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Based on observation, medical record review, document review, and interview, the hospital failed to ensure their staff provided care in a safe setting to patients at risk of harm to themselves. This deficiency had the potential to cause harm for one of 18 sampled patients, Patient 9. The hospital created an Immediate Jeopardy situation for Patient 9, when the patient expressed the threat of suicide on 08/26/18, the physician ordered the staff to initiate suicide precautions and the hospital staff failed to follow the physician's orders. See Tag A-0144 for further details.

Findings Include:

Review of Patient 9's medical record showed that the patient was placed on suicide precautions upon admission from the emergency department on 08/26/18 at 10:31 PM when the patient threatened suicide. The staff placed the patient in room 203, noting the patient should be in a direct line of sight, to keep the door open at all times, and with no visitors. The medical record did not reflect the assignment of a 1 to 1 staff for direct observation and does not reflect that a staff member stayed in the patient's room throughout the night. The patient did not have a mental health evaluation until the following day on 08/27/18 (no time documented). Suicide precautions ordered via verbal order for Patient 9 on 08/25/18 at 11:46 PM and signed on 08/26/18 at 8:25 AM.

Review of the hospital document titled, "Suicide Precaution Procedure" (06/06), showed, patients who demonstrate or verbalize feelings of depression, hopelessness, or have suicidal ideation may be placed on suicide precautions. The charge nurse may place a patient on suicide precautions for 1:1 monitoring without an order from the physician." Section B documented: "Physician will order 'suicide precautions' on patients who may be potentially harmful to themselves. This requires 1:1 supervision of the patient."

During a tour of the Inpatient Nursing Unit, with observation of Room 203, on 11/27/18 at 1:45 PM with Staff E Quality Improvement Coordinator, (QIC), revealed that room 203 is across from the nurse's station. However, the nurses' station can only see the doorway entry to the room. There is nothing visible inside the room, certainly the patient nor the patients bed could be directly observed/visualized from the nursing station. Room 203 also contained many ligature (hanging) risks in the form of the power cord to the bed, power cord to the IV pump, cords to the two window blinds, suction tubing, and a non-breakaway shower curtain. The patient was placed in an unsafe environment for an extended period of time (hours between nursing visits), unobserved by staff thus, creating an Immediate Jeopardy situation in which the patient, who has voiced intent to harm self, was in an environment that was conducive to harm and potentially death.

Interview on 11/27/18 at 1:35 PM, Staff E, QIC, confirmed that room 203 could not be considered direct line of sight as the interior space of the room could not be seen from the nursing station. Staff E, QIC, confirmed the presence of ligature risks and other items that create an unsafe environment for patients on suicide precautions.

Interview on 11/28/18 at 4:00 PM, Staff A, Director of Clinical Services, (DCS), indicated that the medical record for Patient 9 did not contain evidence of 1 on 1 observation. Staff A, DCS, confirmed that the nursing staff failed to follow the suicide precautions policy by not assigning a 1 to 1 observation for a patient on suicide precautions.

Based on observation, medical record review, document review and interview, the hospital failed to ensure that patients who were at risk of harm to themselves were provided care in a safe setting. This deficiency resulted in potential harm for 1 of 18 sampled Patients (9). The hospital created an Immediate Jeopardy (IJ) situation for a patient with a threat of suicide by not implementing suicide precautions.

Findings Include:

Patient 9's medical record review showed that the patient arrived at the Emergency Department, (ED) on 08/25/18 at 9:21 PM with a chief complaint of "I may have overdosed and have been drinking." Patient also stated upon admission "danger to self." Patient received a medical screening exam at 9:39 PM by Physician Assistant #1 who ordered the following test: Ethanol (alcohol) Serum, Salicylate (Aspirin) Level, Comprehensive Metabolic Panel(measure your sugar level, electrolyte and fluid balance, kidney and liver functions), Pregnancy Serum, Acetaminophen (Tylenol) Level, CBC with Differential (measures components of your blood such as red blood cells which carry oxygen) stable, need to obs (observe), IV (in the vein fluids) to be started and a Urine Drug Screen.

Patient 9's vital signs at admission to ED was: Pulse - 88 (normal 60 - 100), Resp - 20 (normal 12 - 20), BP 122/79 (average normal 120/80), SpO2 - 94% (normal 92 - 100% on room air). Patient 9's history is documented as "Suicidal - took 12 trazadone (sedative and antidepressant) and 4 clonazepam (sedative)with vodka." History also indicates patient has attempted suicide before with taking pills, has a history of substance abuse problems and is positive for behavioral problems, dysphoric (profound state of unease or dissatisfaction) mood and suicidal ideas.

EKG (tracing of the heart) results revealed no concerns with a sinus rhythm (normal) that had occasional premature ventricular complexes (extra heart beats than begin in one of the heart's lower pumping chambers). Lab results indicated: comprehensive metabolic panel no remarkable findings, ethanol serum value 335 (normal 0); Urine Drug Screen did not detect the presence of any substance. Decision was made by Physician Assistant #1 after call with the Poison Control center to place the patient in Observation status; ED Physician aware. Patient admitted to inpatient unit for Observation, placed in room 203 at 10:30 PM. PA #1's admitting assessment "A/IP intentional overdose - Suicide attempt." The Physician Assistant documented that "labs stable, neg drug screen, alcohol 335, CBC for oxygen need and prolonged QT ( a disorder that can cause serious irregular heart rhythms) per poison control case."

Review of hospital document titled, "Suicide Precaution Procedure," dated 06/06, showed, patients who demonstrate or verbalize feelings of depression, hopelessness, or have suicidal ideation may be placed on suicide precautions. The charge nurse may place a patient on suicide precautions for 1:1 monitoring without an order from the physician. Physician will order "suicide precautions" on patients who may be potentially harmful to themselves. This requires 1:1 supervision of the patient.

Nurse's note on 8/25/18 at 11:24 PM documented, "patient in direct line of sight, door to room to remain open at all times, no visitors, call light within reach." Patient placed on "Suicide Precaution" on 08/25/18 at 11:40 PM until specified, with the head of bed at least 30 degrees at all times.

Nurse's note on 08/26/18 at 12:57 AM documented "Patient was admitted to room 203 in care of the physician from the ER, Dx (diagnosis) of intentional Benzodiazepine (psychoactive drugs) overdose. Suicide precautions in place. Bolus of NS (a salt solution infused through the vein) upon admit then NS @ 125 ml (a measure - milliliters) continuous. Continuous O2, monitoring VS, Telemetry (heart monitor).

End of shift report on 08/26/18 at 06:09 AM documented, "suicide precautions and aspiration precautions in place, head of bed elevated. Responds to verbal stimulation deep sedation at this time. IVF, [intravenous fluids] running 125 ml/hour. [Indwelling urinary] Foley cath in patient, patent."

Nursing flow sheets indicate nurse assessments on 08/26/18 at the following times: 0000, 0010 [12:10 AM,] 0448 [4:48 AM], 0542 [5:42 AM], 0752 [7:52 AM], 0800 [8:00 AM], 0900 [9:00 AM], 1130 [11:30 AM], 1145 [11:45 AM], 1200 [12:00 PM], 1215 [12:15 PM], 1230 [12:30 PM], 1315 [1:15 PM], 1400 [2:00 PM], 1430 [2:30 PM], 1445 [2:45 PM], 1500 [3:00 PM], 1515 [3:15 PM], 1700 [5:00 PM], 1730 [5:30 PM], 1800 [6:00 PM], 2130 [9:30 PM]. There is no indication in Patient 9's record that nursing staff initiated 1:1 observation or that suicide precautions were followed as established in hospital policy, or that the patient was in direct line of sight during the extended periods of time in between nursing assessments or interventions.

Staff appear to have left Patient 9 unattended from 00:10 AM to 04:48 AM, again from 5:42 AM until 7:52 AM and from 9:00 AM to 11:30 AM. There is no documentation that the patient had been removed from suicide precautions during these extended hours or that the medical staff had determined the patient to be no longer a risk to themselves.

The telehealth behavioral social worker evaluated Patient 9 on 08/26/18 which resulted in a safety plan to be developed and signed by Patient 9. Patient 9 discharged to home with family on 08/26/18 at 9:25 PM with discharge instructions to follow up with behavioral health provider if feelings or ideas about suicide return. Patient 9 had a scheduled follow up appointment with behavior health provider on 08/27/18.

During a tour of the Inpatient Nursing Unit - Room 203 on 11/27/18 at 1:45 PM, Staff E, Quality Improvement Coordinator, (QIC), verified that the room 203 is across from the nurse's station. However, the nurses station can only see the doorway entry to the room. There is nothing visible inside the room certainly the patient nor the patients bed could be directly observed/visualized from the nursing station. Room 203 also contained many ligature (hanging) risks in the form of the power cord to the bed, power cord to the IV pump, cords to the two window blinds, suction tubing and a non-breakaway shower curtain. The hospital staff placed the patient in an unsafe environment for extended periods of time (hours between nursing visits), unobserved by staff, thus creating an Immediate Jeopardy situation in which the patient, who has voiced intent to harm self, was in an environment that was conducive to harm and potentially death.

Interview on 11/27/18 at 1:45 PM, Staff E, QIC confirmed that room 203 could not be considered direct line of sight as the interior space of the room could not be seen from the nurses' station. Staff E, QIC, confirmed the presence of ligature risks and other items that create an unsafe environment for patients on suicide precautions.

Interview on 11/28/18 at 4:00 PM, Staff A Director of Clinical Services, (DCS), stated that the medical record for Patient 9 did not contain evidence of 1:1 observation. Staff A, DCS, confirmed that the nursing staff did not follow the suicide precautions policy by assigning a 1:1 observation to a patient on suicide precautions.

Based on document review and interview, the hospital did not ensure that data was being collected, measured, or analyzed from all departments assessing their processes of care, services and operations. This deficient practice places all patients at risk for care below accepted standards of practice.

Findings Include:

Review of the hospital document titled, "Quality and Performance Improvement Plan FY (fiscal year) 18, showed, These departments involved in patient care will use tools to plan for review activities; these may include monitoring data, benchmark information, patient satisfaction information and information from other departments related to the services provided by the department and Analyze current performance of PI activities throughout the hospital including contracted services.

Review of the hospital document titled, "Quality and Performance Improvement Plan meeting minutes for FY18," did not include any data, monitors, analysis, or performance improvement activities from the following departments: Radiology, Rehabilitative Services, Respiratory Therapy, or Health Information Management.

Review of the hospital document titled, "Quality and Performance Improvement Plan meeting minutes for FY18," did not include any medical record data, audits or analysis for patient care processes that include patients of high risk of harming themselves or care processes that would ensure the delivery of care was provided in a safe environment. There was no data, chart audit analysis or information in the meeting minutes that reflected the facility was reviewing patient care related to suicidal at-risk patients, patients expressing suicidal ideation or those patients who were placed on suicide risk precautions.

Interview on 11/29/18 at 10:00 AM, Staff D, Director of Quality/Compliance, (DQC), stated that the "Quality and Performance Improvement Committee" had not reviewed or analyzed any data from the departments directly. Staff D, DQC, stated that the corporate organization was in a rebuilding process with the hospital and that all data is either collected from corporate offices or from publicly reported data. Staff D, DQC, confirmed that radiology, physical therapy, respiratory therapy, and health information management are not submitting any data into the committee at the current time. Staff D, DQC, confirmed that the emergency department, nursing services nor the medical staff are conducting chart audits or analyzing data related to patients at risk of suicide or those that may have been on suicide precautions. There were no other sources provided for review during this survey.

Based on document review and interview, the hospital failed to ensure that the governing body, medical staff, and administrative officials are responsible and accountable for ensuring that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety are evaluated. This deficient practice places all patients at risk for ineffective and unsafe care.

Findings Include:

1. Review of the hospital document titled, "Quality and Performance Improvement Plan FY (fiscal year) 18)," showed, The Board of Directors are ultimately responsible for assuring that high quality and safe patient care is provided.

Review of the hospital document titled, "Quality and Performance Improvement Meeting Minutes FY18), did not include any reports or data related to patients at risk of harming themselves, those patients who were placed on suicide precautions, those patients who should have been placed in 1:1 observation or those patients at risk with altered mental states, intoxication or those who may display any signs or symptoms that may place them at risk of harming themselves was collected, analyzed or acted upon by the Quality or Performance Improvement committee. There was no indication that the hospital collected data or performed chart audits on high risk patients being cared for in the Emergency Department or those that were ultimately admitted to the hospital.

Interview on 11/29/18 at 10:30 AM, Staff D, Director of Quality/Compliance, (DQC), indicated that the patient records from the emergency room were reviewed by the attending medical staff providers, but that these charts were not being audited or analyzed by the Quality and Performance Improvement Committee. Staff D, DQC, indicated that the medical staff and governing body receive the quality meeting minutes and data reports. However, there was no data collected around high risk patients, there was no data analyzed and there was no data to provide to the governing body.

Based on document review and interview, the medical staff failed to ensure that providers were accountable to the governing body for the quality of medical care provided to the patients. This deficient practice places all patients at risk for care below accepted standards of practice.

Findings Include:

Review of the hospital document titled, "Quality and Performance Improvement Plan FY (fiscal year) 18," showed, The governing body has delegated responsibility to [facility] administration and medical staff leadership to provide for the planned, systematic, organizational-wide approach to process design and performance measurement, analysis and improvement.

Review of the hospital document titled, "Quality and Performance Improvement Plan," meeting minutes for FY18, did not include any medical record data, audits or analysis for patient care processes that included patients of high risk of harming themselves or care processes that would ensure the delivery of care was provided in a safe environment. There was no data, chart audit analysis, or information in the meeting minutes that reflected the hospital was reviewing patient care related to suicidal at-risk patients, patients expressing suicidal ideation or those patients who were placed on suicide risk precautions.

Review of the hospital document titled, "Medical Staff Meeting Minutes FY18," did not include any medical record data, audits or analysis for patient care processes that include patients of high risk of harming themselves or care processes that would ensure the delivery of care was provided in a safe environment. There was no data, chart audit analysis or information in the meeting minutes that reflected the hospital was reviewing patient care related to suicidal at-risk patients, patients expressing suicidal ideation or those patients who were placed on suicide risk precautions.

Review of the hospital document titled, "Medical Staff Executive Committee Meeting Minutes FY 2018," did not include any medical record data, audits or analysis for patient care processes that include patients of high risk of harming themselves or care processes that would ensure the delivery of care was provided in a safe environment. There was no data, chart audit analysis or information in the meeting minutes that reflected the hospital was reviewing patient care related to suicidal at-risk patients, patients expressing suicidal ideation or those patients who were placed on suicide risk precautions.

Interview on 11/29/18 at 10:00 AM, Staff D, Director of Quality/Compliance, stated that the Quality and Performance Improvement Committee, Medical Staff or Medical Executive Committee had not reviewed or analyzed any data from the emergency department, nursing services or individual provider reviews related to patients at risk of suicide or those that may have been on suicide precautions. There were no other sources provided for review during this survey.

Based on medical record review, policy review, and staff interview, it was determined the hospital's staff failed to have a history and physical examination (H&P) documented in the medical record within 24 hours of admission for 2 of 18 sampled patients. This deficient practices places all patients at risk for lack of continuity of care and uninformed healthcare professionals.

Findings Include:

1. The hospital's staff failed to document an H&P in Patient 28's medical record within 24 hours of admission. The patient was admitted on 10/02/18 to the inpatient unit but the physician dictated the H&P was on 11/04/18 (more than 30 days later).

2. The hospital's staff failed to document an H&P in Patient 25's medical record within 24 hours of admission. The patient was admitted on 08/07/18 to the inpatient unit but the physician did not sign the H&P until 08/22/18 at 09:13 AM (about two weeks later).

Review of the hospital document titled, "Medical Staff Bylaws," Board approval on 09/15/16, showed under "Medical Records" that "a complete history and physical shall be recorded within 24 hours of admission...All history and physical examinations shall be performed and recorded by a licensed physician or by a mid-level provider under the supervision of a physician." The hospital's licensed staff were not following the bylaws.

Interview on 11/28/18 at 10:05 AM, Staff 6/Chief Medical Officer was not able to explain for the missing signature and was unaware that it had occurred. Staff 6 mentioned that the recent switch to electronic documentation system (EPIC) could have played a part.

Interview on 11/28/18 at 09:55 AM, Staff A/Director of Clinical Services agreed that the H&P was not signed as should be by the physician. Staff 1 explained that they would have to start monitoring all records for H&Ps.

Based on observation, document review and interview, the hospital did not ensure that the "Utilization Review Committee" reviewed professional services to determine medical necessity and promote the most efficient use of health services. This deficient practice places all patients at risk for receiving unnecessary health services or not having access to needed health services.

Findings Include:

Review of the hospital document titled, "Utilization Management Plan" (3/18), does not indicate that professional services (Radiology, Rehabilitation, Laboratory, or other professional services) will be a required component for the utilization review committee. Section "Extended Stay Review" is the only area in the plan that indicated "Oversight will include review of the professional services provided and the medical necessity of these services." There is no other mention of professional services review in the "Utilization Management Plan."

Review of the hospital document titled, "Medical Staff Executive Meeting Minutes," for 2018, did not include any reviews or oversight that included professional services or medical necessity of the professional services provided within the organization.

Interview on 11/28/18 at 3:00 PM, Staff D, Director of Quality/Compliance (DQC), stated that the "Utilization Review Committee" met as part of the "Medical Executive Committee" and they reviewed admissions, extended stays and admission denials. Staff D, DQC, confirmed that the hospital was not looking at professional services like Radiology (CT, MRI's, Ultrasound) diagnostic labs or physical therapy services as part of the utilization review function. There were no other sources provided for review during this survey.

Based on observations, documentation/policy review, and staff interview, it was determined the hospital's staff failed to maintain supplies to provide safety and quality to patients by removing outdated supplies from their departments, and failed to perform maintenance on equipment used for patients. This deficient practice places all patients at risk for ineffective treatments and therapies.

Findings Include:

1. Emergency Room (ER):

Observation of outdates on 11/26/18 at 1:15 PM, in the emergency room:
a. Three child oxygen masks, two with expiration dates of 02/08/18 and one mask with an expiration date of 07/31/18.
b. One suction catheter with an expiration date of 08/1996.

Interview during the tour on 11/26/18 at 1:15 PM, Staff T/ER Registered Nurse (RN) stated that she did not realize the O2 masks had expiration dates, but would replace them.

2. Inpatient Unit (IPU):

a. Observation on 11/27/18 at 9:05 AM, on the supply room counter, revealed two bottles of blood sugar test strips that were opened but were not dated when first opened.

b. Observation on 11/27/18 at 9:15 AM, in the supply room cabinets, revealed one urinary catheter with an expiration date of 10/2018 and multiple 3ml (milligram) 22G (gauge) syringes with an expiration date of 09/2018.

Interview during the department tour on 11/27/18 at 9:15 AM, Staff L/IPU RN stated that it was the materials supply department staff responsibility to check for out dates, but understood that the blood sugar test strip bottles should have been dated when opened.

3. Obstetric Unit (OB):

a. Observation on 11/27/18 at 10:30 AM, in the birthing rooms, revealed a secure dressing film with an expiration date of 05/2018, one ultrasound gel with an expiration date of 07/2018, culture swabs with an expiration date of 09/2018, one container of chlorhexidine (topical antiseptic) wash with an expiration date of 09/2016, and one topical anesthetic with an expiration date of 10/2018.

Interview during the department tour on 11/27/18 at 10:30 AM, Staff K/ OB RN, stated that routine checks were made for out dated supplies on that unit but did not realize certain containers had expiration dates.

Review of the hospital's policy titled, "Materials Management Safety," not dated, showed, Rotate all stock to promote use of longest held stock first. This will assure that products are not retained past their expiration (safe use) date. Expired supplies must be removed from stock immediately and disposed of in the manner set forth by Materials Management/Administration. The hospital's staff did not following the policy.


32744

4. Physical Therapy Department (PT):

a. On 11/27/18 at 1:30 PM during a tour of the physical environment, it was observed that the hospital did not show evidence of equipment in the physical therapy department being inspected or a part of a preventative maintenance (PM) program. Items included: a Total Gym GTS machine, and a Pre-Cor stair step machine. Neither machine had any evidence the hospital performed inspections to verify the equipment had been inspected according to the manufacturer's recommendations and maintained for safety.

b. On 11/27/18 at 3:00 PM, the preventative maintenance program requested preventative maintenance on all of the wheelchairs and the hospitals stretchers. Staff E, Quality Improvement Coordinator, (QIC), reported back on 11/28/18 that the 15 wheelchairs in the hospital had not been inspected and were not a part of the hospital's preventative maintenance program.

Review on 11/28/18 of the hospital's document titled, "Equipment P.M.'s memo," (dated 11/28/18), showed, the physical therapy equipment will be inventoried, numbered, and put on a P.M. schedule according to the manufacturer's recommendations. The memo also indicated that all wheelchairs will be inventoried, numbered, and put on a P.M. schedule as well.

Interview on 11/28/18 at 10:00 AM, Staff E, QIC, indicated that the equipment in the Rehab [Physical Therapy] department was missed and was not part of the preventative maintenance program. Staff E, QIC, confirmed that non-electrical equipment including the wheelchairs used throughout the hospital (15 in total) had been missed and that these items will be included in the preventative maintenance system. There were no other sources provided for review during this survey.

Based on medical record review, document/policy review, and staff interview, it was determined the hospital's staff failed to properly execute an informed consent for anesthesia and surgery. Staff failed to check the appropriate box for "type of anesthesia planned" on the informed consent for four of five sampled surgical records (Patients 19, 20, 22, and 28) and the surgeon failed to sign an informed consent for a surgical procedure for one of five sampled surgical records (Patient 19). The hospital's staff failed to have mechanisms in place to monitor properly completed informed consents prior to anesthesia and surgery. This deficient practices places all surgical patients at risk for not understanding the purpose benefits, risks, and other option of the test or treatment.

Findings Include:

1. Review of Patient 19, 20, 22, and 28's medical records lacked evidence the anesthesia staff selected and documented which type of anesthesia was planned for the surgery on the "Informed Consent for Anesthesia, Sedation, and/or Analgesia".

Interview on 11/28/18 at 9:30 AM, Staff 10/Certified Registered Nurse Anesthetist (CRNA) stated that he did mark what kind of anesthesia was planned, but when the evidence of the informed consents were presented, he stated that he would take care of it from now on.

2. Review of Patient 19's medical record lacked evidence the surgeon signed the "Informed Consent Treatment/Procedure" after explaining the risks and benefits, the surgical procedure, and other aspects of the surgical process to the patient.

Interview on 11/28/18 at 9:35 AM, Staff 6/Chief medical Officer (CMO) stated that he was not aware that the consent was not signed, but the patient was informed.

Interview on 11/28/18 at 9:37 AM, Staff 1/Director of Clinical Services (DCS), stated that with the new electronic system "EPIC", not all screens have protection to ensure all fields were filled before going on. She stated that they would have to monitor that in the future.

Review of the hospital's policy titled, "Informed Consents", effective 01/01/11, showed, The patient must be given the opportunity to give an "informed consent" prior to the administration of anesthesia by an anesthesiologist and prior to the performance of operative and/or invasive procedure, diagnostic or therapeutic procedures, or situations when it is deemed advisable to have formal documentation of the patient's consent for treatment. Written verification of the informed consent must be on the patient's chart prior to initiation of anesthesia or any of the above stated procedure ...Must consist of ...Confirmation that the patient has been verbally informed about the anesthesia or procedure ...Documentation must clearly indicate that the patient has had the opportunity to ask any and all questions he/she may have about the proposed anesthesia and/or procedure. Documentation by the physician in the medical record ...That the informed consent was obtained ...The anesthesiologist and/or physician obtaining the consent signs in the appropriate location ...The role of the hospital is limited to obtaining verification that the consent has been obtained by the anesthesiologist and /or physician before the physician is permitted to administer anesthesia and/or perform the procedure. The hospital's staff was not following their policy.

Based on document review and interview, the hospital did not ensure that the "Swing Bed Program" addressed the patient right to refuse work, perform work as part of their plan of care or agree to work as part of the plan of care. this deficient practice places all swing bed patients at risk for not understanding their work choices.

Findings Include:

Review of the hospital document titled, "Swing Bed Program (BWM) [Bob Wilson Memorial], (dated 3/17), lacked a process or procedure for informing patients about their right to work, to refuse work, or to agree to work as part of their plan of care. The swing bed program did not address if patients expressed a desire to work, that they could do so as part of the plan of care, or that the patients could volunteer, or even get paid for services performed.

Interview on 11/28/18 at 11:30 AM, Staff E, Quality Improvement Coordinator, (QIC), verified that there was no process developed to inform patients of their right to work or to refuse work. Staff E, QIC, verified the patients were unaware there was an option for those who expressed a desire to work, that they could do so as part of the plan of care, or that the patients could volunteer, or even get paid for services performed.

Based on document review and interview, the hospital did not ensure that the "Swing Bed Program" addressed the patient right to privacy in written communication, the ability to send or receive mail and to have stationary, postage or writing implements available. This deficient practice places all patients at risk for not having access to their mail and being able to communicate with others by mail.

Findings Include:

Review of the hospital document titled, "Swing Bed Program (BWM) [Bob Wilson Memorial]," (dated 03/17), lacked a process or procedure for the patient right to privacy in written communication including their right to send mail, receive mail that is unopened or to have access to stationary, postage and writing implements.

Interview on 11/28/18 at 11:30 AM, Staff E, QIC (Quality Improvement Coordinator), stated that there was no process developed for patients to send or receive mail. Staff E, QIC, indicated that most patients in the "Swing Beds" receive mail via their family, and the hospital had not addressed this process for the patients.

Based on document review and interview, the hospital did not ensure that the "Swing Bed Program" addressed a patient's right to share a room with his or her spouse when married patients require care in the "Swing Bed Program." This deficient practices places all married swing bed patients or patients with significant others at risk from being separated from their spouse or significant other.

Findings Include:

Review of the hospital document titled, "Swing Bed Program (BWM) [Bob Wilson Memorial], (dated 3/17)," showed the document lacked a process or procedure for spouses, married couples or significant others to share a room within the hospital if both patients required swing bed services.

Interview on 11/28/18 at 11:30 AM, Staff E, Quality Improvement Coordinator (QIC) stated that there was no process developed for married couples, spouses or significant others to reside in the same room in the "Swing Bed Program" should both patients require services under the "Swing Bed Program."

Based on document review and interview, the hospital did not ensure that the "Emergency Operations Plan" identified the use of volunteers in an emergency. The hospital failed to include other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This deficient practiced places the hospital at risk for not having people and other healthcare professionals readily available to provide assistance in case of an emergency.

Findings Include:

Review of the hospital document titled, "Emergency Operations Plan," FY (fiscal year) 2018, showed it lacked a plan or process for the identification and/or use of volunteers in an emergency. The medical staff bylaws did contain an emergency credentialing section during an emergency. However, the overall "Emergency Operations Plan" did not address the use of volunteers or the process of integrating State or Federally designated health care professionals during an emergency.

Interview on 11/28/18 at 9:30 AM, Staff E, Quality Improvement Coordinator, (QIC), stated that there was no process developed and the "Emergency Operations Plan" did not contain a process for the use of volunteers in an emergency. Staff E, QIC, confirmed that the hospital has not identified if or how volunteers could be used during an emergency. Staff E, QIC, also confirmed that there was no process for using state of federally designated healthcare professionals during an emergency.