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Based on document review and staff interview the Critical Access Hospital (CAH) failed to schedule patient meals in accordance with applicable state regulations. The Administrative Staff identified a census of 7 patients and the Dietary Manager reported an average of 45 patients meals served daily.

Failure to avoid extensive lapses between meals could potentially result in not meeting nutritional needs of the patients.

Findings include:

1. Review of the Iowa Administrative Code for the Department of Inspections and Appeals, Chapter 51 titled "Hospitals", last updated 12/10/14, revealed in part ". . . 51.20(2)b.(2) Not more than 14 hours shall elapse between the evening meal and breakfast of the following day.

2. Review of a Dietary Department policy titled "Frequency and Type of Meals Served" approved in 12/14, included in part "...For patient meals on oral intake, the interval between the evening meal and the next meal is not more than 14 hours..." The policy identified the usual meal delivery for the ICU as 5:20 PM for evening meal delivery and 7:45 AM for breakfast meal delivery, an interval of 14 hours and 25 minutes. The policy identified the usual meal delivery schedule for the Medical/Surgical unit as 5:15 PM for evening meal delivery and 8:00 AM for breakfast meal delivery, an interval of 14 hours and 30 minutes.

3. During an interview on 6/22/15, at 2:00 PM, Staff P, Registered Dietitian/Dietary Department Manager, reported the patient meal times were recently changed related to a temporary move of the Intensive Care Unit (ICU) with the current scheduled patient meal delivery times as 7:50 AM (breakfast), 11:45 AM (lunch) and 5:20 PM (supper).

During an interview on 6/23/15, at 8:15 AM, Staff P acknowledged the current patient meal delivery times resulted in a 14 1/2 hour interval between the evening meal and breakfast the following day and confirmed the previous meal delivery schedule has exceeded 14 hours for a long time. She relayed the meal time was calculated based on when the patient might be finished eating supper, calculated to be approximately 30 minutes after delivery, to the time the patient would receive breakfast and believed this met the intent of the rule.

Based on review of policy, documents, observations, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure outdated patient supplies were removed from 2 of 8 patient care areas of the CAH so expired supplies were not available for use for patient care. (Surgery Medical/Surgical units) The CAH staff reported a census of 7 patients on the medical/surgical unit and approximately 600 surgeries completes since 1/1/2015.

Failure to remove outdated patient supplies from the CAH's supplies available for use in patient care could potentially result in supplies used for patient care beyond the date set by the manufacturer.

Findings include:

1. Review of CAH policy titled "Checking Expiration Dates ", reviewed 11/2014, included in part, "1. All supplies except those in the Pyxis system will be checked monthly in Surgery and quarterly in the Medical/ Surgical departments. The crash carts will be checked monthly for expiration dates of both medications and supplies ."

2. During the tour of the of the CAH observations revealed the following:

a. On 6/23/15 at 8:00 AM, with Staff C, Certified Registered Nurse Anesthesia (CRNA), the surgery procedure room showed:
(1) 500 ml (milliliter) IV bag of 0.9% Normal Saline - expired 4/2015
(2) tongue blades- expired 4/2015
b. Difficult Intubation Cart:
(1) 4 cc (cubic centimeter) tube of lidocaine ointment - expired 4/2015
During an interview on 6/23/15 at 3:30 PM, Staff C verified the outdated patient supplies found in the surgery area.

b. On 6/22/15 at 1:00 PM, with Staff B, RN, (Registered Nurse), the Medical Surgical unit crash cart showed:
(2) 500 ml IV bags of Lidocaine expired 12/2014
(1) 5% Dextrose IV bag, 500 ml expired 10/2014

3. During an interview on 6/22/15 at 1:25 PM, Staff B verified the outdated patient supplies found in the Medical Surgical unit crash cart and stated staff were to check monthly for the outdated supplies.

Based on review of policy, documents, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the provision of a written agreement for emergency water and failed to assess the quantity of fuel and water supplies readily available at the CAH, and those that may be needed within a short time through additional deliveries during an interruption in services, as part of the planning for emergency fuel and water agreements. The administrative staff identified a census of 7 patients and reported an average daily census of 13 patients.

Failure to ensure adequate emergency water and fuel is available to meet the CAH's critical functions, during an interruption in services, could potentially cause a lack of the necessary resources to provide adequate patient care during an emergency.

Findings include:

1. Review of a Maintenance policy titled "Fuel Supply Management", approved December 2014, revealed in part "...The hospital power plant relies on No. 2 fuel oil as a back up fuel for the boilers and a primary fuel supply for the emergency generators..." The policy lacked assessment details of the amount of fuel the CAH had on hand, the estimated amount needed to continue services, and how quickly a delivery of emergency fuel would be needed.

Review of a Maintenance policy titled "Contingency Plan - Water System Failure ", approved in December 2014, revealed in part "...The hospital shall provide a dependable and safe... water source...The hospital will also provide a contingency plan in case of the systems failure ..." The policy identified the amount of water needed per patient and employee per day but lacked assessment details of the amount of potable and non-potable water that the CAH had on hand, the estimated amount needed to continue services, and how quickly a delivery of emergency water would be needed.

2. Review of the document titled "Contract for Services", dated 10/6/05, identified an agreement with United Farmers Mercantile Cooperative for fuel oil, in the event of an emergency. The agreement lacked details to identify the quantity of fuel and timeframe of delivery expected by the CAH.

3. During an interview on 6/23/15 at 1:30 PM, Staff F, Chief Information Officer/Safety Director and Staff N, Facilities Manager acknowledged the CAH did not have an assessment in policy, or other document, to identify how much fuel would be needed and how quickly a delivery would be needed, in the event of an interruption in power. Staff F reported the facility has had an agreement with a local vendor for potable water, but has not been able to locate it yet.

During an interview on 6/24/15, at 1:45 PM, Staff F reported a water agreement had not been located and would work with a local vendor to get one in place.

Based on review of documents and staff interview the Critical Access Hospital (CAH) failed to ensure the Director of Medicine or Osteopathy in conjunction with the midlevel providers periodically reviewed patient records, medical orders, and the medical care services provided to the CAH patients for 2 of 2 midlevel's providing patient care at the CAH.

Failure to ensure periodical review of the patient records, medical orders, and medical care provided to patients by the Director of Medicine or Osteopathy in conjunction with the midlevel's providing care could potentially result in a lack of necessary medical care to the patient.

1. Review of the CAH records/documents lacked documentation of face to face (in conjunction) review by the Director of Medicine or Osteopathy and midlevel for patient charts, medical orders, and medical care services provided to the patients.

2. During an interview on 6/24/15 at 11:15 AM, with Staff M, Health Information Management Manager acknowledge the administrative staff of the CAH failed to ensure review of patient record by the Director of Medicine or Osteopathy was in conjunction with the midlevel providing patient care.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure the midlevel providers inconjunction with the Director of Medicine or Osteopathy periodically reviewed patient records, medical orders, and the medical care services provided to the CAH patients for 2 of 2 midlevel's providing patient care at the CAH.

Failure to ensure periodical review of the patient records, medical orders, and medical care provided to patients by the midlevel inconjunction with the MD/DO's providing care could potentially result in a lack of necessary medical care to the patient.

Findings include:

1. Review of the CAH records/documents lacked documentation of face to face (inconjunction) review by the midlevel and Director of Medicine or Osteopathy for patient charts, medical orders, and medical care services provided to the patients.

2. During an nterview on 6/24/15 at 11:15 AM, with Staff M, Health Information Management Manager acknowledge the administrative staff of the CAH failed to ensure review of patient record by the Director of Medicine or Osteopathy was in conjunction with the midlevel providing patient care.

Based on observation, review of records, manufacturer's information, and staff interview the CAH (Critical Access Hospital) failed to remove all outdated sterilized supplies from the central sterilization work room in the surgery department. The CAH administrative performed 1378 surgical procedures in 2014.

Failure to remove outdated sterilized supplies from the central sterilization work room could potentially result in sterile instrument package used for patient surgical procedures beyond the maintained sterilization date set by the manufacturer.

Findings Include:

1. Review of manufacturer's information titled, "Kimguard One-Step Sterilization Wrap" dated 7/12/12 stated in part...Sterilization wrap will maintain sterility for at least 365 days..."

2. On 6/23/15 at 8:00 AM during the initial tour of the Surgery Department Observation with Staff D, RN Surgical Manager revealed blue wrapped surgical instrument packages that had dated on the day of the sterilization process. Observation showed the following 16 blue wrapped surgical instrument packages contained a dated sticker over 365 days old.

Circumcision set-male circumcisions dated 3/13/12
Vaginal Speculum dated 12/10/13
Pediatric vaginal speculum dated 2/8/13
Long weighted speculum x 2 dated 5/1/14
Rake retractor dated 7/7/13 (Used to retract tissue for a biopsy procedure like breast biopsy)
Back up cord for insulin scan x 2 dated 4/10/14 (Used for laprascopic procedures)
EEA staple sizer dated 6/12/13 (Used to measure the colon in a low colon resection to identify size of stapler needed)
Pitcher for irrigation dated 10/19/11
Everestt cord dated 4/17/14 (No longer used in surgery)
Golet retractor dated 10/1/13 (Used for retraction for a biopsy procedure)
Deaver retractor dated 3/13/13 (Used to retract tissue during an open procedure)
Blephroplasty tray dated 12/14/12 (Used by plastic surgeon in a reduction of tissue case)
Enucleation tray x 2 dated 9/20/07 (Used to retrieve eye tissue after death)
The above items were taken out of service, resterilized, and put back into service.


3. During an interview on 6/23/15 at 9:30 AM, with Central Supply Technician E, revealed the blue wrapped instrument packages are not checked for outdates, and they have never been pulled for re-sterilization, unless the the blue wrapper is damaged.

During an interview on 6/23/15 at 9:30 AM, Staff D reported the blue wrappers used in the sterilization process are good indefinitely and the staff would only re-sterilized the blue wrapped sterilized instruments if the blue wrapper showed damaged or related to an event requiring re-sterilization. Staff D stated, "We were not aware that the blue wrapper provided sterility for 365 days."

Based on review of policy, document, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to develop a system to screen patients for the risk of malnutrition and nutritional complications, in the absence of the registered dietitian. The CAH administrative staff identified a census of 7 patients and an average census of 13 patients.

Failure to identify patients with nutrition risk factors could potentially result in a lack of assessment and interventions for patients with nutrition-related problems, leading to complications in managing their care and an increased length of stay.

Findings include:

1. Review of a Dietary policy titled, "Nutrition Screening", approved in 12/2014, revealed in part "...It is the policy of Montgomery County Memorial Hospital to conduct nutrition screening by a registered, licensed dietitian on a new inpatients on the next scheduled working day for the dietitian. Inpatients are not screened on weekends, holidays or vacations days...On scheduled working days, a registered licensed dietitian will conduct an initial nutrition screen of new inpatients to determine an altered nutritional status, so therefore the need for a comprehensive nutrition assessment..."

2. Review of a document titled, "Admissions Date January 1 to June 22 2015" identified patient admissions in the past 6 month. The document revealed13 patients with stays exceeding 3 days, up to a maximum of 11 days. The 13 patients did not receive a nutrition screen in order to identify nutrition risk factors and/or address nutrition problems.


3. During an interview on 6/23/15 at 9:30 AM, Staff P, Registered Dietitian/Dietary Department Manager, reported her responsibilities included the completion of a nutrition screen on all newly admitted patients each scheduled work day. Staff P reported the admission assessment, completed by a registered nurse (RN), included a few nutrition-related questions, but responses to the questions do not generate a referral to the dietitian. She relayed she reviews the admission assessment, during her nutrition screen process, to help identify patients in need of a full nutrition assessment. Staff P reported the CAH has a verbal reciprocal agreement with 2 other CAH's for dietitian coverage in her absence, but this does not include nutrition screening. The dietitian's at these CAH's would only be called if there were a practitioner order for a nutrition consult or nursing encountered a nutrition problem (i.e. tube feeding) which they wanted assistance with. Staff P confirmed she has sole responsibility to screen patients for nutrition risk factors and patients are not screened during her absences, including illness or vacation.

During a follow-up interview on 6/24/15 at 10:30 AM, Staff P reported a nutrition screen is not completed in her absence, per CAH policy, and could result in the lack of identification and interventions for patients with nutrition risk factors, which she would normally address if she were there.

During an interview on 6/25/15, at 7:25 AM, Staff R, Intensive Care Unit Manager, reported the patient admission assessment, completed by an RN, included some nutrition-related questions, but responses to the questions did not generate a nutrition referral, because Staff P performs a nutrition screen on all the patients.

During an interview on 6/25/15, at 8:35 AM, Staff B, Medical/Surgical Unit Manager reported the patient admission assessment, completed by an RN, included a few nutrition-related questions but responses did not generate a nutrition referral. She relayed Staff P sees all the patients and nursing staff rely on her to identify patients with nutrition problems. Staff B reported if Staff P is on vacation, a dietitian does not see the patients or perform any type of nutrition screen, but there is dietitian coverage, in case they need to call with questions.

Based on observation, staff interview and facility policy review, the Critical Access Hospital (CAH) failed to ensure 1 of 1 radiation exposure cord was secured in the general x-ray room to not allow staff access into the x-ray room during testing of patients. The CAH staff reported completing an average of 30 x-ray's in the general x-ray room a day.

Failure to secure the radiation exposure cord could potentially allow staff access to the x-ray room during an xray procedure, exposing staff to unnecessary radiation.

Findings include:

1. During tour of the radiology department on 6/23/15 at 2:00 PM with Staff A, Radiology Manager revealed 1 of 1 radiation exposure cord in the general x-ray room DR was not secured and reached approximately 7 feet into the x-ray room. This would allow staff access to the x-ray rooms during the procedures.

2. During an interview on 6/23/15 at 2:00 PM, Staff A agreed the radiation exposure cord was not secured and would allow staff access to the x-ray room during x-ray procedures. Staff A said the exposure cord should be secured at a short length not allowing staff access to the x-ray room during procedures.

Based on review of documents and staff interview the Critical Access Hospital failed to maintain a list of arrangements or agreements that described the nature and scope of the services provided at the CAH. The CAH estimated having approximately 740 contracts.

Failure to maintain a list of arrangements or agreements that described the nature and scope of the services provided at the CAH could potentially result in a misuse or lack of use for these services.

1. Review of records and documents for arrangements and agreements lacked a description of the nature and scope of services that they provided.

2. During an interview on 6/25/15 at 11:30 AM, with Staff T, Chief Executive Officer, acknowledged the list of arrangements or agreements lacked a description of the nature and scope of the services that they provided.

Based on document review and staff interviews the Critical Access Hospital (CAH) failed to integrate the outpatient Diabetes Education Center and outpatient Nutrition Services patient medical records into the hospital medical record system.

The Diabetes Education Center Registered Nurse (RN) reported the program served 81 patients during the 2014 program year and currently stored approximately 500 patient records in the education center. The Registered Dietitian/Dietary Department Manager reported she counseled 5 outpatients for Medical Nutrition Therapy (MNT) in 2014 and currently stored approximately 12 patient records in her office.

Failure to integrate the outpatient Diabetes Education Center and Nutrition Services patient medical records into the hospital medical record system could potentially result in a loss of communication in patient care due to lack of access to the outpatient record.

Findings include:

1. Review of a policy titled "Outpatient Diet Instructions", approved in 12/2014, revealed in part "...At the completion of their use or at least annually, the Dietitian copy of the MNT record is given to the MCMH [Montgomery County Memorial Hospital] Health Information Management department for inclusion in the patient's permanent hospital record..."

Review of a policy, "Diabetes Self Management Education Documentation", approved in 11/2014, revealed in part "...Records inactive for three years are taken to Health Information Management Department..."

2. During an interview on 6/22/15 at 2:45 PM, Staff O, RN/Diabetes Education, reported documentation for all diabetes center patients, by the nurse and the dietitian, remains in the Diabetes Education Center until files are purged annually by the department secretary. At that time the records are sent to the Health Information Management department, which included the practitioner referral order, progress notes of visits and education records.

During an interview on 6/23/15, at 8:15 AM, Staff P, Registered Dietitian/Dietary Department Manager, reported she keeps the documentation, associated with outpatient visits for MNT, secured in her office and purges the files at least annually to send to the Health Information Management department.



During an interview on 6/23/15, at 10:35 AM, Staff Q, Diabetes Education Center Secretary, reported she reviewed the patient records annually and sends patient records with no visits in the past 3 years to the Health Information Management department. Staff O acknowledged that some patients are considered active for several years which would result in the medical record remaining in the Diabetes Education Center indefinitely.


During an interview on 6/23/15, at 3:45 PM, Staff M, Health Information Management Director, reported the Diabetes Education Center patient records and MNT patient records were brought to the department at least annually. She acknowledged this could potentially result in the patient record being unavailable to other practitioners.

Based on document review and staff interview, the Critical Access Hospital (CAH) Administrative staff failed to ensure 4 of 15 medical staff members, selected for review, received outside entity peer review from an equivalent peer, prior to reappointment to the Medical Staff (Practitioners A, B, C and D). The CAH administrative staff identified 118 members of the medical staff.

Failure to ensure all medical staff members received an outside entity peer review, from a physician reviewer with enough knowledge of the respective areas of practice, affects the CAH's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of a CAH policy titled "Medical Staff Peer Review Process", renewed in 2/2015, included in part, "...The policy failed to identify the need for an equivalent peer to complete the outside entity peer review for each practitioner..."

2. Review of the CAH Network Agreement dated 9/10 included in part, "...[Network Hospital] will assist Hospital [Montgomery County Memorial Hospital]...in identifying and arranging for qualified physicians and other practitioners to consult with Hospital on peer review matters...the provision of peer review and advice with respect to individual patient records..."


Practitioner A, B, C and Practitioner D's credential files lacked documented evidence to show outside entity peer reviews were conducted by an equivalent peer. The documentation showed an Internal Medicine physician performed the outside entity peer reviews for the following physicians:

Practitioner A, MD Obstetrics/Gynecology
Practitioner B, MD General Surgeon
Practitioner C, MD Orthopedics
Practitioner D, DPM Podiatry

3. During an interview on 6/24/15, at 8:40 AM, Staff M, Health Information Management Director, reported all CAH outside entity peer reviews were conducted by an Internal Medicine physician from the Network Hospital, with the exception of the radiologists. Staff M agreed Practitioner A, B, C and Practitioner D had not received an outside entity peer review completed by an equivalent peer and the practitioners were currently credentialed to provide services to CAH patients.

4. The CAH administrative staff reported Practitioner A treated 93 patients, Practitioner B treated 3 patients, Practitioner C treated 3 patients and Practitioner D treated 51 patients, based on 2014 statistics.

Based on review of policies, medical records, and staff interviews, the swing bed interdisciplinary team (IDT) and swing bed nurse manager failed to ensure the attending physician participated in the IDT care conferences for the development and review of the patient's individualized care plan. Concerns identified for 1 of 1 active swing bed patient (Patient #1) and 4 of 5 closed swing bed patients (Patients # 2, #3, #4, and #5).

Failure to ensure the attending physician participated in the IDT care conferences, obtained input from the attending physician when formulated and revised the patient's individualized care plan could potentially result in delays in implementing treatment modalities to improve the patient's functional abilities, to enhance healing and to shorten the stay at the hospital.

At the time of entrance the swing bed nurse manager identified 1 swing bed patient (Patient #1) and an average daily census of 2 patients.

Findings include:

1. Review of Critical Access Hospital (CAH) policy "Swing Bed Interdisciplinary Team Meetings" reviewed 2/15, included in part, "...IDT meets to review, discuss and improve the treatment and quality of care for the patents...committee members include the following personnel...Practitioner..."

2. During an interview on 6/16/15 at 3:05 PM, Staff B, Swing Bed Nurse Manager said she had worked at the hospital for a long time and did not recall seeing a physician at the IDT meetings. Staff B said she didn't think the physician's at the CAH had any involvement with the formulation or review of swing bed patients multidisciplinary care plans or the IDT
meetings.

During an interview on 6/22/15 at 3:15 PM, Staff B, Swing Bed Nurse Manager acknowledged the CAH swing bed IDT team failed to follow policy/procedure. Staff B said the policy clearly included the attending physician attended and/or participated in the weekly IDT care plan meetings.

During an interview on 6/23/15 at 10:40 AM, Staff H, Activities Coordinator confirmed she was a member of the IDT committee. Staff H said the physician never attends the care plan meetings nor do they participate in the review of swing bed patients multidisciplinary care plans.

3. Review of patients medical records showed the following:


a. Patient #1 had a physician's order dated 6/16/15 for skilled nursing services for physical and occupational therapy status post right hip repair. An IDT care conference occurred on 6/17/15 but the documentation on the IDT care plan conference date form lacked evidence showing the physician attended, participated, and/or reviewed the patients care plan prior to the IDT meeting. The medical record lacked a physician progress note prior to the weekly care plan meeting.


b. Patient #2 had a physician's order dated 3/4/15, for skilled nursing services for strengthening status post osteomyelitis of the right great toe for Patient #2. An IDT care conference occurred on 3/11/15 but the documentation on the IDT care plan conference date form lacked evidence showing the physician attended, participated, and/or reviewed the patients care plan prior to the IDT meeting. The medical record lacked a physician progress note prior to the weekly care plan meeting.

c. Patient #3 had a physician's order dated 3/30/15 for skilled nursing services for intravenous antibiotic therapy (IV) for treatment of urosepsis for Patient #3. An IDT care conference occurred on 4/1/15 but the documentation on the IDT care plan conference date form lacked evidence showing the physician attended, participated, and/or reviewed the patients care plan prior to the IDT meeting. The medical record lacked a physician progress note prior to the weekly care plan meeting.

d. Patient #4 had a physician's order dated 5/28/15 for skilled nursing services for End Stage Chronic Obstructive Pulmonary Disease (COPD) and severe pain for Patient #4. An IDT care conference occurred on 6/3/15 and 6/10/15 but the documentation on the IDT care plan conference date form lacked evidence showing the physician attended, participated, and/or reviewed the patients care plan prior to the IDT meeting. The medical record lacked a physician progress note prior to the weekly care plan meeting.

e. Patient #5 had a physician's order dated 2/20/15 for skilled nursing services status post bilateral knee repair arthroplasty for Patient #5. An IDT care conference occurred on 2/25/15 but the documentation on the IDT care plan conference date form lacked evidence showing the physician attended, participated, and/or reviewed the patients care plan prior to the IDT meeting. The medical record lacked a physician progress note prior to the weekly care plan meeting.

4. During an interview on 6/25/15 at 7:45 AM, Staff R, Intensive Care Nurse Manager acknowledged the physician's at the CAH failed to participate in IDT care plan conferences for swing bed patients. Staff R said the physicians are invited every time a care plan meeting occurs but choose not to participate.

Based on review of policies, and staff interview the critical access hospital (CAH) failed to maintain a dental services contract for skilled patients. The Medical/Surgical Nursing Manager reported a current census of 1 skilled patient and an average daily census of approximately 2 skilled patients.

Failure to ensure the CAH maintained a dental services contract to ensure dental services are available for skilled patients could potentially result in patients not receiving routine or emergent dental services if necessary during their hospitalization.

Findings include:

1. Review of policy "Swing Bed Program/Patient Rights" dated 2/21/05, revealed the following in part, ...Dental Services...available for any needed routine dental services and 24 hour emergency dental care if the patient doesn't have their own dentist..."

Review of policy "Swing Bed Program/Patient Rights" updated 2/15, revealed dental services were not included in an update of the policy.

2. During an interview on 6/23/15 at 7:35 AM, Staff B, Registered Nurse (RN) /Skilled Nurse Manager acknowledged the policy failed to include provisions for dental services for skilled nursing patients. Staff B said she was not aware of any agreement with a local dentist to provide dental services to skilled patients at this time.

During an interview on 6/23/15 at 8:00 AM, Staff M, Credentialing Specialist reported no dental contracts or agreements since July 2012.

Based on review of policy, document, and staff interviews, the Critical Access Hospital (CAH) failed to ensure outpatients and visitors were informed of their visitation rights, including the ability to receive to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. The Chief Financial Officer (CFO) identified an average monthly outpatient encounters for the following areas (Fiscal 2015):

Total outpatients: 3,932 patients
Surgery: 84 patients
Cardiac Rehab: 49 patients
Respiratory Therapy: 163 patients
Diabetic Education: 15 patients
Oncology: 73 patients
Sleep study: 7 patients

The Laboratory manager identified an average daily census of 12 outpatients

Failure to ensure outpatient and visitors were informed of their visitation rights could potentially result in the staff failing to extend visitation rights to all patient populations and their visitors.

Findings include:

1. Review of "Notice of Privacy Practices" forms provided to all patients who enter the CAH for outpatient services revealed the forms did not included the patients rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. The patient also has the right to deny or withdraw such consent at any time. All visitors shall enjoy full and equal visitation privileges consistent with patient preferences. The visitors shall not be restricted, limited or denied on the basis of race, color, national origin, religion, sex gender identity, sexual orientation or disability.


Review of CAH policy "Patient Rights and Responsibilities" review date 8/15 revealed the policy did include that patient's have the right to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including same-sex domestic partners), another family member or a friend. The patient also has the right to deny or withdraw such consent at any time. All visitors shall enjoy full and equal visitation privileges consistent with patient preferences. The visitors shall not be restricted, limited or denied on the basis of race, color, national origin, religion, sex gender identity, sexual orientation or disability.

2. During an interview on 6/22/15 at 4:00 PM, the Chief Nursing Officer (CNO) acknowledged the information given to outpatients failed to follow the CAH's Patient Rights and Responsibilities Policy and the information provided to outpatients and visitors did not include the patient's right to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including same-sex domestic partners), another family member or a friend. The patient also has the right to deny or withdraw such consent at any time. All visitors shall enjoy full and equal visitation priceless consistent with patient preferences. The visitors shall not be restricted, limited or denied on the basis of race, color, national origin, religion, sex gender identity, sexual orientation or disability. The CNO said she would be making the necessary changes immediately.