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Based on observation, document review, and staff interview the Coffey County Hospital failed to provide surgical services in accordance with acceptable standards of practice and failed to protect the health and safety of patients when they were found to have only half of the required amount of a rescue drug or 18 - 20 milligram (mg) vials of Dantrolene (medication to treat Malignant Hyperthermia- rare life threatening condition triggered by drugs used for general anesthesia) available in the hospital (refer to A-0951).

The cumulative effect of the hospital ' s failure to keep the appropriate amount of a rescue drug available for use resulted in a finding by the Centers for Medicaid and Medicare Service (CMS) of Immediate Jeopardy, a situation that is likely to cause serious injury, harm, impairment or death to a patient on 1/9/2017 at 11:00 AM.

The hospital removed the Immediate Jeopardy on 1/9/2017 at 2:40 PM prior to exit by providing a plan to suspend all surgical services while obtaining the additional Dantrolene and by placing the hospital on ambulance diversion to any potential surgical or obstetrical patients until the hospital had obtained the additional 18 - 20 mg vials of Dantrolene and they were available for use.

The hospital reported a census of 8 inpatients. Based on medical review, staff interview, and policy review the hospital failed to ensure patients received their patient rights and consent for treatment for three of twenty-five medical records reviewed (patient # 8, 21 and 22). The hospital's failure to provide the written patient rights and consents could jeopardize the patient's ability to understand their rights and responsibilities for making decisions about their healthcare, patient experience, and impact their quality of care.

Findings include:

- Medical record review on 1/11/2017 and 1/12/2017 revealed patient # 5, 21, and 22's medical record lacked evidence the patients or their representatives were informed of their patient rights and consent at admission.

HIM Staff BB interviewed on 1/12/2017 at 11:30 AM acknowledged the medical records did not have documentation that the patients or their representatives received their patient rights.

Policy titled "Patient Rights and Responsibilities" reviewed on 1/12/2017 at 1: 00 PM directed staff "...At the time of admission as a hospital inpatient..." "...The individual will be provided with written information concerning the individual's rights under law... "

Based on observation, interview, and policy review, the hospital failed to provide information regarding Advance Directives for 2 of 25 medical records reviewed (Patient #16 and #17). Failure to provide information regarding Advance Directives or acknowledge a patient's current Advance Directive put all patients at risk of failure to acknowledge individual patient's rights and requests.

Findings Include:

- Closed medical record review on 1/12/17 at 9:30 AM of Patient #16 revealed s/he was scheduled as an outpatient for a trigger finger release (tendon release of a finger that catches or locks in one position) on 1/10/17. The medical record lacked evidence that Advance Directives were discussed with the patient.

- Closed medical record review on 1/12/17 at 9:45 AM of Patient #17 revealed s/he was scheduled as an outpatient for a TURP (removal of a portion of the prostate gland) on 1/11/17. The medical record lacked evidence that Advance Directives were discussed with the patient.

Interview with HIM Director Staff BB acknowledged the "admission staff have an area on the medical record to document if the patient currently has Advance Directives, but that doesn't always get accomplished and from what I have been told, outpatient surgeries don't get asked about Advance Directives in the preoperative area".

Review of "Assessment and Reassessment of Surgical Patient "directed" ...Upon admission to the pre-op area, a brief initial assessment shall be performed by the Pre-op RN and the Circulating RN. The data obtained shall include, but not be limited to: ...The patient's advance directive, if available."

Based on policy review and interview the hospital failed to include the requirement in their policy and procedure for reporting deaths occurring within one week following restraint use or seclusion. Failure of the hospital to include this provision in their policy had the potential for not recognizing a restraint or placement in seclusion may have contributed to a patient's death.

Findings include:

- Review of "Restraints, Adult" on 1/12/17 directed "...Death as a result of restraints will immediately be reported to the Center for Medicare/Medicaid Services (CMS)..."

Interview with Chief Nursing Officer Staff A on 1/12/17 confirmed the "policy does not include to follow up on any death that might occur within a week after restraint use. I'm not sure that we ever thought death might be a result of restraint use so long after the use is stopped."

Based on record review and document review the hospital failed to have current history and physical for 1 of 25 medical records reviewed (Patient #16). Failure to have a current history and physical in the medical record put patients at risk for incorrect or outdated medical information and unsafe care.

Findings include:

- Physician Staff X observed on 1/10/17 at 11:50 AM in pre op bay #2 performed a preoperative review of Patient #16, scheduled for a trigger finger release (tendon release of a finger that catches or locks in one position). Physician Staff X asked Patient #16 if s/he had questions about the scheduled surgery and marked the surgical site.

Medical record review of Patient #16 1/12/17 revealed a complete history and physical with system review performed by Physician Staff X on 12/7/16 at the pre surgical office visit. The history and physical was reviewed and updated on 1/11/17 preoperatively with no changes noted and signed by Physician Staff X.

Interview with Chief Nursing Officer Staff A on 1/10/17 at 11:55 acknowledged pre operative history and physicals must be current within 30 days of surgery. "The hospital requirement is if the history and physical is outside 30 days physicians must perform a history and physical immediately prior to surgery."

Policy review on 1/12/17 of "Outpatient Surgery Admission Criteria" directed "...a history and physical done within 30 days of the surgery requires an update within 24 hours of admission, or prior to surgery. If the H & P is older than 30 days, a new H & P is required..."

Based on interview, documentation and policy and procedure review the hospital failed to provide documentation of current preventative maintenance for 1 of 2 X-ray machines. Failure to provide scheduled maintenance to the x-ray machines put all patients at risk for inaccurate readings of their x-rays, wrong diagnosis and treatment of findings.

Findings include:

- Record review on 1/9/17 at 12:00 PM revealed Rad Source provides annual maintenance for the x-ray machines at the facility. Review of the last preventative maintenance performed was dated 11/5/14.

Interview on 1/10/17 at 2:40 PM, Radiology Director Staff S verified the last preventative maintenance to the x-ray machine was completed on 11/5/14. Staff S provided an e-mail stating Rad Source will be contacting them as soon as possible (ASAP) to schedule the next preventative maintenance for the x-ray machine.

Interview on 1/12/17 at 9:56 AM, Radiology Director Staff S stated a policy and procedure for preventative maintenance for the x-ray machine is not part of their policy and procedure manual, and they are not able to locate the manufacturer's guidelines for maintenance of the x-ray machine. Staff S stated an e-mail was received from Rad Source this morning stating there was a miscommunication and the last preventative maintenance was missed. Rad Source will be out today 1/12/17 to complete the preventative maintenance and return to a regular schedule of February in the following years.


Omni imaging states ...There are several reasons for following a schedule of planned maintenance of x-ray equipment. Briefly stated, you want your equipment to produce the images you need for you and you want to avoid disruptions to your practice. More specifically, the reasons for preventative maintenance include the following: 1. Limit patient exposure, 2. Limit retakes, 3. Improve image quality, 4. Lower possibility of major component failure, 5. Longer equipment life, 6. In some cases, compliance with governmental regulations.

Based on observation, interview, and policy review the hospital failed to provide emergency lighting in all areas of the facility. Failure to provide emergency lighting during a power outage had the potential to put all patients' and employees' safety at risk.


Findings Include:


- Observation of unscheduled power outage on 1/10/17 at 9:20 AM revealed no emergency lighting in the preoperative/postoperative area of the Hospital. Power remained off approximately 45 seconds to 1 minute.

Interview with Chief Nursing Officer Staff A, present during the outage, acknowledged "no emergency lights are installed in the pre/postoperative room and staff were unable to locate flash lights".

Maintenance Staff U and R interviewed on 1/12/17 at 11:30 confirmed the lack of emergency lighting in the pre/postoperative room. Maintenance Staff R stated "there are flash lights in the nursing station outside the pre/postoperative area." Maintenance Staff R and U reviewed the power outage report generated after the 1/10/17 outage and acknowledged the pre/postoperative area is not part of the report "meaning there are no emergency lights in the area and we just had not recognized that previously".

Based on observation, interview and policy and procedure review the hospital failed to maintain and ensure an acceptable level of safety and quality for equipment in the physical therapy department as evidenced by documentation for cleaning the Hydrocollator (holds hot moist packs) revealed 48 of 52 weeks missed, dirty tape wrapped around the top of a wooden cane, tears in the cover of the mini trampoline with foam and springs exposed, and rust on the grill of the soda machine in the cafeteria. Failure to maintain and ensure an acceptable level of safety and quality for equipment puts all patients at risk for infection, falls and unsafe treatments. Additionally, the facility failed to ensure expired supplies were disposed properly for one of one Labor and Delivery medication room. Failure to dispose of expired supplies puts all patients at risk for receiving treatments with unsafe and poor quality supplies.

Findings include:

- Observation on 1/10/17 at 1:20 PM in the physical therapy department, treatment room 1 had a wooden cane hanging on the wall with two areas of clear tape wrapped around it. The tape was curling and dirty on the edges. Tape on equipment becomes a dirty environment for bacteria to grow and it is not a cleanable surface. In the center of the room was a mini trampoline with tears in the blue covering which exposed foam and springs. The cleaning logs lacked documentation the hydrocollator was cleaned for 48 of the last 52 weeks.

Interview on 1/10/17 at 1:40 PM, Therapy Director Staff V verified the tape on the cane, the tears and exposed foam and springs on the mini trampoline and cleaning logs on the hydrocollator revealing 48 weeks that the machine failed to be cleaned. Staff V stated the equipment will be changed out and going forward the hydrocollator logs will be completed each week.

Policy and procedure review on 1/10/17 policy "Rehabilitation Services" states ...rehabilitation services department housekeeping ...clean hydrocollator pack units quarterly or as needed ...check and replenish water in hydrocollator as needed ...hydrocollator pack covers are washed quarterly or as soon as they show signs of soiling ...the water in the hydrocollator unit is changed monthly. The unit is drained washed down with a hospital approved germicidal solution ...the outside of the unit is cleaned weekly with a hospital approved stainless steel cleaner.

- Observation on 1/10/17 at 10:35 AM revealed the grill on the bottom of the soda machine in the cafeteria showed rust over all surfaces. Rust on the grill is a potential for acquiring tetanus or other infections. Equipment in a food area of the hospital should be free from all rust.

Interview on 1/10/17 at 10:35 AM, Dietary Staff N verified the rust on the grill at the bottom of the soda machine. Staff N stated it will be fixed or replaced immediately.

Interview on 1/12/17 at 9:20 AM, Staff R stated a new grill has been ordered for the bottom of the soda machine and the facility failed to have a policy and procedure for the cleaning of the grill.

Labor and Delivery medication room observed on 1/9/2017 at 9:40 AM revealed a Clorox Wipes container with expiration date of 11/25/2016.

Registered Nurse Staff D interviewed on 1/9/2017 at 9:40 AM acknowledged the Clorox Wipes had expired and should have been disposed. Staff D was not aware there were expiration dates on Clorox Wipes.

Policy reviewed on 1/11/2017 revealed the hospital failed to ensure to direct staff about disposing of expired supplies on their units.

Based on observation, interview and policy and procedure review the hospital failed to provide documentation of operating room (OR) temperature and humidity logs for 2 of 2 operating rooms and 1 of 1 procedure rooms. Failure to provide documentation of OR temperature and humidity logs put all patients at risk for infections, disease and blood borne pathogens.

Findings include:

- Observation on 1/10/17 at 11:15 AM revealed the facility failed to have documentation of OR temperature and humidity logs for the ORs.

Interview on 1/11/17 at 10:23 AM, Preventative Maintenance Staff U stated with the power outage yesterday (1/10/17) they were not able to obtain documentation of the OR temperatures and humidity. Staff U was asked to provide documentation of the temperature and humidity logs from 2016 and he/she stated they do not have any. Staff U stated a new process will be started and will provide the actual temperature and humidity in numbers and graphs.

- Policy and Procedure review on 1/12/17 revealed policy "Infection Prevention and Control Measures" states ...Relative humidity shall be maintained at 20-60 percent, as recommended by the American National Standards Institute (ANSI), the American Society of Healthcare Engineers (ASHE), and the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE)...Temperature of the operating room shall be maintained at 68-75 degrees F (FGI Guidelines 2014, ANSI/ASHRAE/ASHE Standard 170-2008)...

- Association of perioperative Registered Nurses (AORN) recommends OR temperatures range from 68-75 degrees Fahrenheit (F) and OR humidity ranges from 20-60 %. IT Watch Dogs by Geist states ...One reason to maintain the OR temperature range is to prevent the buildup of humidity in the OR. When the space is kept too warm, condensation can collect on surfaces, including the room's ceiling and various operating equipment. In addition to making the room uncomfortable, this condensation buildup can pose serious risks to patient health. If this moisture is left to collect and not prevented through temperature monitoring, it can build up to the point that it falls from these surfaces. It is possible and dangerous, for this condensation to fall onto sterilized surfaces, operating tools or possibly into an open wound. As moisture moves along these surfaces, it can pick up additional bacteria that can seriously infect a patient. In order to prevent the buildup of these droplets, the operating room should be equipped with a temperature sensor and monitoring system for maintaining the recommended range.

The hospital reported a census of 8 inpatients. Based on observations, staff interviews, and policy review the hospital's Infection Control Officer failed to ensure wearing of proper attire in one of one surgical and procedure areas (Staff K), enforce compliance with disposal of contaminated articles in one of one pre/post-operative areas (Staff Q), hand hygiene in four of four observations (Staff I, J, K, C, and E), and that expired food was disposed of in one of one Medical Surgical Unit patient's refrigerator. These deficient practices had the potential to expose all patients in the facility to contamination with microorganisms.

Findings Include:

- CRNA Staff K observed on 1/10/17 at 11:40 AM, exiting surgical suite 2 wearing a cloth skull cap with hair exposed on the sides and back of head and wearing a mask with beard exposed below and to each side of the mask.

Interview on 1/10/17 at 11:40 AM with CRNA Staff K stated "the American College of Surgeons (ACS) Guidelines no longer require full hair coverage and those are in reference to those working directly in the surgical field anyway."

- Review of policy "Attire in the Operating Room" directed "...All head and facial hair shall be covered while in the restricted areas of the surgical suite. The surgical hat or hood shall be clean, free of lint and confine the hair..."

- The Board of Regents of the ACS approved this statement in July 2016 "...During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections..."

- Recommendations by American Operating Room Nurses (AORN) for proper surgical attire includes "...hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squamous and hair shed from the scalp from falling onto the surgical field ..."

- Observation on 1/9/17 at 12:54 PM, Tech Staff Q wearing a surgical mask around their neck in the pain clinic.

Interview on 1/9/17 at 12:55 PM, Tech Staff Q stated he/she had not removed the mask when leaving the operating room (OR). Staff Q stated he/she took the portable C-Arm (a medical imaging device based on X-ray technology) into the OR and forgot to remove the surgical mask when brining the C-Arm back down the hallway into the pain management room. Staff (Orio) removed the mask and discarded it into the trash immediately.

- Observation on 1/11/17 at 1:32 PM, Certified Registered Nurse Anesthetists (CRNA) Staff K walked into the pharmacy wearing a surgical mask around their nose and mouth obtained some medication bags and walked back out of the pharmacy.

Interview on 1/11/17 at 1:33 PM, CRNA Staff K verified he/she had left the OR walked down the hall into the pharmacy and was going back into the OR and did not remove the surgical mask. Staff K stated he/she "had no intention to change it" and walked away.

- RN Staff I observed starting an IV on patient #16 (needle placed in a vein of the arm to administer fluids and medications through) on 1/10/17 at 9:00 AM in pre op bay #2 with blood spill on the floor next to the bed. RN Staff I cleaned the spill with gauze pads and Clorox wipes and threw all contaminated articles in the trash container next to the bed.

OSHA (Occupational Safety and Health Association) guideline definition for Universal Precautions is "...an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens..."

Interview with Chief Nurse Officer Staff A acknowledged that "currently there is not a designated container to dispose of contaminated articles in the pre op/post op area. I will make sure one is provided in the area."

- RN Staff J observed admitting Patient #16 to the pre op area on 1/10/17 at 8:50 AM applied gloves, reviewed the surgical consent with Patient #16, and charted on the computer, and removed the gloves without washing hands before or after wearing the gloves.

- RN Staff I observed wearing gloves in pre op bay #3 on 1/11/17 at 9:15 AM drawing Zofran (medication for pre-treatment of nausea) from a vial into a syringe at Patient #17 bedside. RN Staff I logged onto computer wearing the gloves and then drew versed (medication used for relaxation) from a vial into a syringe while wearing the same gloves.

- CRNA Staff K observed in pre op bay #3 on 1/12/17 at 10:00 AM and discussed surgery with Patient #17, shook hands with Patient #17, followed by accessing computer in the nursing area without washing hands.

Medical Surgical Unit observation on 1/10/2017 at 8:40 AM and 9:02 AM revealed Staff C failed to perform hand hygiene prior to entering room 102 (patient # 21) and room 106 (patient # 22). Staff C was passing their morning medications.

Registered Nurse Staff C interviewed on 1/10/2017 at 9:10 AM acknowledged they did not do hand hygiene prior to entering the patient rooms. Staff C stated it is in their policy to perform hand hygiene prior to entering a patient's room.

Medical Surgical Unit observation on 1/10/2017 at 8:50 AM revealed Staff E failed to perform hand hygiene prior to entering room 102 (patient # 23). Staff E was passing their morning medications.

Licensed Practical Nurse Staff D interviewed on 1/10/2017 at 8:55 AM acknowledged they did not do hand hygiene prior to entering the patients room. Staff D stated they should have done hand hygiene prior to entering the patient's room but was nervous with the surveyor watching them.

Policy titled "Hand Hygiene" reviewed on 1/10/2017 directed staff "...Alcohol base hand rubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation..." "...Handwashing must be done prior to caring for a patient..." "...Alcohol-based foam dispensers are located in all patient care areas. The foam is acceptable to use in place of soap and water in all instances between patients except when the hands are visibly soiled ..."

Medical Surgical Unit patient's refrigerator observed on 1/9/2017 at 9:30 AM revealed the following expired foods:
1) One Breeze Nutritional Drink 8 ounce with expiration date of 9/27/2016.
2) Three Mighty Nutritional Shakes 4 ounce with expiration dates of 8/13/2015 and 1/6/2017.
3) Two Tomato Soup cans 7 ¼ ounces with expiration dates of 8/10/2016.

Certified Nurse Assistant Staff O interviewed on 1/9/2017 at 9:35 AM acknowledged the Nutritional drink/shakes and soup was expired and should have been disposed.

Kitchen Manager Staff N interviewed on 1/10/2017 at 9:00 AM stated their department was responsible to dispose all food that had expired in the nurse's patient refrigerator. Staff N handed the surveyor their policy on expired food. Staff N acknowledged those foods should have been disposed.

Policy titled "Dietary" reviewed on 1/10/2017 directed staff "...Nursing refrigerator will be checked daily and any out dated food will be removed ..."

Based on review of the Quality Assurance and Performance Improvement (QAPI) program and staff interview, the hospital failed to provide documentation of ongoing discharge planning review by the facility through the QAPI committee. Failure to provide ongoing review of the discharge planning put all patients at risk for not having their rights, protection, costs and services provided in a safe and appropriate manner.

Findings include:

Interview on 1/11/17 at 9:16 AM, Social Worker Staff AA reviewed the discharge planning for patients at the facility. Staff AA stated she/he was not aware of who would be providing ongoing review of the discharge planning at the facility.

- Review of the QAPI program on 1/11/2017 at 9:16 AM revealed the facility lacked documentation of an ongoing review of discharge planning.

Interview on 1/11/17 at 11:58 AM, Registered Nurse (RN) Staff P verified the facility failed to have documentation providing ongoing review of discharge planning in the QAPI program Administrative Staff P stated review of discharge planning will be brought to the QAPI committee.

- The Center for Medicare Advocacy states ...Receiving oral and written notice of a proposed discharge from one care setting to another is essential ...A notice is any written or oral discussion of one's rights and protections, particularly with respect to costs and services available in a proposed care setting.

The hospital reported a census of 8 inpatients at the time of survey. Based on observation, staff interview, and policy review the hospital failed to provide adequate amounts (at least 36 vials) of Dantrolene (a medication used for the rescue of a patient who develops malignant hyperthermia (MH) - a life threatening reaction to general anesthesia that can quickly result in death) in their MH cart.
This deficient practice created the potential for the hospital to be unable to manage a life threatening MH Crisis (rapid rise in body temperature as a result of medication used during general anesthesia). An immediate jeopardy situation was identified on 1/9/17 at 11:00 am at which time the hospital's administration halted all surgical procedures and placed themselves on emergency room diversion to all potential surgical or obstetrical patients. The facility removed the immediacy by obtaining the required 36 vials of Dantrolene on 1/9/17 at 2:40 pm prior to the survey exit.

Findings include:

- Observation of the Dantrolene cart in the Surgery Department on 1/9/2017 at 11:00 AM revealed 18 vials of Dantrolene. The requirement for Dantrolene is 36 vials with sterile water readily on hand.

CNO Staff A interviewed on 1/9/2017 at 11:00 AM acknowledged they only have 18 vials of Dantrolene available. Staff A notified pharmacy to see if they had any in stock. Pharmacy did not have any more Dantrolene. Staff A was not aware that 36 vials of Dantrolene were required. Staff A stated that the pharmacist had called other facilities and can get more Dantrolene by tomorrow morning. Staff A mentioned they had discussed the Dantrolene in one of the medical staff meetings and they came up with 18 vials of Dantrolene was required.

CEO Staff B interviewed on 1/9/2017 at 11:30 AM indicated they will call around to get the Dantrolene sooner than tomorrow am.

Interview with the DON (Director of Nursing) Staff A 1/10/17 at 10:.00 AM " I misunderstood the decision on how much Dantrolene we keep on hand. I guess about 15 years ago, Medical Staff did look at how much Dantrolene was to be kept on hand and at that time, there were no changes made. Within about the last year, our Pharmacist Staff F and Certified Registered Nurse Anesthetist (CRNA) Staff K talked about it again and Staff K thought the amount on hand is sufficient and the decision was made not to order anymore."

- Malignant Hyperthermia Association of the United States "Proposed Protocol for Management "reviewed on 1/9/17 at ?am revealed "...To maintain an emergency cart stocked with all the drugs and supplies needed during a critical situation ...Dantrolene -36 (20 milligram) vials ... ... Give IV Dantrolene 2.5 mg/kg rapidly through large-bore IV, if possible. Repeat as frequently as needed until the patient responds with a decrease in ETCO2 (end tidal carbon dioxide - a measure for the concentration of respiratory gases during inhalation and exhalation) decreased muscle rigidity, and/or lowered heart rate. Large doses (>10mg/kg) may be required for patients with persistent contractures or rigidity.

- Policy titled " Management of Patient with Malignant Hyperthermia " reviewed on 1/10/0217 directed staff " Administer Dantrolene IV as soon as possible. The recommended dosage is 2.5mg per kg, and repeat the dose until the signs are controlled. Dissolve 20mg of Dantrolene in each vial with a minimum of 60 ml of sterile preservative-water for injection. As a large quantity may be necessary, a sufficient supply must be available. Vials are available in the Pharmacy. Additional vials will be obtained by the Pharmacy from outside sources, if needed ... "

Based on policy review and interview the hospital failed to provide provision of transfer in the case of the facility closing for all swing bed patients. Failure to provide for patient transfer put all swing bed patients at risk of lack of continuous health care.

Findings include:

- Policy review of "Patient Bill of Rights" directed "...CCH must permit you to remain in CCH, and not transfer or discharge you from CCH unless it is: Necessary for your welfare and your needs cannot be met by CCH, The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by CCH, The safety of individuals in CCH is endangered, The health of individuals in CCH would otherwise be endangered, You have failed, after reasonable and appropriate notice to pay for (or to have paid under Medicare or Medicaid) a stay at CCH..."

Interview with Medical Social Worker Staff AA confirmed the statement for transfer of swing bed patients did not include closure of the facility and made note the change to the patient rights would be brought to the attention of administration.

Based on policy review and interview the hospital failed to provide information to swing bed patients regarding their right to appeal a transfer or contact information for advocacy agencies for developmentally challenged patients. Failure to provide the information put all swing bed patients at risk of lack of protection in unsafe care.

Findings include:

- Policy review of "Patient Bill of Rights" directed "...You have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of CCH. CCH must protect and promote the rights of each resident, including each of the following rights: ...Be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion ..."

Interview with Medical Social Worker Staff AA on 1/12/17 at 1:00 PM confirmed the patient bill of rights does not include contact information to the state appealing a transfer if the patient does not believe the transfer should occur. Also, no contact information is stated as provided for developmentally challenged individuals regarding advocacy contacts.