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Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure a system was in place to verify that its patients received a copy of the hospital's patient bill of rights information for 9 of 14 discharged patient records and 4 of 7 inpatient records reviewed for patient rights information. (Discharged Patient 1, 2, 3, 4, 5, 6, 7, and 8), and Discharged Swing Bed Patient 6, and (Inpatient 1, 2, 3, 4 and 6).

The findings are:


On 5/17/17 at 4:00 p.m., review of Discharged Patient 3's chart revealed no documentation that the patient or
patient's representative received the hospital's patient bill of rights information.

On 5/18/17 at 3:00 p.m., review of Inpatient 1's chart revealed no documentation that the patient or
patient's representative received the hospital's patient bill of rights information.

On 5/18/17 at 11:00 a.m., review of Inpatient 4's chart revealed no documentation that the patient or
patient's representative received the hospital's patient bill of rights information.

On 5/19/17 at 2:00 p.m. the findings were verified with Director 5.

On 5/17/17 at 11:15 a.m., review of Discharged Patient 2's chart revealed there was no documentation the patient or patient's representative received a copy of the hospital's patient bill of rights information.

On 5/17/17 at 12:10 p.m., review of Discharged Patient 4's chart revealed there was no documentation the patient or patient's representative received a copy of the hospital's patient bill of rights information.

On 5/17/17 at 12:55 p.m., review of Discharged Patient 5's chart revealed there was no documentation the patient or patient's representative received a copy of the hospital's patient bill of rights information.

On 5/17/17 at 2:20 p.m., review of Inpatient 3's chart revealed there was no documentation the patient or patient's representative received a copy of the hospital's patient bill of rights information. The findings verified with RN 1 on 5/19/17 at 11:47 a.m.

Patient Rights and Responsibilities policy and procedure states "....Patients are given a Patient Handbook that explains facility services, visiting hours admitting process, smoking regulations, etc...." .




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On 5/17/2017 at 1:00 p.m., review of Inpatient 6's chart revealed there was no documentation that either the patient or the patient's representative was informed in writing of the patient's rights. In an interview on 5/19/17 at 1:00 p.m., Registered Nurse 1 stated that each patient is given a brochure which talks about their rights, but there is no documentation that the patient or the patient's representative received a copy of the bill of rights information.

Review of Inpatient 2's chart revealed there was no documentation that the patient or the patient's representative received the hospital's patient's bill of rights information.

Review of Swing Bed Discharged Patient 6's chart revealed there was no documentation that the patient or the patient's representative received the hospital's patient's bill of rights information.

Review of Discharged Patient 7's chart revealed there was no documentation that the patient or the patient's representative received the hospital's patient's bill of rights information.

Review of Discharged Patient 8's chart revealed there was no documentation that the patient or the patient's representative received the hospital's patient's bill of rights information.

On 5/17/17 at 4:15 p.m., review of Discharged Patient 1's revealed there was no documentation that the patient or the patient's representative received the hospital's patient's bill of rights information. In an interview on 5/19/17 at 1:00 p.m., Registered Nurse 1 stated that each patient is given a brochure which talks about their rights, but there is no documentation that the patient or the patient's representative received a copy of the bill of rights information.

Based on review of personnel files, interviews, and review of the hospital's policy and procedure, the hospital failed to maintain documentation of employee annual competencies per hospital policy for 8 of 31 personnel files reviewed. (Registered Nurse (RN) 1, 2, 5, 9 and 10, and Director 8 and 10)

The findings are:

On 5/19/2017 at 10:00 a.m., review of the hospital's policy, titled, "Hospital Wide Education/Competency Program policy and procedure", reads, "....Annual Assessment: Maintaining competency is the responsibility of the employee. Competency and performance will be assessed on all employees initially, annually thereafter, or as needed thereafter by the department manager. Annual skills validation will include high risk, low risk, problem prone procedures....".

On 5/18/17 at 9:30 a.m., review of RN 1's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 9:45 a.m., review of RN 2's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 10:00 a.m., review of RN 5's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 10:15 a.m., review of RN 9's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 10:30 a.m., review of RN 10's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 10:45 a.m., review of PCT 1's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 11:00 a.m., review of Director 8's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy.

On 5/18/17 at 11:15 a.m., review of Director 10's personnel file revealed there was no documentation of the employee's annual competencies per hospital policy. On 5/19/17 at 09:30 a.m., Director 7 verified the findings.

Based on observations, interviews, and review of the hospital's policy and procedure, the hospital failed to maintain the building appropriately.

The findings are:

On 5/16/17 at 1:55 p.m., random observations of building 5 revealed the main hospital entrance door to the reception area was off track. On 5/16/17 at 1:55 p.m.,the findings were verified with Facility Manager.

Hospital Policy, titled, Maintenance Department Plan of Care" reads, "....The hospital ' s environment is safe and comfortable...." .

Based on observations, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that seasonings in the kitchen were labeled when opened and failed to ensure drugs and biologicals were labeled when opened in the emergency department, pharmacy, and central processing.

The findings include:

Observations in the kitchen at 12:57 p.m. on 5/16/17 revealed a half full container of ground pepper located on a shelf with other seasonings. There was no "opened" date labeled on the container. In an interview with the Certified Dietary Manager (CDM) on 5/16/17 at 12:58 p.m., he/she verified the ground pepper container was not labeled with the date it was opened.























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On 5/16/17 at 1:00 p.m., observations in the Emergency Department medication room revealed an opened twenty (20) milliliter (ml) vial of Xylocaine 1%(percent) that had not been labeled when opened. On 5/16/17 at 1:04 p.m., observations in the Emergency Department medication room refrigerator revealed 3 vials of NPH insulin that had not been labeled when opened.
On 5/16/17 at 1:25 p.m., observations in the Emergency Department medication room revealed the high control solution for the glucometer had not been labeled when opened. The findings were verified with Director 1 at the times of the observations from 1:00 p.m. to 1:25 p.m. on 5/16/2017.

On 5/16/17 at 1:38 p.m., observations in the Pharmacy medication room revealed a 473 ml vial of Phenobarbital that had not been labeled when opened. The finding was verified with Pharmacist 1 at the time of the finding at 1:38 p.m. on 5/16/2017.

On 5/18/17 at 11:16 a.m., observations in the Central Sterile Processing revealed an open container of Alcohol 70% that was not labeled when opened. The findings were verified with Director 4 at the time of the observation at 11:16 a.m. on 5/18/2017.

Hospital Policy, titled, "Medication Administration", reads, "....6. On multiple dose vials, medication expires once punctured in 28 days....".

Based on observations, interviews, and review of the hospital's policies and procedures, the hospital failed to follow accepted principles of infection control to minimize the potential transmission of infectious agents in the hospital setting by failing to designate clean versus dirty areas in the laundry area, disinfecting equipment between patients, cleaning the Endoscopy area between patients, replacing Sharps containers, failing to clean medication vial septum, and failed to perform hand hygiene for 2 of 10 Registered Nurses (RN) 4 and 7, 1 of 4 Medical Doctors (MD) 3, and 2 of 3 Certified Scrub Technicians (CST) 2 and 3 when observed in the provision of patient care.


The findings are:


On 5/16/17 at 1:11 p.m., observations in the Emergency Department in Examination Room 6 revealed an opened package of Yankeur suction connected to a wall canister. The findings were verified with Director 1 on 5/16/17 at 1:11 p.m. at the time of the observation.

On 5/18/17 at 9:40 a.m., observation in the Same Day Hospital Examination Room 145 revealed Medical Doctor(MD) 3 failed to wipe the septum of the Propofol medication vial prior to drawing up the medication. On 5/18/17 at 9:42 a.m., observations in Same Day Hospital Examination Room 145 revealed MD 3 failed to clean the injection port of the patient's intravenous access prior to administering Propofol. On 5/18/17 at 9:50 a.m., observations in Same Day Hospital Examination Room 145 revealed MD 3 failed to wipe the septum of the Propofol medication vial prior to drawing up the medication.

On 5/18/17 at 09:57 a.m., observations in Same Day Hospital Examination Room 145 revealed CST 2 wearing soiled gloves reached into the clean covered supply cart to retrieve a 250 milliliter (ml) container of sterile water to pour into the bowl on the back table during the Colonoscopy procedure. On 5/18/17 from 10:06 a.m. to 10:08 a.m., observations in Same Day Hospital Examination Room 145 revealed staff failed to empty the trash can and did not mop the floor between patient cases. At 10:06 a.m., Director 4 reported "We don't mop the floor between the cases."

On 5/18/17 at 10:07 a.m., observations in Same Day Hospital Examination Room 147 revealed RN 4 failed to disinfect the stethoscope after using it on a patient. On 5/18/17 at 10:09 a.m., observations in Same Day Hospital revealed MD 3 failed to perform hand hygiene after glove removal when exiting Examination Room 147 and entering Examination Room 144.

On 5/18/17 at 10:59 a.m., an observation in the sterile processing area revealed CST 3 failed to perform hand hygiene after glove removal in the sterile processing area. The findings were verified with CST 3 at the time of the observation at 10:59 a.m. on 5/18/17.
On 5/18/17 at 11:14 a.m., an observation in sterile processing area revealed CST 1 failed to perform hand hygiene after glove removal in the sterile processing area. The findings verified with CST 1 at the time of the observation at 11:14 a.m. on 5/18/17.

On 5/19/17 at 11:15 a.m., the Infection Control Officer revealed, "The Same Day Hospital is not an ideal place to perform these procedures. Also, with Sterile Processing down the hall in a different area is and has posed a concern since the beginning because there is still a potential for contamination. These just need to be ceased until the OR has been completed."

Hospital policy, titled, "Hand Hygiene", reads, "....each employee in every department is responsible for appropriate hand hygiene by using either soap and water or an alcohol-based hand rub....".

Hospital policy, titled, "General Infection Control in Patient Care Areas", reads, "....All equipment which has been in contact with a patient or in their room is considered "dirty" and is to be placed in the soiled utility room....F. Departmental stethoscopes are to be thoroughly cleaned with alcohol, including ear pieces, by the user after each use....IV. A. Locked, wall-mounted Sharps containers will be present in all patient rooms. Liners will be routinely checked at least daily and replaced when 3/4 full....E. Walls and cubicles are to be washed at least once a month, when visibly soiled, or when the room has to be terminally cleaned....

Hospital policy, titled, "Operating Room Cleaning", reads, "....1. Preparation for first case: h. Only anticipated supplies and laundry will be taken into the room. All of those items in the room during the case (whether in direct patient contact or not) are considered soiled and are to be discarded after the case with the exception of blankets in warmers....2. During surgical procedures: c. Doors leading into the operating room suites and hallway doors are to be opened minimally. They are NEVER to remain open....4. Cleaning between cases: a. a standard terminal cleaning protocol will follow all cases....h. Cleaning the room: I. the designated person for cleaning will remove all plastic waste liners, close the bags and transport to appropriate areas. II. The frames, horizontal surfaces of the room, kick buckets and walls ("spot cleaning") are wiped with a hospital approved disinfectant and allowed to air dry....III. Floors are spot cleaned of body fluid or antiseptic spills first, then mopped....7. Staff cleaning assignments: d. Supply and equipment closets outside of the operating room suites will be neat, clean and organized. All equipment that cannot be contained in a cabinet or case will be covered....".





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Observations of the medication pass on 5/17/17 revealed RN 7 transported the medication cart in the patient's room and completed the medication pass for Inpatient 4 at 10:16 a.m., and then, RN 7 proceeded to the next patient room and transported the medication cart into the patient's room and completed Inpatient 5's medication pass at 10:16 a.m.. Observations revealed RN 7 transported the medication cart into and out of patient rooms without disinfecting the medication cart between patients. In an interview on 5/19/17 at 11:35 a.m., RN 1 verified the hospital's policy addressed medication carts going into patient rooms during medication pass and cleaned weekly. RN 1 verified the the policy did not address cleaning the cart after medication pass in each room.

Review of Hospital Policy No.: 6010.014, titled, "Bar-coded Medication Administration Procedure" issued 3/1/01 and revised 11/2016, reads, in section E, "Take medication cart to room...."
Review of Hospital Policy No.: 8415.535, titled, "General Infection Control in Patient Care Areas", issued on 03/2001 and revised on 06/2016, reads, "Medication carts are to be cleaned by nursing staff at least weekly and when visibly soiled." The policy failed to address potential cross contamination as medication carts go in and out of patient rooms without being disinfected.










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Observations on 05/16/17, 05/17/17, 05/18/17, and 05/19/17 revealed the hospital's laundry room did not have a divider or any method of dividing the clean and dirty sides or clean and dirty linens. Staff were observed at multiple times during the survey walking in from outside of the hospital, through the maintenance area, and then through the laundry room into the cafeteria taking no precautions to avoid contaminating clean linen. In an interview on 05/19/17 at 10:58 a.m., Registered Nurse (RN) 1 and Director 8 confirmed there was no divider in the laundry room and employees were walking through the laundry with no contamination protections to enter the hospital.

On 5/16/17 at 1:55 p.m., during a random observation of the medical/surgical unit, a Sharps box was observed to be filled to over two-thirds full with syringes and needles. On 5/16/17 at 1:55 p.m., the Manager verified the findings.

Based on record reviews and interview, the hospital failed to ensure Registered Nurses (RN's) developed and updated nursing care plans daily for 1 of 7 Inpatient charts (Inpatient 3) and 2 of 14 Discharged Patient charts. (Discharged Patient 6 and 8)


The findings are:


Review of Inpatient 3's chart revealed the patient was admitted to the hospital on 5/14/17 with left arm pain. Review of the nursing plan of care in the patient's chart revealed the plan of care was developed on 5/14/17 at 08:50 a.m.. Review of the patient's plan of care revealed the plan of care was not evaluated on a daily basis with no evaluation completed on 05/15/17. In an interview on 05/19/17 at 11:34 a.m., Registered Nurse (RN) 1 confirmed nursing plans of care should be developed within 24 hours following admission and should be evaluated on a daily basis. RN 1 confirmed the patient's care plan was not evaluated on a daily basis.

Review of Discharged Patient 6's chart revealed the patient was admitted to the hospital swing bed unit on 04/21/17. Review of the patient's nursing plan of care revealed the plan of care was not developed until 04/23/17. Review of the patient's plan of care revealed the plan of care was not evaluated on a daily basis with no evaluation completed on 04/24/17. In an interview on 05/19/17 at 11:34 a.m., Registered Nurse (RN) 1 confirmed nursing plans of care should be developed within 24 hours following admission and should be evaluated on a daily basis. RN 1 confirmed the care plan for the patient was not developed in 24 hours and was not evaluated on a daily basis.

Review of Discharged Patient 8's chart revealed the patient was admitted to the hospital on 01/29/17. Review of the patient's nursing plan of care revealed it was not developed until 01/31/17. Review of the patient's plan of care revealed it was not evaluated on a daily basis, with no evaluation completed on 02/01/17 or 02/04/17. In an interview on 05/19/17 at 11:34 a.m., Registered Nurse (RN) 1 confirmed nursing plans of care should be developed within 24 hours following admission and should be evaluated on a daily basis. RN 1 confirmed the care plan for the patient was not developed in 24 hours and was not evaluated on a daily basis

Based on record reviews and interviews, the hospital failed to maintain records including consents, assessments, physician orders and patient needs for 3 of 7 Inpatient charts (Patient 1, 2, and 3), and 3 of 14 Discharged Patient charts. ( Discharged Patient 6, 7, and 8)


The findings are:


Review of Discharged Patient 7's chart revealed the patient was discharged on 03/31/17, and there was no discharge note authenticated by the physician until 05/04/17. In an interview on 05/19/17 at 1:20 p.m., Registered Nurse (RN) 1 confirmed the physician discharge note for the patient had not been authenticated by the physician for more than 30 days after discharge.

Review of Discharged Patient 8's chart revealed the patient was ordered to receive intravenous medications including 5%(percent) Dextrose and 0.45% Sodium Chloride in Normal Saline on a continuous drip, Ceftriaxone with 5% Dextrose 1 gram IV piggy back every 24 hours, Levaquin premix bag 250 milligrams (mg)/50 milliliters (ml) 500 mg IV piggy back every 24 hours, Levofloxacin premix bag 250 mg/50 ml 250 mg IV piggy back every 48 hours, and Vancomycin 100 ml/500 mg 500 mg IV piggy back every 48 hours. There was no physician order in the patient's chart to obtain an IV access. In an interview on 05/19/17 at 11:14 a.m., RN 1 confirmed there was no physician order to obtain an IV access for the patient.
Review of Discharged Patient 8's chart revealed a stress test ordered by the physician at admission on 01/29/17. The stress test was completed on 01/30/17, but no consent form signed by the patient in the patient's chart. In an interview on 05/19/17 at 12:22 p.m., the Lead Radiology Technician confirmed the was no consent form obtained for the stress test.

Review of Inpatient 2"s chart revealed the patient had physician orders for medications including 5% Dextrose and 0.45% Sodium Chloride in Normal Saline on a continuous drip and Thiamine Hydrochloride 100 mg/ml daily. There was no physician order in the chart to obtain an IV access. In an interview on 05/19/17 at 11:14 a.m., RN 1 confirmed there was no order to start an IV for the patient.

Review of Swing Bed Discharged Patient 6 revealed a physician order dated 04/21/17 to admit the patient the swing bed unit. Review of the patient's consent and admission records for the patient revealed the forms were not signed until 04/25/17. In an interview on 05/19/17 at 1:14 p.m., RN 1 confirmed the physician orders for the patient's admission were dated 04/21/17, and the admission and consent paperwork was not signed until 04/25/17.

On 5/17/19 at 2:20 p.m., review of Inpatient 3's chart revealed the patient was admitted on 5/14/17 at 3:28 a.m. with a diagnosis of left arm pain. There was no consent signed by the patient on admission and there was no date written on the consent signed by the patient and witness on 5/15/17 for a cardiac stress test. The physician wrote an order on 5/14/17 at 1:47 p.m. for finger stick blood sugars at ac (before meals) and hs (bedtime). On 5/15/17 at 4:30 p.m., there was no fingerstick blood sugar completed on the patient. The findings were verified with RN 1 on 5/19/17 at 11:47 a.m..

On 5/18/17 at 3:00 p.m., review of Inpatient 1's chart revealed a nurse note dated 5/17/17 at 6:12 a.m. that reads, "Dressing change completed to I & D(Incision and Drainage) site to right inner thigh". There were no physician orders for the patient's dressing change in the chart. On 5/19/17 at 12:24 p.m., the finding was verified with RN 1.

Based on record reviews, interview, and review of the hospital's policies and procedures, the hospital failed to ensure its staff followed the hospital's policies and procedures for documentation of vital signs and rounding assessments for 1 of 7 Inpatient charts (Swing Bed Inpatient 6), and 3 of 14 Discharged Patient charts. (Discharged Patient 6, 7, and 8)


The findings are.


Review of Discharged Patient 8 revealed the physician ordered vital signs every 4 hours on 01/30/17 at 1:49 a.m.., but review of the documentation of the vital signs in the patient's chart revealed no documentation of the patient's vital
intermittently throughout the patient's hospitalization.
Review of the vital sign records in the patient's chart revealed the patient's vital signs were not documented for 5 hours and 11 minutes between 4:00 p.m. and 9:11 p.m. on 01/31/17
On 02/01/17, the patient's vital signs were not documented for 4 hours and 33 minutes from 4:00 p.m. until 8:33 p.m. and for 4 hours and 42 minutes from 8:33 p.m. until 1:15 a.m. on 02/02/17.
On 02/02/17, the patient's vital signs were not documented for 5 hours and 10 minutes from 4:00 p.m. until 9:10 p.m..
On 02/03/17, the patient's vital signs were not documented for 4 hours and 53 minutes from 4:00 p.m. until 8:53 p.m..
On 02/05/17, the patient's vital signs were not documented for 4 hours and 54 minutes from 12:23 a.m. until 5:17 a.m., 4 hours and 28 minutes from 12:00 noon until 4:28 p.m., and 4 hours and 47 minutes from 8:00 p.m. until 12:47 a.m. on 02/06/17.
In an interview on 05/19/17 at 11:30 a.m., Registered Nurse (RN) 1 confirmed vital signs had not been documented every 4 hours as ordered for the patient, and this should have been done per physician's orders.

Review of Discharged Patient 7's chart revealed the patient was admitted to the hospital on 03/21/17. Review of the hourly rounding sheets on the patient's that were completed by the hospital's nursing staff and technicians revealed hourly documentation had not been completed on 03/23/17 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m.. The hourly rounding sheet dated 03/26/17 revealed documentation was not completed at 4:00 p.m. and 6:00 p.m., the hourly rounding sheet dated 03/26/17 revealed documentation was completed at 6:00 p.m..

Review of Swing Bed Patient 6's chart revealed the patient was admitted to the hospital swing bed unit on 04/21/17. Review of the hourly rounding sheets on the patient's chart revealed the documentation was not completed by nursing staff and technicians on 04/22/17 at 6:00 p.m., on 04/23/17 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m., on 04/24/17 at 7:00 p.m., on 04/25/17 at 8:00 p.m., and 10:00 p.m., and on 04/26/17 at 12:00 a.m., 2:00 a.m., and 8:00 p.m..

Review of Discharged Patient 6's chart revealed a Rounding Documentation Tool which noted a schedule where nurses round every (2) hours on the even hours and technicians round every (2) hours on the odd hour. During rounds, the areas to be assessed were pain, toileting, positioning and environmental factors. The rounding document for the patient dated 5/12/17 revealed there was no documentation that rounds were made by the nurses or the technicians at the 1900 hour, 2100 hour, and from 2300 - 0600 hours. The rounding document dated 5/15/17 revealed there was no documentation that rounds were made at 1300 hours, 1500 hours, and 1700 hours.

In an interview on 5/19/17 at 11:20 a.m., Registered Nurse(RN) 1 verified the lack of documentation on the
Rounding Documentation Tool for 5/12/17 and 5/19/17. In an interview on 5/19/17 at 11:20 a.m., RN 1 verified the lack of documentation on the Rounding Documentation Tool for 5/12/17 and 5/19/17, and that the hospital's policy was not followed.

Review of Hospital Policy No.: 6010.015, titled, "Bedside Rounding", issued on 8/2006 and revised on 10/2016, reads, "It is the responsibility of all licensed and non-licensed staff to ensure patients receive safe and efficient care during each 24-hour period. The 24-hour patient Assessment Record will be initiated for the 24-hour period beginning at 7:00 a.m.. The sheet will be labeled with patient's identification sticker. The staff initials should be placed in the time slot across from the appropriate monitored item to verify completion of item every hour." According to the policy, the "3 P's" were to be assessed (pain, toileting, and positioning), Environmental factors (fall precautions, bed/chair alarm, essential items within reach, type of bath given, mouth care, Pericare) and prior to leaving the room ask, "Is there anything I can do for you?"

Review of Community Access Hospital Policy Number 6010.015 - Bedside Rounding revealed patients were to be assessed and monitored hourly. In an interview on 05/19/17 at 1:50 p.m., RN 1 confirmed hourly documentation had not been completed for the patients reviewed, and per hospital policy 6010.015, this should have been completed.

Based on record review, interview, and review of the hospital's policies and procedures, the hospital failed to ensure that each patient's medical record was signed, timed, and dated by the physician and other healthcare professionals for records reviewed for 3 of 7 Inpatient charts (Inpatient 3, 6 and 7) and 4 of 14 Discharged Patient charts. (Discharged Patient 5, 6, 7, and 9)


The findings include:


Review of Discharged Patient 5's chart revealed a Physical Therapy (PT) Evaluation completed on 5/3/17 that was not signed or dated by the Physical Therapist or the physician. In an interview on 5/19/17 at 1:07 p.m., Registered Nurse (RN) 1 verified the PT evaluation was not signed or dated by the Physical Therapist and the physician.

Review of Inpatient 6's chart revealed a Consent Form For Cardiac Stress Test that was signed by the patient and witnessed by the hospital staff. Review of the consent form revealed there was no documentation of the date that the consent was signed by the hospital witness or the patient. In an interview on 5/19/17 at 12:20 p.m., Director 9 verified the patient's consent was signed but not dated by either the patient or the hospital witness.

Review of Discharged Patient 9's chart revealed a "Bill of Rights and Responsibilities for Swing Bed Patients" that was signed by the patient's s representative but was not dated. The bill of rights form was not signed or dated by the witness. Record review revealed an Occupational Therapy (OT) Evaluation for the patient that was completed on 2/17/17. The OT evaluation was not signed or dated by the Occupational Therapist and the physician.
Record review revealed a form for services that included in a Medicaid or Medicare stay for which there is no additional charge and items and services for which a patient and family may be financially responsible. The form was signed by the patient's representative but was not dated. There was no witness signature or date on the document.
In an interview on 5/19/17 at 11:19 a.m., Registered Nurse (RN) 1 verified that all entries in Discharged Patient 9's record should have been signed and dated.

Review of Discharged Patient 6's chart revealed the documentation for the patient's Physical Therapy goals and a treatment plan developed on 04/25/17 were not signed by either the Physical Therapist or the Physician.

Review of Discharged Patient 7 revealed the documentation for the patient's Physical Therapy goals and a treatment plan were developed on 03/21/17 that were not signed by either the Physical Therapist or the Physician.

In an interview on 05/19/17 at 1:07 p.m., Registered Nurse 1 confirmed the Physical Therapy goals and treatment plans for Discharged Patient 6 and 7 had not been signed by either the Physical Therapist or the Physician and the goals and plans should have been signed.

Review of Hospital Policy No.: 6010.035, titled, "Documentation", issued on 7/2007 and revised on 10/2016 reads in section D, "All entries to the record must be dated and timed", and Section I reads, "All entries in the record should be signed legible with full name and title or licensure."

Based on review of the hospital's Quality Assurance Program and interview, the Critical Access Hospital staff failed to document review of occurrence reports and follow through with action plans for prevention of reoccurrence to prevent potential reoccurrence.


The findings are:


On 5/19/17 at 11:00 a.m., review of the hospital's Quality Assurance data revealed 32 occurrence reports that had no documentation that the occurrence reports were reviewed and no documentation that an action plan was developed to address the issues in a quality review. On 5/19/17 at 11:21 a.m., Director 8 revealed that she is the employee designated with the responsibility to address the occurrence reports. Director 8 reported that the occurrence reports were reviewed but were not authenticated and the action plan was not documented.

Based on record review and interview, the Critical Access Hospital failed to ensure its employees received training on its policies and procedures related to organ procurement for 3 of 6 Registered Nurses (RN). (Registered Nurse 4, 5, and 6)

The findings include:

On 05/16/17 at 2:43 p.m., review of the data submitted by the hospital for review of the training requirements for its staff related to organ procurement, there was no documentation of training annually related to the hospital's OPO policies and procedures for RN 4, 5 and 6 in their files. Interview on 5/17/17 at 3:00 p.m., RN 4 verified the findings, and stated, "There is no annual training for OPO processes."

Based on observations, record reviews, interview, and review of the hospitals policies and procedures, the hospital failed to ensure privacy during wound care for 1 of 1 patients provided with wound care (In Patient 5) and for 1 of 2 patients observed during medication pass in that the door to both patient rooms was left open with a potential to expose the patient to anyone in the vicinity. (Inpatient Patient 4)


The findings include:


Observations of Inpatient 5's receiving wound care on 5/18/17 from 8:37 a.m. to 8:48 a.m. revealed the door to the patient's room remained opened during the patient's wound care treatment. In an interview on 5/18/17 at 8:51 a.m., Registered Nurse(RN) 8 verified that privacy was not maintained during the patient's wound care treatment.

Observations during the medication pass on 5/17/17 at 10:06 a.m. revealed RN 7 rubbed Aquaphor Cream to Inpatient 4's chest, stomach, back, and bilateral arms with the door opened to the patient's room . Observations showed RN 7 lifted the patient's gown, exposed the patient's stomach and applied the cream to the patient's stomach. The patient's back was exposed when RN 7 rubbed cream to the patient's back. The door to the patient's room was open throughout the patient's treatment. In an interview on 5/18/17 at 9:03 a.m., RN 7 verified that privacy was not maintained during treatment.

Review of Hospital Policy No.: 8312-47, titled, "Patients Rights and Responsibilities", revised 3/20/17, reads, "The hospital and the medical staff respect the rights of the patient as an individual with unique health care needs and because of the importance of respecting each patient's dignity, provides considerate, respectful care focusing upon the patient's individual needs."