was discharged home 11/13/16.

Interview on 1/18/17 at 3:00 PM, Medical Record Director Staff CC verified the record for Patient # 19 was missing an H & P and records for Patients #17 and #18 failed to have the physicians' signatures within the 30 day timeframe. Staff CC stated the 2 records with late physician signatures were from a physician who is not at their facility often.

- Document review on 1/18/19 Medical Staff By-Laws, Article IV states ...Timely completion of medical records. Members of the Medical Staff are required to complete the medical records within a reasonable time, which may not in any event exceed 30 calendar days.

- Policy and Procedure review on 1/19/17 revealed policy "Inpatient Chart Analysis" stated ...Requirements for chart review and completion include the following: a. A history and physical must be completed within 24 hours by the admitting physician...All charts must be completed within 30 days from discharge.

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Based on observation and interview the Holton Community Hospital failed to store medical records in a manner which prevents damage or destruction by having 33 boxes of medical records on the floor in the outside storage area. Failure to keep medical records off the floor put the records at risk for being damaged or destroyed.

Findings include:

- Observation on 1/19/17 at 12:08 AM revealed a storage unit for old medical records located outside of the hospital and on the hospital grounds. The last row of medical records in the storage unit revealed approximately 33 boxes actually stored on the floor.

Interview on 1/19/17 at 12:08 AM, Medical Record Director, Staff CC verified the medical records on the floor in the outside storage area. Staff CC stated the boxes of medical records were waiting to be picked up by Jay Hawk Storage for off-site storage and placed in a separate area so that they would be aware of what boxes needed to go offsite. Jay Hawk Storage has been called a couple of times and not yet come to pick them up. Staff CC stated they will be called today to be picked up immediately. Staff CC stated the facility failed to have a policy and procedure for storage of medical records.

Based on policy review, record review, and staff interview the Facility did not provide opportunity for patient notification of swing bed transfer 30 days prior to the transfer in three of three swing bed records reviewed (Patient #2, #5, #6). Failure to provide notification puts all swing bed patients at risk of inappropriate transfer.


Findings include:


--Review of patient rights for swing bed patients and "Patients' Rights Policy" on 1/19/16 at 12:00 PM revealed the documents lacked a statement regarding the required 30 day notice to the resident of a transfer or discharge.


- Patient #2 admitted to swing bed on 6/20/16, signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 6/21/16.


- Patient #5 admitted to swing bed on 12/26/16, signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 12/26/16.


- Patient #6 admitted to swing bed on 8/5/16, signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 8/5/16.


Interview on 1/19/16 with Director of Nursing Staff H acknowledged the lack of the 30 day transfer notification in the facility documents.


Interview on 1/19/16 with CEO Staff BB confirmed the statement was not included in the documents "We simply don't keep our patients that long. Our average length of stay for swing beds is only about 9 days."