HospitalInspections.org

(Iowa Code Section 235B.16 5b: A person required to report cases of dependent adult abuse . . . shall complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment. . .)

Based on policy review, personnel file review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure new employees receive Dependent Adult Abuse (DAA) training within 6 months of initial employment, according to State law, for 5 of 18 personnel files reviewed, (Staff R, Staff S, Staff T, Staff F, and Staff D).


Failure to ensure Dependent Adult Abuse training for all staff may result in the lack of reporting of suspected dependant adult abuse.

Findings include:

1. Review of a CAH policy titled "Freedom From Abuse", approved 12/11/13, revealed in part ". . . All new staff members receive in-service education on identification and reporting of dependent adult abuse within 6 months of initial employment . . ."

2. Review of personnel files identified the following lacked documentation of any DAA training:

a. Staff R, Pharmacy Technician, hired 10/7/13
b. Staff S, Scrub Technician, hired 9/30/14
c. Staff T, Registered Nurse, hired 9/30/14
d. Staff F, Dietary Manager, hired 1/14/13
e. Staff D, Chief Nursing Officer, hired 2/25/13

3. During an interview on 4/22/14 at 4:00 PM, Staff U, Finance and Human Resources Manager, acknowledged she was unable to find any documented evidence for the identified employees to demonstrate completion of the mandatory DAA training.

Based on review of documents and administrative staff interviews the CAH (Critical Access Hospital) failed to have the current Blood Bank Agreement Approved by the Medical Staff. The CAH identified a census of 4 at the time of the survey.

Failure of the Medical Staff to approve the Blood Bank Agreement could potentially result in a lack of/or insufficient blood on available for the patients of the CAH.

Findings include:

Review of the Blood Supply and Services Agreement, dated 9/19/13, showed it lacked evidence of Medical Staff Approval.

An interview on 4/22/14 at 2:50 PM, the Interim CEO (Chief Executive Officer) and Laboratory Manager verified the Medical Staff lacked involvement with the current Blood Supply and Services Agreement.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to document the date 1 of 1 bottle of glucometer test solution in the Nursing Unit was opened in accordance with the manufacturer's requirements. The CAH 135 glucose control tests performed on the nursing unit from 4/1/2013 - 3/31/2014.

Failure to document the date that the bottle of glucometer test solution potentially allowed staff to use the test solution after the manufacturer's shortened expiration date of three months after the bottle of control solution was opened for the first time. This potentially resulted in inaccurate test results using the expired test solution with the glucometer. This could lead to inaccurate test results when the glucometer is used to measure the blood glucose level for a patient and any changed treatments based on the potentially inaccurate results of the glucometer.

Findings include:

1. Observation on 4/21/14 at 1:50 PM, during tour of the Medication Room, located on the Nursing Unit, with Staff B, Registered Nurse, revealed 1 of 1 opened bottle of Free Style (glucometer) Control Solution available for use. The bottle of Control Solution lacked documented evidence of the date the staff first opened the bottle.

2. Review of manufacturer's instructions for the FreeStyle Lite Control Solution stated, in part, ". . . FreeStyle Control Solution is good for three months after opening the bottle or until the expiration date printed on the label, whichever comes first. . . ."

3. During an interview at the time of the tour, Staff A acknowledged the Glucometer Control Solution lacked documented evidence showing the date the staff initially opened the bottle to reflect the shortened expiration date, as required by the manufacturer.

Based on review of policies, medication error documentation, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to notify the physician when medication errors occurred for 3 of 6 Patients, (Patients #1, 2, 3). The CAH had a current census of 4 inpatients at the beginning of the survey.

Failure to report medication errors to the physician could potentially cause harm to patients if the patient received the wrong dosage of medication or medication at the wrong time.

Findings include:

1. Review of the undated CAH policy titled, "Medication Errors", revealed in part ". . . When any of the above occur [wrong dosage of medication administered or wrong time of medication administered] you shall: . . . Notify the attending physician of the medication error. . . ."

Review of patient medication error reports revealed:

The Medication Error report for Patient #1 dated 4/17/14 revealed the patient received a nebulizer treatment (used to treat breathing problems) 2 hours late.

The Medication Error report for Patient #2 dated 4/7/14 revealed the patient received a wrong dose of Vancomycin (used to treat infection).

The Medication Error report for Patient #3 dated 4/26/13 revealed the patient received a wrong dose of Zithromycin (used to treat infection).

2. During an interview on 4/24/14 at 10:40 AM, Staff A, Assistant Chief Nursing Officer, stated the nursing staff did not follow the facility policy for reporting the medication errors to the physician. Staff A acknowledged the documentation revealed nursing staff failed to notify the physician about the medication errors for Patients # 1, 2, and 3.

Based on policy review, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure a system is in place for identifying, reporting, investigating, and controlling infections and communicable diseases among contracted staff, who provide patient care services in the CAH, for 1 of 2 contracted staff (Staff V). The administrative staff reported an inpatient census of 4.

Failure to perform health screening could result in a person working at the facility with a communicable disease, which could be passed to other staff or patients.

Findings include:

1. Review of the policy titled "Employee Health Policies", approved 12/11/13, revealed in part "Policy: Van Buren County Hospital provides a comprehensive . . . employment health program for employees to assure staff members . . . are free of communicable disease . . . 8. All hospital employees must have a physical assessment every 4 years . . . "

2. During an interview on 4/22/14, at 4:00 PM, Staff U, Finance and Human Resources Manager reported she did not have any documented evidence of a physical assessment for contracted Staff V, ultrasonographer. Staff U reported she did not maintain any personnel files on contracted employees and was not sure if any other department within the CAH did either.

3. During an interview on 4/23/14, at 4:00 PM, Staff M, Interim Administrator, provided copy of a documented health appraisal for Staff U, dated 7/6/08, obtained from another facility. Staff M acknowledged the health appraisal was over 4 years old and was unaware who, within the hospital, ensured contracted staff met the requirements of their employee health policies.

I. Based on observation and staff interview, the Critical Access Hospital (CAH) dietary department failed to follow sanitary practices to prevent the contamination of patient food and beverages. The CAH had a census of 4 patients at the time of the survey. The Dietary Manager reported the dietary department served approximately 270 patient meals monthly.

Failure to follow acceptable guidelines for kitchen sanitation could potentially result in contamination of patient food and beverages, which could contribute to an outbreak of food borne illness.

Findings include:

The following concerns were identified during the initial kitchen environment tour on 4/21/14, at 10:25 AM:

1. The bulk containers of sugar and flour had scoops stored inside with the handles in contact with the product. During an interview at the time, Staff F, Dietary Manager, reported the scoops should not be left in the product, but hung on the hook inside the container, specifically for that purpose.

2. The Cornelius ice machine drain ran into the floor and failed to provide an air gap to prevent potential backflow and contamination of the ice. During an interview at the time Staff F confirmed the potential for contamination and reported she did not think the ice machine any internal backflow prevention on the drain pipe.


II. Based on observation, facility menu review, policy review and staff interview, the CAH Dietary Manager and Consultant Dietitian failed to ensure a planned menu for all patient diet types, ordered by the physician, was available to dietary staff, in order to meet their nutrient needs. The CAH had a census of 4 patients at the start of the survey. The Dietary Manager reported the dietary department served approximately 270 patient meals monthly.

Failure to provide a planned menu, for dietary staff to follow, could potentially result in patients receiving inadequate or excess nutrients resulting in complications, including in part, high or low blood sugar, altered fluid balance, missed tests, delayed surgical procedures, and potential malnutrition.

Findings include:

1. Review of a Dietary/Nutritional Services policy titled "Nutritional Care", approved 12/11/13, revealed in part ". . . a menu cycle is used to accommodate general therapeutic diets . . . The Clinical Dietitian will make adjustments for additional modifications as ordered by the physician . . ."

Review of patient diet orders revealed Patient #4's diet order, on 4/16/14, included a diabetic diet with a 1600 calorie diet restriction and pureed texture.

Review of the CAH diet spreadsheets revealed they failed to include a planned menu for a Diabetic diet/1600 calorie restriction.

2. Observation of patient meal service on 4/21/14 at 11:45 AM and 4/22/14 at 11:45 AM revealed Patient #4 was served the same planned menu items as patients on a regular diet, except the texture was pureed.

Review of the nutrient analysis for the regular diet, provided by Staff F, Dietary Manager, revealed an average daily calorie content of approximately 3000 calories.

3. During an interview on 4/21/14 at 11:15 AM, Staff G, cook, acknowledged the menu available in the kitchen did not include a planned 1600 calorie diet, and relayed diabetic diets are basically served the same thing as a regular diet, except they are given sugar-free items.

During an interview on 4/21/14 at 1:15 PM Staff F confirmed the diet spreadsheets lacked a planned menu for a 1600 calorie restriction. She reported there was a planned diabetic diet titled "CCHO/LCS" (Consistent Carbohydrate/Limited Concentrated Sweets) but acknowledged she did not know how many calories that diet would provide.

During an interview on 4/21/14 at 1:45 PM Staff H, cook, acknowledged the menu available in the kitchen, did not include a planned 1600 calorie diet, but relayed diabetic diets are basically served the same thing as a regular diet, but receive sugar substitute, sugar-free jello, etc instead of regular items.

During an interview on 4/22/14 at 10:00 AM, Staff I, cook, explained the diet spreadsheet identified what patients are to receive on the various diets but acknowledged there was no column for a 1600 calorie diet restriction. She relayed she followed the column titled "CCHO/LCS" because that was the diabetic diet.


III. Based on medical record review, document review, policy review and staff interviews, the Critical Access Hospital (CAH) Contracted Dietitian failed to continue the nutrition screening process on all patients identified upon admission, with nutrition risk factors. The CAH administrative staff identified a current census of 4 patients at the start of the survey. In the past six months, the CAH admitted 5 skilled and 36 acute patients that were identified by the admission nutrition screen to need further assessment by a dietitian in order to address nutrition risk factors.

Failure to follow-up on patients identified with nutrition risk factors could potentially result in the failure to identify patients with nutrition-related problems, leading to complications in managing their care and an increased length of stay.

Findings for 1 of 4 open medical records (Patient #4), 1 of 10 closed skilled admissions (Patient #5) and 10 of 11 closed acute admissions(Patient #5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) revealed a lack of documentation by the Contracted Dietitian to address the admission nutrition screen scores of 4 or higher within 2 calendar days of admission. (Patient #5 was identified on both an acute and skilled admission.)

1. Review of a contract for dietitian services, with an effective date of 5/16/13, revealed a contract for services of a registered dietitian to provide consultation for professional dietetic services including, but not limited to, reviewing patient charts and appropriately documenting all services for patients in the electronic medical record (EMR).

2. The CAH staff use policies and procedures to provide guidance to staff for consistency and continuity of patient care. During an interview on 4/21/14 at 1:15 PM, Staff F, Dietary Manager, reported she had not located the department policy and procedure manual yet and was not sure the department had one. During a follow-up interview on 4/22/14 at 9:15 AM, Staff F confirmed she eventually found the department policy and procedure manual in the kitchen, but acknowledged she has not had any involvement in reviewing or revising any of the department policies since her initial employment beginning in January 2013.

a. Review of Dietary/Nutrition Services policies and procedure revealed:

b. Review of a Dietary Services policy titled "Nutrition Assessment and Follow Up", approved on 12/11/13, revealed in part "Definitions: Low Risk = 0-3, Moderate = 4-6, High Risk = 7 or > . . . The Dietary Services Department provides nutritional assessment for all patients deemed to be at nutrition risk . . . The computer assigns a risk level to each patient based on the results of the screen. A report of these patients and their corresponding risk level is displayed on the Dietitian's system list . . . A clinical dietitian will evaluate patients determined to be at nutrition risk. Based on the evaluation, the dietitian may reassign risk level. A clinical dietitian will complete a nutrition assessment within 2 calendar days of determination of risk. Documentation is recorded in the patient's electronic medical record . . ." Review of minutes from the CAH board of trustees meeting on 9/24/13, revealed the approval of this policy, however, the policy was not found in the nursing, swing bed or dietary policy and procedure manuals.

c. Review of a Dietary/Nutritional Services policy titled "Nutritional Screening and Monitoring" approved on 12/11/13, revealed in part "1. The admission assessment will be completed by an RN (Registered Nurse) for each patients within 24 hours of admission . . . 2. The RD/Dietary Manager will continue the nutritional screening process by reviewing the patient's EMR and interviewing the patient and/or patient's family. 3. . . the RD will assign appropriate nutrition acuity level and document the screening accordingly . . ." This policy was in the Swing Bed policy and procedure manual but was not in the Dietary/Nutritional Services manual.

d. Review of a Dietary/Nutritional Services policy titled "Nutritional Screening and Monitoring" approved on 12/11/13, revealed in part ". . .The admission assessment form will be completed by an RN for each acute patient within 24 hours of admission. The RN will evaluate the nutrition screening criteria and inform the Dietician/Dietary Manager of patients needing further nutrition intervention. A copy to be placed in patient . . . chart. The RD/Dietary Manager will continue the screening process of the admission assessment form by reviewing patient charts and interviewing the patient and/or patient's family . . . the RD will assign appropriate nutrition acuity level and mark the screening card accordingly . . . " This policy appeared in the Dietary/Nutritional Services policy and procedure manual.

In addition, the Dietary/Nutritional Services policy and procedure manual contained a form titled "Nursing Nutritional Screening Form". Review of the form revealed it directed nursing to complete the form and request a dietitian consultation if the criteria, outlined on the form, was met. The form included an area for a signature and date.

3. During an interview on 4/23/14 at 8:45 AM, as part of the total CAH program review interview, Staff C, Health Information Management Director, reported the expected practice for the reviewing and revising of policies and procedures included the department manager to review them previous to the annual total program review. A portion of the annual meeting is used to review and approve the department policy and procedure manuals. Staff M, Interim Administrator, acknowledged a problem with the process in regards to the dietary department policies and procedures not being updated to reflect current practice.

During an interview on 4/28/14 at 12:15 PM, Staff J, Consultant Dietitian, reported she has not had any involvement in the development or review of the nutrition services policies and procedures and did not know what the CAH nutrition screen/follow-up policy included.

4. Open record review, on 4/21/14 at 2:30 PM, of Patient #4's medical record revealed the Nutrition Screening/Adult was completed on 4/16/14 and identified the patient had 4 points each for food intake less than 50% of usual for greater than 7 days, unintentional weight change greater than 9 pounds and chew/swallow difficulty, in addition to 2 points for vomit/diarrhea greater than 3 days. Staff B, RN, confirmed the medical record lacked any documentation by Staff J to address the patients nutrition status. Staff J reported the nutrition screen results are sent to the dietitian so she can further evaluate the nutrition risk factors of the patients.

During an interview on 4/22/14 at 11:15 AM, Staff L, Information Technology Director, demonstrated the EMR access available to Staff J and where her documentation would appear. Staff L confirmed the EMR for Patient #4 lacked any documentation by Staff J.

5. Review of reports generated by Staff L, from the EMR, identified 10 skilled patient admissions and 11 acute patient admissions, in the past six months, with a nutrition screen score of 4 or greater, whose admission lasted beyond 2 days. The reports further identified 1 of the skilled patient admissions and 10 of the acute patient admissions had no entries documented by Staff J, to address their nutrition risk.

During an interview on 4/21/14 at 4:00 PM, Staff F reported the results of nutrition screens do not print to the kitchen. She further reported she does not have access to the EMR, thus has no knowledge of patients that may have been identified to have nutritional risk factors. During a follow-up interview on 4/22/14, beginning at 9:15 AM, Staff F reported that a nutrition screen score of 4 or greater would trigger the patient for further review by Staff J. She relayed Staff J is able to access the EMR off-site and can check the computer daily for any new patients and their nutrition screen results. Staff F reported Staff J will be out of state beginning this morning but unsure for what time period. She relayed Staff J arranged for another dietitian to provide coverage in her absence. Staff F was not sure if the covering dietitian would have access to the EMR but could call her if she was aware of any special patient needs, that would require her involvement.

During an interview on 4/22/14 at 12:10 PM, Staff K, Dietitian, confirmed the arrangement for dietitian coverage in Staff J's absence. Staff K reported she had not provided coverage at the CAH before and was not familiar with their nutrition screening and follow-up process. Staff K confirmed she did not have access to the EMR and would depend on Staff F to notify her of any patients needs.

During an interview on 4/23/14 at 9:30 AM, as part of the CAH Quality Assurance (QA) interview, Staff D, Chief Nursing Officer, Staff M, Interim Administrator, Staff O, Social Work/Utilization Review and Staff P, Performance Improvement Director were present. The interview confirmed there were no current problems identified in the QA process with the nutrition documentation on the lack of documentation for patients identified with nutrition risk factors. In addition, the interview confirmed the CAH failed to provide administrative oversight of the contract fulfillment to ensure Staff J provided adequate oversight of patient's nutrition status. Staff P reported Staff J would review charts on each visit and evaluate patients identified on the nutrition screens, except would not look at obstetrics patients.

During an interview on 4/23/14 at 1:15 PM, Staff A, Assistant Director of Nursing, reported she received information from the University of Iowa (assisted with the EMR system set up) which documented Staff J receives results of all patient nutrition screen scores in a report to address accordingly.

During an interview on 4/28/14 at 12:15 PM, Staff J reported she becomes aware of patient nutrition screen scores via a status report set up on the EMR, which she checks about 3 times a week. She explained the report includes new patient admissions, their admission date, diet order and nutrition screen score. Staff J confirmed the status report includes acute and skilled patients and she addresses patients with a nutrition screen score of 4 or higher, but acknowledged that she probably misses some. She was surprised to learn there were several acute patients that lacked documentation from her, but acknowledged she did not assess obstetrics patients, even if the score was 4 or higher. Staff J acknowledged she had not thought through how the dietitian she arranged for coverage in her absence, would be aware of any nutrition screen results, since she did not have access to the EMR.

Based on observation, review of policies and procedures, and staff interviews, the respiratory therapy department failed to secure and protect patient information from unauthorized users by not securing 1 of 1 binders containing respiratory therapy daily schedules with patient names and diagnoses and 2 of 2 hanging files containing confidential patient information. The respiratory therapy manager identified an average daily census of approximately 2 in patients and 5 out patients.


Failure to secure the patient information could potentially cause a misuse of patient information but those with access to the information.

Findings include:

1. An observation on 4/22/14 at 9:45 AM, revealed a binder containing the respiratory daily patient schedule that identified the patient's name and diagnoses within a file cabinet in the respiratory area on the west wall. Additionally, hanging files were found in a drawer containing approximately 1,700 respiratory patient files from January to December 2013 and 350 respiratory patient daily charge forms from January 2014 to March 2014. Each file contained patient information including but not limited to name, name of doctor, medical record number, date of birth, age, admit date and confidential health information and diagnosis.

2. During an interview, at the time of the observation, Staff N, Respiratory Therapist manager stated housekeeping clean the respiratory therapy office after hours and they would not be supervised by respiratory therapy staff and respiratory therapy is not staffed 24 hours a day. Staff N verified that staff are educated regarding the hospital policy for confidentiality and security of patient medical records and "obviously" this would be something they would have to correct.

During an interview, on 4/23/14 at 10:15 AM, Staff C, Health Information Manager (HIM) verified that anyone who is providing care of all patients should have access to the patients confidential health information and it would be hospital policy and procedure. Staff C stated she was aware there were problems with medical record security in the respiratory therapy office and they should have "known" that any and all patient medical record information should be locked and secured when housekeeping staff are cleaning their office after hours. Additionally, Staff C said "ultimately" it is the departments responsibility to have their records secured against unauthorized access.

3. During an interview, on 4/23/14 at 10:55 AM, Staff Q, Housekeeping Supervisor verified they cleaned the respiratory therapy office during the evening hours from 10 PM to 6 AM. Staff Q stated that housekeeping staff receive education regarding security of medical record information for all patient's and the only staff who should have access to patient medical record information would include doctors, laboratory, radiology, and "whoever" takes care of the patient and housekeepers should "not".

4. Review of policy titled, "New Employee Orientation and Training for Housekeeping", reviewed 12/11/13, revealed the following in part, ..."The housekeeping manager will review the information in the new employee department orientation with the new hire...the following hospital policy shall be reviewed in this part of the orientation program:...patient bill of rights."

Review of policy titled, "Your Rights and Responsibilities as a Patient" reviewed 12/11/13, revealed the following in part, ...you have protection from unauthorized review of your records...confidentiality will be maintained of medical and other appropriate information's."

Review of policy titled, "Access by Workforce" reviewed 12/13/13 revealed the following in part, ..."The minimum necessary standard applies to access and use of protected health information by the members of the workforce...This means the workforce members may access and use the minimum necessary protected health information only - b. within the scope of the individual's authority, based on role and responsibility at Van Buren County Hospital."

Based on document review and staff interviews, the CAH (Critical Access Hospital) failed to ensure 1 of 1 active family practice physicians and 2 of 2 teleradiologists selected for review, received outside entity peer review performed by the Network Hospital during their previous re-appointment period, in order to evaluate the appropriateness of diagnosis and treatment furnished to patients at the facility. (Physicians A, B and C). TheCAH staff identified Physician A evaluated 6 patients, Physician B interpreted 1 radiology report and Physician C interpreted 3 radiology reports in the past 3 months. .

Failure to ensure all medical staff members received outside entity peer review affects the facility's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of the physician credential files on 4/22/14 revealed the facility failed to ensure the Network Hospital completed peer review for Physicians A, B and C. One CAH may not conduct outside peer review for another CAH .

2. During an interview on 4/22/14 at 1:35 PM, Staff C, Director of Health Information Services, reported another CAH provides external peer review for Physician A (Family Practice). Physician's B and C (Teleradiologists) do not have an external peer review completed during the physicians' last credentialing cycle. All other physician peer review is completed at the CAH's network hospital. The CAH Utilizes a quality assurance report from Virtual Radiology for Physicians B and C but does not complete an external peer review for them.

3. Review of the CAH Policy titled External Medical Staff Peer Review revised 12/2012 revealed in part... "To ensure that the patient care provided at Van Buren County Hospital and Medical Clinics is of high quality and is appropriate to the patient's needs, the medical staff, in addition to completing its own internal assessment of patient care, will submit a random sampling of medical records for external review to a network facility or other outside entity."

Based on review of policies and staff interview, the Critical Access Hospital (CAH) staff failed to update the Patient Rights policy that contained the current Patient Visitation Rights information. The CAH had a current census of 4 inpatients at the beginning of the survey.

The CAH staff identified an average number of outpatients served in the following out patient areas:

Out patient surgery: 6 patients per month
Emergency room: 150 patients per month
Out patient treatments: 120 patient encounters per month
Out patient blood transfusions: 2 patients per month
Lab: 35 patients per day
Cardiac rehab: 14 patients per month
Pulmonary rehab: 5 patients per month
Respiratory therapy: 5 patients per month
Obstetrics: 5 patients per month
Scopes: 15 patients per month
Sleep study: 4 patients per month
Therapies (Physical and Occupational): 54 patients per month
X-ray: 350 patients per month

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

Findings include:

1. Review of Administration policies revealed Patient Rights policy titled "Van Buren County Hospital and Medical Clinics Your Rights and Responsibilities As A Patient - Acute Care", revised 10/20/03, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 4/22/14 at 1:50 PM, Staff D, Chief Nursing Officer (CNO), acknowledged the Administration Patient Rights policy lacked the current patient visitation rights information as required by the regulation.

Based on review of policies and documents, observations, and staff interviews, the Critical Access Hospital (CAH) staff failed to provide out-patients with current patient visitation rights.

The CAH staff identified an average number of outpatients served in the following out patient areas:

Out patient surgery: 6 patients per month
Emergency room: 150 patients per month
Out patient treatments: 120 patient encounters per month
Out patient blood transfusions: 2 patients per month
Lab: 35 patients per day
Cardiac rehab: 14 patients per month
Pulmonary rehab: 5 patients per month
Respiratory therapy: 5 patients per month
Obstetrics: 5 patients per month
Scopes: 15 patients per month
Sleep study: 4 patients per month
Therapies (Physical and Occupational): 54 patients per month
X-ray: 350 patients per month

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

1. Review of Administration policies revealed Patient Rights policy titled "Van Buren County Hospital and Medical Clinics Your Rights and Responsibilities As A Patient - Acute Care", revised 10/20/03, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. Observations during tour of the CAH on 4/21, 22, 23/14 revealed the Patient Rights document posted in the outpatient areas (Emergency room, Lab, Pulmonary rehab, Physical and Occupational Therapy, X-ray) lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Observations during tour of the CAH on 4/21, 22, 23/14 revealed no Patient Rights information posted in the following outpatient areas: Outpatient surgery, respiratory therapy, Cardiac rehab, Sleep Study, outpatient blood transfusion area, outpatient non-stress test area.

3. During an interview on 4/22/14 at 1:15 PM, Staff E, Admissions Receptionist, stated registration staff did not provide outpatients a copy or tell them of their patient visitation rights during the registration process.

During an interview on 4/22/14 at 1:50 PM, Staff D, Chief Nursing Officer (CNO), acknowledged the Patient Rights posted in the outpatient areas failed to include the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. Staff D acknowledged the Administration Patient Rights policy lacked the current patient visitation information.

During an interview on 4/23/14 at 8:20 AM, Staff N, Respiratory Therapy Manager, acknowledged the Patient Visitation Rights were not posted in the outpatient Cardiac Rehab area.