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Based on observations and interviews, the facility failed to ensure medications, supplies, and equipment commonly used in the Emergency Department (ED) were readily available for patient use. Specifically, the facility failed to remove expired medications and supplies in the patient care areas.

Findings:

Cross Reference to C-0203 - Drugs and Bioliogicals: for findings related to the facility's failure to ensure drugs and biologicals commonly used in life-saving procedures were readily available for patient care. Specifically the facility failed to remove expired medications from patient care areas.

Cross Reference to C-0204 - Equipment and Supplies: for findings related to the facility's failure to ensure equipment and supplies commonly used in life-saving procedures were readily available for patient use. Specifically, the facility failed to remove expired and unusable supplies from patient care areas.

Based on observations and interviews the facility failed to ensure drugs and biologicals commonly used in life-saving procedures were readily available for patient care. Specifically the facility failed to remove expired medications from patient care areas.

Findings:

1. The facility policy titled "Unusable drugs and Devices" was reviewed on 08/22/12 at 11:00 a.m. It stated unusable drugs include those that are expired, contaminated, mislabeled (improper, illegible, missing, or worn), otherwise unsuitable for administration or use (questionable integrity, effectiveness, and stability). The policy also states unusable drugs shall not be distributed or administered.

2. A tour of the Emergency Department (ED) was conducted on 08/21/12 at 9:50 a.m. with the ED Manager and Quality/Education Coordinator. It was discovered during observations that the department had available for patient use the following expired medications:
2 bottles of Mannitol in the blanket warmer with expiration dates of 12/11
2 bottles of Enfalyte with expiration dates of 08/01/12

3. The ED Manager was interviewed on 08/21/12 at 10:00 a.m. S/he confirmed both of the medications were expired and removed them from the patient care area.

Based on observations and interviews the facility failed to ensure equipment and supplies commonly used in life-saving procedures were readily available for patient use. Specifically, the facility failed to remove expired and unusable supplies from patient care areas.

Findings:

1. The facility policy titled "Unusable drugs and Devices" was reviewed on 08/22/12 at 11:00 a.m. It stated unusable drugs and devices include those that are expired, contaminated, mislabeled (improper, illegible, missing, or worn), otherwise unsuitable for administration or use (questionable integrity, effectiveness, and stability). The policy also states unusable drugs and devices shall not be distributed or administered.

2. A tour of the Emergency Department (ED) was conducted on 08/21/12 at 9:50 a.m. with the ED Manager and Quality/Education Coordinator. It was discovered during observations that the department had available for patient use the following expired and unusable supplies:
Anesthesia tray with expiration date of 02/11
Arterial line with expiration date of 05/12
2 Angiocaths with expiration date of 04/12
1 Angiocath with expiration date of 04/11
6 laboratory tubes with expiration date of 06/12
3 boxes of suture sets with the expiration date of 07/12
1 package of coagulation tubes with expiration date of 07/12
2 ABG kits with expiration date of 05/12
1 bone injector with expiration date of 01/12
Several sets of sterile gloves with expiration dates of 07/11, 12/11 and 06/12
20 sets of sterile gloves with expiration date of 05/12
15 Pediatric EKG patches with expiration date of 06/12
8 Spinal needles with expiration date of 08/05
3 Spinal needles with expiration date of 08/10
2 Spinal needles with expiration date of 07/08
2 Spinal needles with expiration date of 05/19
1 Spinal needle with expiration date of 02/12
1 Spinal needle with expiration date of 05/11
1 Spinal needle with expiration date of 03/09
1 Foley Catheter tray opened and unusable in cabinet

3. An interview with the ED Manager was conducted on 08/21/12 at 10:00 a.m. S/he confirmed the expired and unusable supplies and was having them removed from the patient care area.

Based on observations and interviews, the facility failed to ensure all patient care equipment and supplies are maintained in safe condition that includes an acceptable level of quality.

Findings:

1. The facility policy titled "Unusable drugs and Devices" was reviewed on 08/22/12 at 11:00 a.m. It stated unusable drugs and devices include those that are expired, contaminated, mislabeled (improper, illegible, missing, or worn), otherwise unsuitable for administration or use (questionable integrity, effectiveness, and stability). The policy also states unusable drugs and devices shall not be distributed or administered.

2. A tour of the Patient Care Unit (PCU) was conducted on 08/21/12 at 9:50 a.m. with the PCU Manager and the Quality/Education Coordinator (QEC). The following observations of expired or unusable supplies were made:
Three boxes of Chlorahexidine wipes with expiration date 04/12
Ten sets of sterile gloves with expiration date 11/11
Five central venous line trays with expiration date 07/12
One open unusable lumbar puncture tray
Seven bottles of Enfalyte expiration date 08/01/12

A tour of the Radiology department was conducted on 08/21/12 at 9:20 a.m. with the Radiology Manager (RM). Both the CT scan room and the X-ray room were observed to contain crash carts stocked with expired supplies.

In the CT scan room there was an emergency crash cart that contained the following expired supplies:
Pediatric easy cap with expiration date 10/06
Adult easy cap with expiration date 04/11
Zoll defibrillation pads with expiration dates 04/12 and 04/08
Multiple angiocaths with expiration dates 06/05, 07/05, 08/05, and 01/05
Spinal needle with expiration date 05/04
Seven ABG kits with expiration date 03/11
Scalpel with expiration date 11/09
EKG electrodes with expiration date 11/10
Radiation markers with expiration date 04/10

In the X-ray room there was an emergency crash cart that contained the following expired supplies:
Two defibrillation pads with expiration date 07/12
Two defibrillation pads with expiration date 04/08
Peds easy cap with expiration date 06/10
Adult easy cap with expiration date 11/08
EKG electrodes with expiration dates of 01/07 and 06/11
Three ABG kits with expiration dates of 03/11 and 03/10
Multiple angiocaths with expiration dates of 02/05, 05/09 and 05/11
Occlusive dressing with expiration date of 06/11

3. During an interview conducted on 08/21/12 at 9:30 a.m., the PCU Manager and QEC confirmed the expired and unusable patient supplies.

During an interview conducted on 08/21/12 at 9:30 a.m. with the RM, s/he confirmed the expired and unusable patient supplies. S/he stated the radiology staff did not check the crash cart supplies because s/he thought it was done by the pharmacy staff.

Based on observations, facility document review, and staff interview the facility failed to ensure that there was proper temperature controls in place for all pharmaceutical storage areas.

Findings:

1. The facility failed to ensure that there was a method to monitor the temperature of pharmaceuticals in the pharmacy department.

a. A review of the Food and Drug Administration's (FDA) guidelines found at 21CFR205.50 revealed: "Minimum requirements for the storage and handling of prescription drugs and for the establishment and maintenance of prescription drug distribution records.
The State licensing law shall include the following minimum requirements for the storage and handling of prescription drugs, and for the establishment and maintenance of prescription drug distribution records by wholesale drug distributors and their officers, agents, representatives, and employees:
(c)Storage. All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF).
(2) Appropriate manual, electromechanical, or electronic temperature and humidity recording equipment, devices, and/or logs shall be utilized to document proper storage of prescription drugs.
(3) The recordkeeping requirements in paragraph (f) of this section shall be followed for all stored drugs."

A review of the State of Colorado's Board of Pharmacy Rules and Regulations state at 5.01.31 (e) that "(8) A refrigerator, dedicated to storing only drugs, meeting the compendia requirements and with an accurate thermometer in the refrigerator. The temperature of which shall be maintained between two and eight degrees Celsius (2 and 8 degrees C.) or thirty-six and forty-six degrees Fahrenheit (36 and 46 degrees F.). The temperature shall be either manually or electronically monitored each calendar day."

b. Observations were conducted of the facility's pharmacy department on 08/22/12 at 10:00 a.m. with the facility's Pharmacist. The pharmacy contained a refrigerator in which multiple refrigerated medications were stored. The refrigerator contained a thermometer and the refrigerator had a log on the outside of the door that was completed by pharmacy staff each day the pharmacy was in operation.

c. An interview was conducted with the facility's Pharmacist during the times of the observations. S/he stated that the pharmacy was staffed only Monday through Friday. S/he stated that the refrigerator that was in the pharmacy did not have a continuous monitor to notify the facility's staff if the temperature had gone beyond the acceptable limits at any time.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Provision of Services. The facility failed to ensure that services provided to patients were performed in a safe and effective manner that adhered to facility policies/procedures and standards of practice.

The facility failed to meet the following standards under the Condition of Participation of Provision of Services:

C0273 - Patient Care Policies: The facility failed to provide a policy that describes the services they furnish and those they are unable to furnish. Also not included were any specific agreement or arrangements with facilities that do provide the services they cannot.

C0276 - Patient Care Policies: The facility failed to maintain proper storage of drugs and biologicals.

C0278 - Patient Care Policies: The facility failed to ensure that practices in the facility's outpatient clinic were guided by policies that would prevent communicable diseases.

C0283 - Radiology Services: The facility failed to ensure radiation protective equipment was in good condition and inspected on a yearly basis.

C0294 - Nursing Services: The facility failed to ensure nursing services met the needs of the patients.

C0297 - Nursing Services: The facility failed to ensure that patients were administered medications according to accepted standards of practice and CAH policy.

Based on interviews, facility document, and policy reviews, the CAH failed to provide a policy that describes the services they furnish and those they are unable to furnish. Also not included were any specific agreement or arrangements with facilities that do provide the services they cannot.

Findings:

1. In reviewing hospital policies, none provided a description of services the CAH furnishes directly and those furnished through agreement or arrangement.

2. In an interview on 08/22/12 at 10:00 a.m. the Quality/Education Coordinator confirmed the facility did not have a policy describing the services the CAH was able or not able to furnish.

Based on observations and interviews, the facility failed to maintain proper storage of drugs and biologicals.

Findings:

1. A position paper from the Association of Professionals in Infection Control and Epidemiology (APIC) titled, "Safe Injection, Infusion and Medication Vial Practices in Healthcare" published July 30th, 2009 stated the following, in pertinent parts:
"The transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures continues to occur due to unsafe and improper injection, infusion and medication vial practices being used by healthcare professionals within various clinical settings throughout the United States ...
APIC strongly supports adherence to the following safe injection, infusion and medication vial practices ...
Vials
?Always follow the manufacturer's instructions for storage and use...
?Discard single-dose vials after use. Never use them again for another patient.
?If a multidose vial must be used, it should be used for a single patient whenever
possible. The risk of transmission posed by inappropriate handling of multi-dose vials has been clearly demonstrated and mandates a practice of one vial per one patient whenever possible. Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient...
?Dispose of opened multidose medication vials 28 days after opening, unless specified otherwise by the manufacturer, or sooner if sterility is questioned or compromised..."

2. The facility policy titled "Unusable drugs and Devices" was reviewed on 08/22/12 at 11:00 a.m. It stated unusable drugs include those that are expired, contaminated, mislabeled (improper, illegible, missing, or worn), otherwise unsuitable for administration or use (questionable integrity, effectiveness, and stability). The policy also states unusable drugs shall not be distributed or administered.

3. Tours were conducted throughout the facility which revealed unusable medications available for patient use.

a. The Radiology department was toured on 08/21/12 at 09:20 a.m. with the Radiology Manager (RM). The following observations were made:
A 500 ml bag of 5% Dextrose with expiration date of 07/12 in the crash cart
A tube of KY Jelly with expiration date of 11/03 in the crash cart
A bag of Normal Saline (NS) with connection tubing hanging from an IV pole dated 08/20/12

b. A tour was conducted of an offsite clinic on 08/21/12 at 2:40 p.m. with the Risk Manager and Quality/Education Coordinator (QEC). The following observations were made:
An open undated bottle of sterile water with expiration date 07/07
Three tubes of Surgi-lube with expiration date of 04/10, one tube with expiration date 06/09 and one tube with expiration date 06/12
Multiple antibiotic packets with expiration date 06/06
A bottle of sterile water with expiration date 07/07
Also observed sitting on the counter in a patient care room were two unlabeled specimen cups that appeared to contain gauze and a brown liquid.

c. A tour of a second offsite surgical clinic was conducted on 08/21/12 at 3:00 p.m. with the Risk Manager and QEC. Several bottles of Betadine were observed with no expiration date. The Office Manager stated she received the bottles from the pharmacy already dispensed from a larger bottle.

d. The facilities surgical suite was toured on 08/21/12 at 3:30 p.m. with the Quality/Education Coordinator, the Surgery Manager and a Certified Registered Nurse Anesthetist (CRNA). An open undated bottle of Ketamine was found in the CRNA's locked cart.

e. A tour of the Patient Care Unit (PCU) was conducted on 08/22/12 at 9:30 a.m. with the PCU Manager and QEC. One of the two unit crash carts was unlocked at the rear of the unit outside of a patient room. The PCU Manager stated that according to the log it was last checked the previous evening.

4. Interviews were conducted during the facility tours with the accompanying staff members.

a. An interview was conducted on 08/21/12 at 9:30 with the RM. S/he verified the expired medications and stated the bag of NS should have been discarded after its use the day before and should only be single patient use. The fact that it was left hanging presented the potential for multiple patient use.

b. An interview was conducted on 08/21/12 at 2:50 p.m. with QEC, RM and Office Manager of the first offsite clinic. All confirmed the expired and unusable supplies observed. The Office Manager also stated s/he could not identify the contents of the specimen cups with the brown liquid.

c. An interview was conducted on 08/21/12 at 3:10 p.m. with the Risk Manager, QEC, and Office Manager of the second offsite clinic. All confirmed there was no way to determine the expiration date of the Betadine observed in undated bottles.

d. An interview was conducted on 08/21/12 at 3:30 p.m. with the CRNA of the surgical suite. S/he verified the open bottle of Ketamine and stated s/he was unaware it was in the cart and was unsure when it was used.

e. An interview was conducted on 08/22/12 at 9:35 a.m. with the PCU Manager and QEC. Both verified the crash cart was unlocked and the medications inside had been unsecured since the previous evening.

Based on observations and staff interview the facility failed to ensure that practices in the facility's outpatient clinic were guided by policies that would prevent communicable diseases.

Findings:

1. The facility's outpatient clinic failed to store instruments for procedures in a way that adequately identified if the instruments had been decontaminated and sterilized or had been used, which exposed facility staff and patients to possible contaminants that could increase the likelihood of the spread of communicable diseases.

a. A review of the the 2011 Edition of the Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Setting by the Association of periOperative Registered Nurses (AORN) stated the following within "Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment," pages 431 and 432, in pertinent part: "Cleaning and Decontamination should occur as soon as possible after instruments and equipment are used. All instruments opened in the procedure room should be decontaminated whether or not they have been used. Contaminated instruments must be contained during transport and should be transported in a timely manner to a location designated for decontamination."

A review of the the 2011 Edition of the Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Setting by the Association of periOperative Registered Nurses (AORN) stated the following within "Recommended Practices for Sterilization the Perioperative Practice Setting," page 475, in pertinent part: "Sterilized materials should be packaged, labeled, and stored in a manner to ensure sterility, and each time should be marked with the sterilization date."

b. Observations of the facility's offsite clinic were conducted on 08/21/12 at 2:35 p.m. with the Risk Manager and Quality/Education Coordinator. The clinic provided urology medical care. Within two of the examination rooms it was found that each examination room had a silver basin with a lid. The silver basin was found to contain multiple instruments and rubber catheters. The instruments did not appear to be sterile, nor clean. The instruments were not individually packed to indicate that they had been sterilized. There were no indicators on the outside of the basin that there was any biohazardous contents within the basins. No other instruments were found in the examination rooms.

c. An interview was conducted with the nurse of the clinic at the time of the above observation. S/he stated that the clinic did not use the instruments that were found in the silver basins.

Based on staff interview and policy review, the facility failed to ensure radiation protective equipment was in good condition and inspected on a yearly basis.

Findings:

1. Radiology policies were reviewed on 08/21/12 at 11:15 a.m. The facility policy "Lead Apron/Shield Annual Safety Check" stated all aprons/shield will be taken to the Radiology department for an annual inspection by fluoroscopy. Each apron/device will have an identifying number and will be logged accordingly. If there are any defects in question, the item is to be pulled out of service immediately. All information and apron inspections will be reported to the Radiation Safety Committee.

2. A review of the log book titled Annual Lead Apron/Shield Inspection was conducted on 08/21/12 at 11:30 a.m. Each item was numbered and had a separate page in the log with dates reflecting the last inspection being on 04/10.

3. An interview was conducted with the Radiology Manager (RM) on 08/21/12 at 11:40 a.m. S/he stated lead shields are inspected annually by fluoroscopy. When the RM was shown the log book and asked if there was documentation of current inspections, s/he went to her office and returned with a separate page that stated "All" in the apron/shield identification field.

4. A review of the page provided by the RM revealed that the page contained the following entries:
"2010 - None noticed look at log
2011 - No damage
2012 - everything looks ok"

5. The RM confirmed that the above log entry page was not consistent with the facility's policy and each item needed to be identified and inspected on a yearly basis.

Based on interviews, policy, and document review the facility failed to ensure nursing services met the needs of the patients.

Findings:

1. The facility failed to provide agency staff an initial orientation to the CAH and it's policies including units specifics, emergency procedures, nursing services and safety procedures. The facility also failed to provide annual competency evaluations for the agency staff.

a. A review of the facilities policy and procedures related to orientation and competence was conducted on 08/22/12 at 2:00 p.m. The policy "Orientation and Inservice" states the CAH shall provide for orientation and inservicing of the patient care clinical staff to assess competence and that inservice education for all patient care unit staff will be given on an ongoing basis. The policy "Orientation of a New Employee" states orientation to the employee's department, unit, work setting and/or program-specific policies and procedures will be conducted by the department manager/director/supervisor. Orientation to working conditions and specific aspects of the job will be conducted by that individual appointed by the department manager on an "on-the-job" basis. successful completion of orientation will be documented by the employee's department manager/director/supervisor and kept in the employee's personnel file. The policy "Staff Competence" states competencies are evaluated on an annual basis.

b. Personnel files were reviewed on 08/22/12 at 11:50 a.m. Of the 3 agency personnel files reviewed for staff who had been employed by the CAH since 01/12 or before, only Employee #1 had documentation of being provided an initial hospital orientation dated 05/09. Neither of the 3 agency staff (Employees #1, #2 and #3) had been provided annual competency evaluations as required per the CAH policy.

c. An interview was conducted on 08/23/12 at 12:00 p.m. with the Quality/Education Coordinator. S/he verified there was no documentation of hospital orientation for Employees #2 and #3 and none of the 3 employees had documentation of annual competency evaluations conducted by the CAH.

Based on observation, policy review, and interviews, the facility failed to ensure patients were administered medications according to accepted standards of practice and CAH policy.

Findings:

1. The facility policy titled "Unusable drugs and Devices" was reviewed on 08/22/12 at 11:00 a.m. It stated unusable drugs include those that are expired, contaminated, mislabeled (improper, illegible, missing, or worn), otherwise unsuitable for administration or use (questionable integrity, effectiveness, and stability). The policy also states unusable drugs shall not be distributed or administered.

2. A tour was conducted of the patient care unit (PCU) on 08/22/12 at 09:30 a.m. with the Quality/Education Coordinator and the PCU Manager. Observations in the medication room included an open unlabeled insulin syringe with unknown content found in a patient medication drawer. The PCU Manager took the syringe at that time and asked the nursing staff about it and confirmed the contents as being insulin. S/he verified along with the Quality/Education Coordinator that there was no label on the syringe indicating what it was, the dosage, and when it was prepared.
Another patient drawer contained a medication cup of 5 pills that was labeled with the date and time. There was no indication of what the pills were or their dosage. The Quality/Education Coordinator verified the medications were not labeled or identified in any
way besides having a date and time written on the medication cup.

Based on medical record review and staff interview the facility failed to maintain a record that included dated and timed signatures of the doctor of medicine or osteopathy on physician orders.

Findings:

1. The facility failed to ensure that physician signatures in emergency department records were dated and timed in 17 (Sample Patients #4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 20, 22, 23, and 24) of 18 (Sample Patients #4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 20, 21, 22, 23, and 24) records reviewed.

a. A review of 18 medical records of patients who were cared for in the emergency department and had physician orders revealed that in 17 records the physician orders contained a signature of the physician but did not also contain the date and time of the signature or of the orders.

2. The facility failed to ensure that orders for surgery patients included original (not photocopied) signatures of the operating physician in 1 (Sample Patient #31) of 4 surgical patient records (Sample Patients #28, 29, 30, and 31) reviewed.

a. A review of Sample Patient #31's record on 08/23/12 at 2:23 p.m. revealed that the chart contained a physician order that ordered the admission of the patient and the discharge of the patient when the patient was stable. The order (including the physician's signature) were photocopies and did not contain an original signature of the operating physician.

b. An interview was conducted on 08/23/12 at 2:50 p.m. with the facility's Operating Room Supervisor. S/he stated that the two physicians that perform outpatient surgery in the facility "use the copied orders for their colonoscopies." S/he confirmed that the signature on the order was not an original signature.

Based on observations and interviews, the facility failed to ensure the confidentiality of medical record information.

Findings:

1. A tour was conducted of the Radiology department on 08/21/12 at 9:20 a.m. with the Radiology Manager (RM). During observations an unlocked cabinet was found to contain a log and cd's with patient information. The RM stated the cabinet usually remains locked and the key is kept behind the cat scan console. The RM acknowledged the patient information was not kept secure.

2. A tour of the offsite clinics was conducted on 08/21/12 at 2:40 p.m. with the Quality/Education Coordinator and Risk Manager. A file cabinet containing medical records was noted in one of the clinics. The Receptionist stated the cabinet was locked at the end of the day and that it was behind a locked door. When asked where the key for the cabinet was kept she opened a desk drawer and presented the key. The Quality/Education Coordinator, Risk Manager and Receptionist acknowledged the medical records were not secure as housekeeping had acces to the area and key after hours.

Based on facility policy/procedure review and staff interview the facility failed to have a policy in place that allowed Swing Bed patients the right to choose a personal attending physician.

Findings:

1. A review of the facility's policies/procedures that applied to Swing Bed patients revealed that there was not a policy that stated that patients could choose a personal attending physician.

2. An interview was conducted with the facility's Discharge Planner was conducted on 08/21/12 at 1:52 p.m. S/he confirmed that the facility did not have a policy which stated that Swing Bed patients had the right to choose a personal attending physician. When asked if the facility allowed patients to choose a personal attending physician, s/he stated that "we don ' t do that." S/he stated that the hospital used a "Hospitalist type system" which resulted in each Swing Bed patient having the same attending physician that was on-call and was present at the hospital. S/he stated that "patients do not like it." S/he stated that s/he was not aware of the requirement to allow a choice of physician.

Based on policy review and staff interviews, the facility failed to ensure patients were provided visitation rights. The facility had no written policies on visitation or any related restrictions placed upon them.

Findings:

Cross Reference C-1001/C-1002 - Patient Visitation Rights: for findings related to the facility's failure to have written policies that ensured patients were provided visitation rights as required by this standard.

Based on policy review and staff interviews, the facility failed to have written policies that ensured patients were provided visitation rights as required by this standard.

Findings:

1. A review of the facility policies on 08/22/12 found no written policies regarding patient visitation rights. The facility did not have a policy stating how to inform each patient of his or her visitation rights including any clinical restriction or limitations on these rights. There was also not a policy stating how to inform each patient of the right to consent for whomever he or she chooses as a visitor and the right to withdraw the consent at any time.

2. In an interview on 08/22/12 at 4:00 p.m., the Quality/Education Coordinator confirmed the CAH did not have any policies addressing patient visitation rights.

Based on policy review and staff interviews, the facility failed to have written policies that ensured patients were provided visitation rights as required by this standard.

Findings:

1. A review of the facility policies on 08/22/12 found no written policies regarding patient visitation rights. The facility did not have a policy stating how to inform each patient of his or her visitation rights including any clinical restriction or limitations on these rights. There was also not a policy stating the CAH does not restrict, limit or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. In addition, there was not a policy stating the CAH would ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

2. In an interview on 08/22/12 at 4:00 p.m., the Quality/Education Coordinator confirmed the CAH did not have any policies addressing patient visitation rights.