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I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH staff removed outdated supplies from the inpatient unit, the Emergency Department (ED) and the Outpatient Therapy Clinic. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, after which the manufacturer will no longer guarantee the safety and quality of the supply. The CAH identified a census of 9 patients on entrance, approximately 190 ED visits per month, and approximately 307 outpatient therapy visits per month.

Findings include:

1. Observations during a tour of the inpatient unit on 12/2/19 beginning at 10:00 AM, revealed the following expired supplies:

Room 224
a. 2 of 2 Quaternary Disinfectant Wipes, expired 11/2018 and 10/2019

Dirty Utility Room
a. 1 of 1 Quaternary Disinfectant Wipes, expired 10/2019

Crash Cart
a. 4 of 4 BD Insyte Autoguard IV Catheter, 14 gauge, all expired 10/31/19
b. Crash Cart, 1 of 1 blue top tubes (used to collect blood), expired 11/30/19
c. Crash Cart, 1 of 1 red top tubes (used to collect blood), expired 11/30/19
d. Crash Cart, 1 of 5 7.0 Mallinckrodt ET tube (breathing tube), expired 02/18
e. Crash Cart, 1 of 3 7.5 Mallinckrodt ET tube (breathing tube), expired 11/19
f. Crash Cart, 1 of 1 8.0 Mallinckrodt ET tube (breathing tube), expired 11/19

Infusion Room
a. 1 of 1 orange top tubes (used to collect blood), expired 06/30/19
b. 1 of 1 Huber Plus non-coring needle safety infusion set (used to access a vascular port), expired 12/31/18
c. 3 of 6 BD Insyte Autoguard IV Catheter, 18 gauge, 1 expired 06/2018, 2 expired 04/2019
d. 1 of 28 BD Insyte Autoguard IV Catheter, 20 gauge, expired 10/31/19
e. 2 of 21 BD Insyte Autoguard IV Catheter, 22 gauge, expired 07/31/19 and 10/31/19
f. Quaternary Disinfectant Wipes, expired 10/19


2. During an interview at the time of the tour, the Medical Surgical Manager revealed a CNA on the night shift was responsible for removing outdated supplies. The Medical Surgical Manager and the Chief Nursing Officer verified the supplies available for patient use had expired.

3. Observations during a tour of the Emergency Department (ED) on 12/02/19 at 02:00 PM revealed the following expired supplies:

ED Exam room #4
a. 4 of 6 Hemoccult (checks for blood in the stool) testing cards, expired 11/19
b. 1 of 1 Skin stapler PGX35W, expired 11/19
c. 1 of 5 Suture removal kits, expired 11/30/19

ED Trauma Room #2
a. 3 of 8 Hemoccult testing cards, expired 11/2019

ED Hallway Supply Cart
a. 2 of 3 Foley urinary catheters, size 18 French, expired 08/2019


4. During a tour of the ED on 12/03/19 at 09:00 AM, the ED Manager confirmed the expired supplies.

5. Observations during a tour of the Outpatient Therapy Clinic on 12/04/19 at 09:18 AM revealed 1 of 1 one-gallon container Wavicide-01 Disinfectant solution, expired 07/31/18.

6. During an interview at the time of the tour, the Rehab Director confirmed the Wavicide-01 disinfectant solution was outdated.





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II. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 1 of 2 sinks available for patients to wash their hands in 1 of 1 off-site Out Patient Therapy Clinic. Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in the water causing burns to patients of the CAH. The CAH administrative staff identified 3684 out patient therapy visits for fiscal year 2019 (July 1, 2018 to June 30, 2019).

Findings include:

1. Observations on 12/04/19 at 09:56 AM, during a tour of the off-site Out Patient Therapy Clinic with the Rehab Director, revealed 1 of 2 sinks available for patients to wash their hands, hot water temperature 128.3 degrees Fahrenheit, temperature confirmed by the Rehab Director. The surveyor noted steam rising from the running hot water.

2. Further observation and retesting of the hot water temperature at the patient hand washing sink on 12/04/19 at 01:05 PM with the Facilities Director, revealed the Facilities Director obtained a hot water temperature of 126.5 degrees Fahrenheit.

3. Review of the maintenance policy, "Section 10.4 Domestic Water System/Management," revised 06/2019, revealed "...Temperature Balancing: Stabilizing the domestic hot water to ensure constant temperature readings between 110 degrees F [Fahrenheit] and 130 degrees F [Fahrenheit] maximum...."

4. During an interview on 12/04/19 at 03:40 PM, the Facilities Director acknowledged the policy did not reflect a hot water temperature maximum under 120 degrees Fahrenheit.




III. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure staff performed maintenance on the aquatic therapy pool located at 1 of 1 off-site Out Patient therapy clinic. Failure to perform the manufacturer's recommended pool maintenance and electrical safety checks could potentially result in pool chemical imbalances and the growth of germs, which could potentially result in patient skin irritation or infection, or electrocution, which could potentially result in patient death. The CAH administrative staff identified 622 aquatic therapy patient visits for fiscal year 2019 (July 1, 2018 to June 30, 2019).

1. Observations during a tour of the off-site Out Patient therapy clinic on 12/04/19 at 09:18 AM, revealed 1 HydroWorx aquatic therapy rehabilitation pool, including an underwater treadmill, used for out patient aquatic therapy treatments.

2. Review of the CAH policies/procedures revealed the policies/procedures lacked evidence of a policy/procedure that addressed how the CAH staff would perform manufacturer's recommended aquatic therapy pool maintenance.

3. Review of the aquatic therapy pool manufacturer's recommendations, undated, revealed in part, "...Pool Maintenance Schedule ...Weekly: Check Bromine level in Brominator. Clean baskets in both pumps (side jet/maintenance pump). Clean skimmer Baskets. Shock pooll [sic] with Chloro Brite III. Check Alkalinity and Calcium hardness surface water chemical levels. Monthly: Test the main breaker GFCI [Ground Fault Circuit Interrupter]. Clean or change the pool filter...."

4. Review of aquatic therapy pool maintenance logs revealed a lack of documentation for the following performed maintenance:

-Weekly:
a. Check Bromine level in Brominator.
b. Clean baskets in both pumps (side jet/maintenance pump).
c. Clean skimmer baskets.

-Monthly:
a. Test the main breaker GFCI.


5. During an interview on 12/04/19 at approximately 09:18 AM, the Rehab Director confirmed the CAH lacked a policy/procedure that addressed how the CAH staff would perform the aquatic therapy pool manufacturer's recommended maintenance.

6. During an interview on 12/04/19 at approximately 01:30 PM, the Rehab Director confirmed the CAH lacked documentation the CAH staff performed the following aquatic therapy pool manufacturer's recommended pool maintenance items:

-Weekly:
a. Check Bromine level in Brominator.
b. Clean baskets in both pumps (side jet/maintenance pump).
c. Clean skimmer baskets.
Monthly:
a. Test the main breaker GFCI.


7. During an interview on 12/04/19 at approximately 01:30, the Rehab Director confirmed the CAH staff failed to perform the following aquatic therapy pool maintenance per the manufacturer's recommended maintenance schedule:

-Monthly
a. Clean or change the pool filter.

-Weekly:
a. Shock pool with Chloro Brite III.
b. Check alkalinity and calcium hardness surface water chemical levels.

Based on review of policies, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually for 15 of 23 patient care departments (Administration, Laboratory, Anesthesia, Behavioral Health, Dietary, Maintenance, Respiratory Therapy, Diabetes Education, Discharge Planning/Utilization Review, Rehabilitation Services, Infection Prevention, Medical Records, Obstetrics/Birthing Center, Quality Improvement, and Pharmacy). The CAH administrative staff identified a census of 9 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy "Joint Conference Committee," dated 10/2019, revealed in part, "... All policies will be reviewed by the appropriate department manager and then reviewed and approved by the Joint Conference Committee annually ... Membership: ... Medical Staff, Physician Assistant and/or Nurse Practitioner ..."

2. Review of the Joint Conference Committee Meeting minutes, dated February 6, 2019, revealed the CAH staff performed the Annual Policy and Procedure review for the Administration and Laboratory departments. The meeting minutes lacked documentation a mid-level provider attended the meeting to approve the policy manuals.

Review of Joint Conference Committee Meeting minutes, dated August 7, 2019, revealed the CAH staff performed the Annual Policy and Procedure review for the Anesthesia, Behavioral Health, Dietary, Maintenance, and Respiratory Therapy departments. The meeting minutes lacked documentation a physician attended the meeting to approve the policy manuals.

Review of Joint Conference Committee Meeting minutes, dated November 6, 2019, revealed the CAH staff performed the Annual Policy and Procedure review for the Diabetic Education, Discharge Planning/Utilization Review, Rehabilitation Services, Infection Prevention, Medical Records, Obstetrics/Birthing Center, and Quality Improvement departments. The meeting minutes lacked documentation a mid-level provider attended the meeting to approve the policy manuals.

Review of Joint Conference Committee Meeting minutes, dated February 6, 2019, May 1, 2109, August 7, 2019, and November 6, 2019 lacked documentation a physician and a mid-level provider approved the policy manual for the Pharmacy Department.

3. During an interview on 12/3/2019 at 3:40 PM, the Chief Nursing Officer confirmed the lack of annual policy review for Administration, Laboratory, Anesthesia, Behavioral Health, Dietary, Maintenance, Respiratory Therapy, Diabetes Education, Discharge Planning/Utilization Review, Rehabilitation Services, Infection Prevention, Medical Records, Obstetrics/Birthing Center, Quality Improvement, and Pharmacy by the required group of professionals that included a physician and a midlevel provider.

I. Based on observation and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 observed Certified Registered Nurse Anesthetists (CRNA A) cleansed the stopper on medication vials prior to removing the medication from the vials for 1 of 1 observed surgical patients (Patient #1). Failure to cleanse the stopper could potentially result in the staff introducing bacteria, viruses, or fungi into the medication and then administering the contaminated medication to the patient. Administering contaminated medication could potentially result in the patient developing a life threatening infection. The CAH's administrative staff identified the surgical services staff performed an average of 636 surgical procedures per year.

Findings include:

1. Observations on 12/03/19 beginning at 11:01 AM in OR #2 while setting up for Patient #1's surgery revealed the following:

a. CRNA A (a nurse with specialized training to administer the medications used during surgery to ensure patients do not feel pain during surgery) removed the plastic cover on the top of the medication vial and removed Propofol (a drug used for anesthesia and sedation) using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

b. CRNA A removed the plastic cover on the top of the medication vial and removed Fentanyl (a medication used to ensure patients do not feel pain during surgery) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

c. CRNA A removed the plastic cover on the top of the medication vial and removed Versed (a medication used to ensure patients are drowsy and do not remember the surgery) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

d. CRNA A removed the plastic cover on the top of the medication vial and removed Lidocaine (drug used to numb an area of the body) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

e. CRNA A removed the plastic cover on the top of the medication vial and removed Rocuronium (drug used to ensure patient's muscles are relaxed during surgery) from the vial using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.


2. During an interview at the time of the observation, CRNA A confirmed they did not know they needed to cleanse the vial stoppers prior to removing medication from the vials.

3. During an interview on 12/04/19 at 9:40 AM, the Pharmacy Director confirmed the CAH lacked a policy that required the CAH staff to cleanse the medical vial stoppers with alcohol prior to the staff removing the medication from the vial. The Pharmacy Director acknowledged the CAH followed the requirements of USP <797> (enforceable standards related to sterile IV preparation) which required the CAH staff to cleanse the medication vial stoppers with alcohol prior to removing the medication from the vial.






II. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 3 of 7 surgical staff (Surgeon B, Certified Registered Nurse Anesthetist [CRNA] E, and Physician Assistant [PA] student F) wore surgical attire that covered all hair and upper extremities during surgery for 1 of 1 patients (Patient #1). Failure to ensure all members of the surgical staff wore appropriate surgical attire could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair or skin entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The CAH's administrative staff identified the surgical services staff performed an average of 636 surgical procedures per year.

Findings include:

1. Review of the AORN Guidelines (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) for Surgical Attire, copyright 2019, revealed in part, "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns and nape of the neck should be worn ... When in the restricted areas, all nonscrubbed personnel should completely cover their arms with a long-sleeved scrub top or jacket."

2. Review of the policy "Operating Room Dress Code Policy," last revised 05/2018, revealed in part, "Clean disposable ... hair coverings that cover all hair must be worn by all surgical personnel upon entering surgical core areas or operating rooms." The policy lacked a requirement for the surgical staff in the operating room to fully cover their arms during invasive procedures.

3. Observations on 12/03/19 beginning at approximately 11:30 AM, during a surgical procedure for Patient #1, revealed the following:

a. Surgeon B wore a skull cap. The skull cap consisted of a cap covering Surgeon B's forehead and central part of Surgeon B's hair. The skull cap did not cover the lower approximately one inch of Surgeon B's hair on the side of Surgeon B's head and the back of Surgeon B's head. CRNA E wore a skull cap. The skull cap consisted of a cap covering CRNA E's forehead and central part of CRNA E's hair. The skull cap did not cover the lower approximately one inch of CRNA E's hair on the back of CRNA E's head.

b. CRNA E a wore a green scrub top. The scrub top failed to cover CRNA E's arms from the middle of their upper arms to their wrists. PA Student F wore a green scrub top. The scrub top failed to cover PA Student F's arms from the middle of their upper arms to their wrists.

4. During an interview on 12/03/19 at 1:20 PM, the OR Manager revealed the CAH staff followed the AORN guidelines for surgical attire. The OR manager confirmed the AORN guidelines required the CAH staff to cover all hair and skin while in the restricted areas, acknowledged that Surgeon B and CRNA E wore skull caps, and CRNA E and PA Student F had exposed arms during Patient #1's surgery.


III. Based on observation and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgical services staff had a policy for the cleaning of brushes used while cleaning surgical instruments. Failure to have a policy for the cleaning of brushes used to clean surgical instruments could potentially result in the cleaning process failing to remove all of the bacteria and debris on the brush, which could then potentially infect a different patient when the brush was re-used on another patient's instruments. The CAH's administrative staff identified the surgical services staff performed an average of 636 surgical procedures per year.

Findings include:

1. Observations on 12/03/19 at approximately 1:15 PM, during the pre-cleaning of surgical instruments after Patient #1's surgery, revealed a container on the counter with multiple types of brushes. Central Sterile Technician (CST) D removed one of the brushes from the container and used the brush to scrub the surgical instruments.

2. During an interview at the time of the observation, CST D revealed they thought the Central Sterile Department staff cleaned the brushes in the washer every 2 weeks, but was not sure of the exact process.

3. During an interview on 12/03/2019 at 1:20 PM, the OR Manager acknowledged the CAH surgical services staff lacked a policy or procedure for appropriate cleaning of the brushes used to pre-clean surgical instruments.

4. During an interview on 12/04/19 at approximately 3:15 PM, the OR Manager further revealed that the OR Manager was unable to obtain any manufacturer's instructions for cleaning the brushes, because the brushes were sample brushes that the CAH had used for some time. The OR Manager was unable to identify any guidelines or standards that would provide instructions for cleaning or disposal of brushes used to pre-clean surgical instruments.




IV. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgical services staff followed the manufacturer's instructions for use when using an enzymatic cleaner to pre-clean surgical instruments. Failure to follow the manufacturer's instructions could potentially result in the enzymatic detergents not functioning adequately and failing to remove all bacteria or other infectious agents from the surgical instruments, potentially allowing the bacteria or other infectious agents to pass to the next patient, potentially resulting in the next patient developing a life-threatening infection. The CAH's administrative staff identified the surgical services staff performed an average of 636 surgical procedures per year.

Findings include:

1. Observations on 12/03/2019 at approximately 1:15 PM, during the pre-cleaning of surgical instruments after Patient #1's surgery, revealed the CAH staff used ENZOL Enzymatic Detergent Solution to pre-clean surgical instruments. Central Sterile Technician (CST) D put water in a sink and added 5 pumps (ounces) of ENZOL Enzymatic Detergent Solution to the water.

2. Review of the manufacturer's instructions located on the bottle of the ENZOL Enzymatic Detergent Solution revealed in part, "Add 1 ounce (1 pump) of ENZOL Enzymatic Detergent liquid concentrate per gallon of water ... For equipment with dried-on organic matter, use 2 ounces per gallon of water ..."

3. During an interview at the time of the observation, CST D confirmed that they did not measure the amount of water in the sink and could not tell for sure how many gallons of water were in the sink. CST D acknowledged the manufacturer's instructions on the bottle and did not know why they used 5 pumps (ounces) of the enzymatic cleaner.




V. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the endoscopy staff changed the sterile water flush bottles for 1 of 1 patients (Patient #2) in 1 of 1 Endoscopy Rooms in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The CAH identified that the endoscopy staff performed an average of 708 endoscopy procedures per year.

Findings include:

1. Observations on 12/04/19 at 10:05 AM during an endoscopy (a surgical procedure where a physician inserters a flexible camera into a patient's body) for Patient #2 in Endoscopy Room 1 revealed a bottle of Hospira 500 mL sterile water for irrigation connected to the endoscopy equipment.

2. Review of the manufacturer's instructions on the bottle revealed in part, "Single dose container. Contains no bacteriostat [to prevent bacteria from growing in the sterile water]. Discard unused portion."

3. During an interview on 12/04/19 at approximately 10:15 AM, RN H explained the endoscopy staff's routine was to open a bottle of sterile water for irrigation each morning and connect it to the equipment. Endoscopy staff would use the bottle for 24 hours and would only discard the bottle of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

4. During an interview on 12/04/19 at 11:00 AM, the OR Manager reviewed the manufacturer's directions for the Hospira 500 mL bottles of sterile water for irrigation and acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.




VI. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical service and maintenance staff followed their policy and maintained a temperature from 68 - 75 degrees Fahrenheit (F) in the Operating Rooms. Failure to follow their policy and maintain stated temperature may result in patients becoming hypothermic during surgery which could lead to patients being at higher risk of infections post operatively. The CAH's administrative staff identified the surgical services staff performed an average of 636 surgical procedures per year.

1. Review of policy "Environmental Controls in Surgical/Central Services/Recovery/and Obstetrical Areas, last revised 06/2018, revealed in part, "A temperature of 68-75 degrees F. is comfortable for both patient and personnel in surgical suites..."

2. Review of temperature logs for OR #1 from 10/03/19 through 12/03/19 revealed surgical services staff documented temperatures below 68 degrees Fahrenheit on 28 out of 38 days.

3. Review of temperature logs for OR #2 from 10/03/19 through 12/03/19 revealed surgical services staff documented temperature below 68 degrees Fahrenheit on 24 out of 34 days.

4. During an interview on 12/04/19 at 11:00 AM, the OR Manager confirmed the CAH did not maintain temperature between 68 - 75 Fahrenheit in OR #1 or OR #2.

5. During an interview on 12/04/19 at approximately 4:00 PM, the Maintenance Director revealed maintenance has a system that monitors temperature and humidity in the OR Suite. The Maintenance Director stated they maintained a temperature between 62 and 65 degrees Fahrenheit in the Operating Rooms.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to inform each patient of their visitation rights, including those setting forth any clinically necessary or reasonable restrictions or limitations that the CAH may need to place on such rights, and the reasons for the clinical restriction or limitation. Failure to inform each patient of their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The CAH's administrative staff identified a census of 9 on entrance, approximately 2,409 outpatient visits per month, and approximately 190 ER visits per month.

Findings include:

1. Review of the policy, "Myrtue Medical Center Visitation", last revised 01/2019, revealed the CAH delineated multiple clinical reasons that may necessitate restriction of visitation rights.

2. Review of the brochure "Patient's Rights Information," last revised 06/2019, revealed the brochure lacked information related to any clinical restrictions or limitations that could be placed on a patient's right to have visitors.

3. During an interview 12/04/19 at 4:00 PM, the Chief Nursing Officer (CNO) confirmed the CAH's registration staff provided the Patient Rights and Responsibilities brochure to all patients at registration or admission. The CNO acknowledged the CAH staff failed to include in the patient right's brochure information on any clinical restrictions or limitations the CAH staff could place on the patient's rights to have visitors.




II. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to document each patient received the notice of visitation rights including:

a. the right of the patient to have designated visitors, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and the right to withdraw or deny consent to visitation.

b. including any limitations or restrictions, such as visiting hours, numbers of visitors, or unit-specific restrictions, etc., and the clinical rationale for such limitations or restrictions.

Failure to document that each patient received their visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment. The CAH's administrative staff identified a census of 9 on entrance, approximately 2,409 outpatient visits per month, and approximately 190 ER visits per month.

Findings include:

1. Review of policy, "Myrtue Medical Center Visitation", last revised 01/2019 revealed the policy lacked a requirement to notify patients of their visitation rights.

2. Review of "Registration Consent and Agreement", a document each patient signs upon registration for admission or services at the CAH, revealed the document lacked any information related to receipt of patient visitation rights.

3. Review of medical records revealed the following:

a. Patient #3 was admitted to the CAH on 11/30/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

b. Patient #4 was admitted to the CAH on 11/29/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

c. Patient #5 was admitted to the CAH on 11/29/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

d. Patient #6 was admitted to the CAH on 11/29/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

e. Patient #7 was admitted to the CAH on 11/27/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

f. Patient #8 was admitted to the CAH on 11/30/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

g. Patient #9 was admitted to the CAH on 11/30/19 and signed the Registration and Consent Agreement. The Registration and Consent Agreement lacked information related to visitation rights.

3. During an interview on 12/04/19 at 4:00 PM, the Chief Nursing Officer confirmed the Registration and Consent Agreement did not contain any information related to patient visitation rights.