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Based on observation, policy review and staff interview, the facility failed to ensure annual safety checks were completed for 25 of 25 electric beds, 1 of 1 Bipap machines (machine to assist patients with breathing)and 1 of 1 defibrillators (machine to assist patients initiate a heart beat) located on the medical/ surgical floor. The facility had a current census of 14 patients.

Failure to complete annual inspections of electric equipment could potentially result in unsafe functioning of the equipment.

Findings include:

During an observation on 2/17/14 at 225 PM with Staff A, Nurse Manager revealed:

1. 25 of 25 electric beds lacked evidence of electric safety checks.
2. 1 of 1 Bipap machine located in the supply room had an electric safety check on 6/2012.
3. 1 of 1 defibrillators located on the crash cart by the nurse's station had an electric safety check on 6/2012.

Review of the facility policy titled "Electric Beds and Equipment" effective 8/2002 revealed in part... "Procedures: All electric beds in general patient care areas will be checked annually for leakage and routinely for mechanical malfunctions. Each bed will have a sticker showing when it was checked, by whom and electrical reading."

During an interview on 2/17/14 at 3:25 PM, Staff B, Chief Engineer stated none of the electric beds have had safety checks in the past year. The facility thought the Biomedical contractor had checked them and the Biomedical contractor thought the facility checked the beds. Staff B also stated the Bipap machine and the defibrillator had not been checked for safety since 6/2012.

Based on observation, menu review, policy review and staff interviews the facility failed to plan defined food portions for all items on the patient menu and failed to plan a non-select menu, for all diet types, to use for patients unable or unwilling to make their own selections. The administrative staff reported a census of 14 patients and the Dietary Manager reported the department served approximately 40 patient meals daily.

Failure to provide a planned menu with defined food portions, for dietary staff to follow, could potentially result in patients receiving inadequate or excess nutrients.

Findings include:

Review of the facility menu/tray tickets revealed they lacked portion sizes for all menu items.

During an interview on 2/17/14, beginning at 3:15 PM, the Clinical Dietitian reported the facility did not have a standard/house menu for dietary staff to use for patients who were unable or chose not to make their own selections. She reported if there were no family members available to select for the patient, the Roomservice/Diet Aides would select for them, but acknowledged there was not any written guidelines or planned meal pattern for them to follow, to ensure selections meet the patients diet order and nutrient needs.

During an interview on 2/18/14 at 9:30 AM, Staff G, Roomservice/Diet Aide, reported many patients make their own menu selections but some will defer the meal choices to the Roomservice/Diet Aides. Staff G relayed she selects a variety of foods for the meal, taking into consideration any known preferences, but confirmed there was no set pattern or menu to follow in this case.

During an interview on 2/18/14 at 10:00 AM, Staff F, cook, reported many of the items served to the patients are pre-portioned, but if not, he learned the portion sizes from another cook. Staff F reported the portion size for the mashed potatoes was a 2 ounce (oz) portion and then obtained the serving utensil he would use, which was a #12 scoop (equivalent to 1/3 cup/3 oz.).

During an interview on 2/18/14, the Dietary Manager (present at the interview with Staff F), reported the serving size for mashed potatoes should be a #8 scoop (equivalent to 1/2 c./4 oz) and confirmed this was the standard portion size for all vegetable, fruit and potato/starch items served to patients. The Dietary Manager acknowledged the need for education on the expected portion sizes and reported the previous select menus had the portion sizes for all items identified on the menu slips.

Observation during noon meal service on 2/18/14 revealed Staff F served corn with a #12 scoop, to 3 of 12 patients, with corn selected on their menu.

During an interview on 2/18/14 at 1:20 PM, the Dietary Manager confirmed Staff F should have used a #8 scoop for the corn.

Review of a dietary policy titled "Diets Orders", reviewed in 6/2013, revealed in part ". . . Purpose: To provide appropriate and accurate meal service to patients . . . "

Review of a dietary policy titled "Hospital Menus", reviewed in 6/2013, revealed in part ". . . Purpose: . . . To ensure adequate nutrition for patients . . . to ensure that proper diets, serving sizes and tray accuracy are in place . . ."

Based on observation, policy and document review, and staff interviews, on-site Speciality Clinic staff failed to secure medical records from unauthorized access in rolling file cabinets and upright filing cabinets and wall mounted cabinets. The speciality clinic director identified an average daily census of 29 patients.

Failure to secure medical records from access by unauthorized individuals could potentially result in unauthorized use of a patient's personal information found in the medical record.

Findings include:

Review of hospital policy titled "Confidential Information" reviewed 6/13, revealed the following in part, "It is the policy of Jefferson County Health Center to restrict unnecessary or inappropriate access to and disclosure of protected health information...The following categories of employees are not permitted access to confidential healthcare information...environmental services."

Review of "Patient Rights and Responsibilities" revision date 1/11, distributed to all patients when they register for inpatient or outpatient care services, revealed the following in part, "You are entitled:...to the confidentiality of your clinical records."

Observation during the speciality clinic tour on 2/18/14, beginning at 11:50 AM, accompanied by Staff E, Registered Nurse (RN)/Clinic Coordinator, revealed approximately 1,400 active medical records stored on rolling file cabinets, approximately 250 active medical records stored in upright filing cabinets, approximately 70 medical records stored on the counter for easy access, and approximately 420 closed medical records stored in wall mounted cabinets in the front office. The medical records contained the patient's name, date of birth, and personal medical information.

During an interview at the time of the observation, Staff E stated the environmental services staff cleaned the office after specialty clinic staff left in the evening. Staff E acknowledged that environmental services staff could access patient medical records, and the environmental services staff did not have a need to access the information in the patient's medical records.

During an interview on 2/18/14 at 1:10 PM, Staff D, RN/Clinic Supervisor acknowledged environmental services staff could access patient medical records and they did not have a need to know the patient's confidential medical information and they failed to follow the hospital's policy for security of patient's confidential information.

Based on review of policies, procedures, public documents, and staff interview, critical access hospital (CAH) staff failed to update the patient rights and responsibilities policy and the patient rights and responsibilities information provided to all patients that received services at the CAH with the current regulatory requirements that changed 12/2/11. The hospital had a current census of 8 swing bed patients at the time of survey entrance. Additionally, the Chief Financial Officer (CFO) identified an average monthly census for the following inpatient and outpatient areas:

Outpatient surgery: 79 patients
Cardiac Rehabilitation: 4 patients
Emergency room: 570 patients
Laboratory: 1,481 outpatients
Pulmonary rehabilitation: 137 patients
Multi departmental outpatients: 193 patients
Endoscopy procedures: 59 patients
Sleep laboratory: 24 patients
Rehabilitation therapy: 66 patients
Wellness laboratory: 23 patients
X-ray: 548 outpatients

Failure to provide patients with the current Patient Visitation Rights information could potentially result in restricting access of visitors to patients or limiting the patients' rights to designate which visitors that would be allowed during hospitalizations, or outpatient services.

Findings include:

Review of the policy "Patient Rights", with a review date of 6/13, directed all hospital staff to provide a copy of the Patient Rights and Responsibilities brochures to all patient during the admission process, however, it did not include the updated 12/2/11 regulatory guidelines.

Review of the Patient Rights and Responsibilities brochure, with a revision date of 1/11, revealed the brochure lacked the new patient rights information, that became effective 12/2/11. The 12/2/11 requirements included the patients' rights to receive visitors that the patient designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and the patients' right to withdraw or deny consent at any time.

During an interview on 2/19/14, at 7:45 AM, the Chief Executive Officer (CEO) acknowledged the patient rights policy and patient rights and responsibilities brochures lacked the updated information contained in the regulatory guidelines, effective 12/2/11. The CEO stated that the department managers were responsible for updating the patient rights brochures. The CEO said she did not know the managers had not updated the brochures. The CEO acknowledged the hospital administration failed to update the hospital's policy and the managers failed to update the brochures that were distributed to the CAH patients.