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Based on observation, document review, and staff interviews, the facility failed to ensure current safety inspection of 1 of 1 steam sterilizer, used to sterilize all of the facility's surgical instruments, in the only sterile processing area of the facility. The facility processed approximately 4 loads of instruments in the in the steam sterilizer per day, which included all surgical instruments used in all areas of the facility such as surgery, emergency room, specialty clinic, and other patient care areas.

Failure to ensure current safety inspections of the steam-sterilizer could potentially result in the sterilizer failing kill bacteria on facility instruments and could result in infections to patients. In addition, the lack of safety inspection of the pressure vessel could potentially result in harm to the operator if the steam sterilizer would malfunction.

Findings include:

1. During tour of the sterile processing area on 4/2/13 at 3:10 PM, the Surgery Director stated a certificate of current safety inspection could not be found for the steam sterilizer.

2. During an interview on 4/3/13 at 9:20 AM, Staff F, Maintenance Worker, stated there was not a boiler certificate available to verify current safety inspection for the steam sterilizer and the sterilizer had not been inspected since the facility opened.

During an interview on 4/3/13 at 2"15 PM, the Surgery Director stated the facility began using the steam sterilizer to sterilize instruments on 12/17/12.

During an interview on 4/18/13 at 9:15 AM, the Chief Boiler Inspector at the Division of Labor Boiler and Pressure Vessel Safety Inspections reported the facility had 8 pressure vessels. A certified pressure vessel inspector from Chubb insurance company had inspected 7 of 8 pressure vessels on 10/9/13. The Chief Boiler Inspector verified the facility had a 9.7 cubic foot Getinge 533HC Vacuum/Gravity Steam Sterilizer IA092869 installed in December of 2013 and confirmed no safety inspection occurred until 4/4/13. According to the Chief Boiler Inspector, the facility is required to have an inspection and operating certificate 10-days before putting the equipment into operation.

Based on document review and staff interview, the facility failed to have a current emergency fuel and water agreement and consider the facility's usual water supply on hand and quantities needed during an interruption in service, as part of the planning for emergency fuel and water agreements. The administrative staff identified an average census of 4 patients and 101 employees.

Failure to ensure emergency water and fuel were available to meet the facility's critical functions during an emergency/crisis situation could potentially cause a lack of necessary resources to provide adequate patient care during an emergency.

Findings include:

1. Review of a document titled "Emergency Preparedness, Emergency Fuel Supply," revealed an agreement dated 11/29/10, which did not reflect the facilities current location of fuel storage and current storage capacity, following the relocation of the facility.

During an interview on 4/3/13 at 9:00 AM Staff F, Maintenance Worker, acknowledged the agreement had not been updated recently. During an interview on 4/3/13 at 9:10 AM, the Chief Executive Officer acknowledged the current fuel agreement had not been updated since the facility relocation and lacked details specific to the new location.

2. Review of a facility policy titled "Utilities Management: Potable Water Failure", dated 9/3/03, revealed in part ". . . In situations of potable (drinking) water failure or concern of quality or quantity . . . 3. Engineering Department will notify Purchasing and bottled water will be purchased to dispense to all affected areas . . . 4. An agreement has also been reached with Leon Fire Department to transport water to the hospital if needed. . . ."

3. Review of a document titled "Emergency Preparedness City Water Disruption", dated 3/22/06, revealed an agreement with the local Hy-Vee Store for potable water, which lacked any details regarding the quantity of water needed by the facility.

4. Review of another document titled "Emergency Preparedness City Water Disruption", dated 12/15/01, revealed an agreement with the Leon Volunteer Fire Department for potable water, which lacked any details regarding the quantity of water needed by the facility.

During an interview on 4/3/13 at 9:20 AM, Staff F acknowledged the water agreements were not current, lacked details regarding the quantity of water the facility might need and lacked provisions for non-potable water. Staff F stated he was not aware of any planning regarding the facilities potential water needs during an emergency of both potable and non-potable water.

Based on document review and staff interview, the facility failed to have a system in place that assured a periodic review of medical records occurred, in conjunction with the nurse practitioners and physician. Medical record review included, 5 medical records for patients cared for by Nurse Practitioner A (#19, 20, 21, 22, and 23) and 5 medical records of patients cared for by Certified Registered Nurse Anesthetist (CRNA) (#24 [X 2 records], 25, 26, and 27). Practitioner A treated approximately 22 patient per month and CRNA C treated approximately 11 per month.

Failure to ensure a physician periodically reviews the medical records of patients who received care from Nurse Practitioner A and CRNA C potentially affects the facility's ability to assure the mid-level practitioners are consistently providing quality care to it's patients.

Findings include:

1. Review of medical records for Patient #'s 19 through 23 revealed no evidence of review by a physician in conjunction with (CRNA) C .

Review of medical records for Patient #'s 24 through 27 revealed no evidence of review by a physician in conjunction with Nurse Practitioner A.

2. Review of facility policy titled "Physician Requirements for Medical Records," reviewed 8/10, revealed the policy lacked a requirement for the physician to periodically review medical records of patients cared for by Nurse Practitioner A or CRNA C in conjunction with Nurse Practitioner A and CRNA C.

3. During an interview on 4/3/13 at 2:30 PM, the Health Information Management (HIM) Director stated the facility required a physician to review the medical records of patients who received care from Nurse Practitioner A. The HIM Director stated the physician did not review the medical records in conjunction with Nurse Practitioner A. Instead, the physician and Nurse Practitioner A independently reviewed the chart, and signed a form. The physician and Nurse Practitioner A did not interact during the review of the medical record. In addition, the HIM Director stated the facility did not require a physician to review any medical records of patients who received care from CRNA C.

Based on document review and staff interview, the facility failed to ensure 2 of 2 Nurse Practitioners (Nurse Practitioner A and Nurse Practitioner B) participated in 3 of 4 Professional Advisory Committee meetings during the year. The facility identified 2 Nurse Practitioners working at the facility during the prior year, and 4 Professional Advisory Committee meetings during the prior year.

Failure to include the Nurse Practitioners in the Professional Advisory Committee could potentially result in the committee failing to know about and/or include information the Nurse Practitioners could provide that would ensure the policies were current, as well as, enhance the content, development, and execution of CAH policies.

Findings include:

1. During an interview on 4/3/13 at 2:00 PM, the Chief Executive Officer (CEO) stated Nurse Practitioner A (a nurse with advanced education that allows them to treat patients independently) worked at the facility until 2/28/13, and Nurse Practitioner B started working at the facility on 3/1/13. The CEO stated the Professional Advisory Committee reviewed all of the policies at the facility on an annual basis.

2. Professional Advisory Committee meeting minutes dated 6/7/12 lacked evidence Nurse Practitioner A participated in the meeting. The meeting minutes revealed the committee reviewed the policies from the ambulance department, emergency/medical/surgical department, laboratory department, dietary department, anesthesia department, Quality Improvement/Utilization Review department, and central sterile processing departments.

Professional Advisory Committee meeting minutes dated 12/6/12 lacked evidence Nurse Practitioner A participated in the meeting. The meeting minutes revealed the committee reviewed the policies from the surgical services department, the laboratory department, the medical/surgical department, the radiology department, the purchasing department, the pharmacy department, business department, dietary department, housekeeping department, infection control department, engineering department, outpatient clinic department, human resources department, medical records department, respiratory therapy department, respiratory therapy department, and the Medical Staff By-Laws.

Professional Advisory Committee meeting minutes dated 3/7/13 lacked evidence Nurse Practitioner B participated in the meeting. The meeting minutes revealed the committee reviewed the policies from the laboratory department, the pharmacy department, the purchasing department, the physical therapy department, the business office department, the specialty clinic department, the surgical services department, the infusion therapy department, the dietary department, the medical records department, the medical/surgical department, the safety department, the human resources department, the administration department, the skilled/social services department, and the swing bed department.

3. During an interview on 4/3/13 at 2:00 PM, the CEO acknowledged the Professional Advisory Committee did not include Nurse Practitioner A or Nurse Practitioner B in the meetings. The CEO stated Nurse Practitioner A chose not to attend the meetings on 6/7/12 and 12/6/12. The CEO stated Nurse Practitioner B had recently joined the medical staff, and the CEO did not want to impose on Nurse Practitioner B to attend the Professional Advisory Committee.

Based on document review and staff interview, the facility failed to have a system in place that assured a periodic review of medical records occurred, in conjunction with the nurse practitioners and physician. Medical record review included, 5 medical records for patients cared for by Nurse Practitioner A (#19, 20, 21, 22, and 23) and 5 medical records of patients cared for by Certified Registered Nurse Anesthetist (CRNA) (#24 [X2 records], 25, 26, and 27). Practitioner A treated approximately 22 patient per month and CRNA C treated approximately 11 per month.

Failure to ensure Nurse Practitioner A and CRNA C periodically review the medical records of patients they cared for with a physician potentially affects the facility's ability to assure the mid-level practitioners are consistently providing quality care to it's patients.

Findings include:

1. Review of medical records for Patient #'s 19 through 23 revealed no evidence of review by a physician in conjunction with (CRNA) C .

Review of medical records for Patient #'s 24 through 27 revealed no evidence of review by a physician in conjunction with Nurse Practitioner A.

2. Review of facility policy titled "Physician Requirements for Medical Records," reviewed 8/10, revealed the policy lacked a requirement for the physician to periodically review medical records of patients cared for by Nurse Practitioner A or CRNA C in conjunction with Nurse Practitioner A and CRNA C.

3. During an interview on 4/3/13 at 2:30 PM, the Health Information Management (HIM) Director stated the facility required a physician to review the medical records of patients who received care from Nurse Practitioner A. The HIM Director stated the physician did not review the medical records in conjunction with Nurse Practitioner A. Instead, the physician and Nurse Practitioner A independently reviewed the chart, and signed a form. The physician and Nurse Practitioner A did not interact during the review of the medical record. In addition, the HIM Director stated the facility did not require a physician to review any medical records of patients who received care from CRNA C.

I. Based on review of documents and staff interviews, the facility failed to follow the time frame guidelines for the Infection Control Meetings as established in the facility's policy. The facility identified a census of 5 inpatients.

Failure to follow established facility established time frames for meetings could potentially lead to unrecognized infection control issues potentially resulting in health care acquired illnesses, complications of existing illnesses, and longer patient stays.

Findings include:

1. Review of Infection Control Committee Meeting minutes revealed staff held their first meeting on January 18, 2011.

Review of facility policy titled Infection Control Committee By-laws, revised date 8-2011, revealed in part ... C. Infection Control Committee shall meet as frequently as necessary but at least quarterly.

2. During an interview on 4/3/12 at 9:00 AM, the Infection Control Officer identified that she/he had been on medical leave from 12/11 to 4/12 and the administrative staff failed to assign these duties to another staff member. The Infection Control Officer identified the last Infection Control Committee Meeting was January 18, 2011.

During an additional interview on 4/3/12 at 9:55 AM, the CNO (Chief Nursing Officer) verified the CEO (Chief Executive Officer) and CNO failed to assign the duties of the Infection Control Officer to another staff member during her medical leave of absence.

II. Based on review of documents and staff interviews, the facility failed to follow the CDCs (Centers for Disease Control and Prevention) guidelines for the SSI (Surgical Site Infections) as established in the facility policy. The facility performed 134 surgical procedures in 2012.

1. Review of the policy titled, CDC/NHSN (National Health Safety Network) Definitions for Health Care Acquired Infections, revised date of 8/2011, revealed in part ...Surgical Wound Infections-includes incisional surgical wound infections, deep surgical wound infections, and organ/space surgical site infections. Incisional surgical wound infection must meet the following criterion: Infection occurs at incision site within 30 days after surgery and involves only skin and subcutaneous tissue of the incision. Deep surgical wound infection must meet the following criterion: Infection occurs at operative site within 30 days after surgery if no implant is left in place or within one year if implant in place, and infection appears related to operative procedure, and infection involves deep soft tissues. Organ/space surgical site infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, opened or manipulated during the operative procedure. Infection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operative procedure and the infection appears to be related to the operative procedure and the infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure.

2. During an interview on 4/3/13 at 9:00 AM, the Infection Control Officer revealed the facility failed to have a system in place to track SSI after discharging a patient from the facility. According to the Infection Control Officer, staff monitored and tracked SSI that occurred in the hospital according to cultures obtained from the wounds.

An additional interview on 4/3/14 at 9:55 AM with the CNO, verified the facility failed to have a system in place to track SSI after discharging a patient from the facility.

Based on medical record review, policy review and staff interviews, the facility failed to follow their policy to identify patients that may be at nutrition risk. The facility administrative staff identified a census of 5 patients and 374 admissions in the fiscal year 2011-2012.

Failure to identify patients at nutrition risk could potentially result in the failure to identify patients with nutrition-related problems, leading to complications in managing their care and an increased length of stay.

Findings for 2 of 3 open medical records (Patient #1 and #2) and 10 of 13 closed medical records (Patient #3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) reviewed include:

1. The facility staff used policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed:

Review of a nursing policy titled "Admission of a Patient", reviewed and approved on 1/23/13, revealed in part ". . . There will be a clearly defined process and identified responsibilities to ensure . . . optimal patient outcomes . . . h. The RN will assess the patient's status and obtain adequate information/history to complete the Initial Interview, including: . . . dietary assessment screening. . . ."

Review of a dietary policy titled "Nutrition Assessment," reviewed and approved on 3/1/12 revealed in part ". . . 1. Nursing service will complete nursing admission history/data base form including nutritional risk. . . ."

2. On 4/2/13, beginning at 9:30 AM, review of Patients #1 and 2 open medical records revealed the medical records lacked a completed dietary assessment screening. During an interview at the time, Staff D, Clinical Dietitian, confirmed the nutrition screen section of the patient initial interview was blank for both records.

3. On 4/3/13, beginning at 2:05 PM, review of Patients #3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 closed medical records lacked a completed dietary assessment screening. During an interview at the time, Staff E, Clinical Informatacist, confirmed the nutrition screen section of the patient initial interview was blank for all 10 records.

During an interview on 4/3/13 at 9:30 AM, Staff G, Clinical Dietitian, reported nutrition screening of patients was completed by nursing on admission with the initial patient interview. She said the dietitians reviewed all patient medical records when they were in the facility, but they were dependent on the screening tool, completed by nursing, to identify patients at nutrition risk and notify them accordingly, since they were only on site two days each week.

During an interview on 4/3/13 at 10:10 AM, the Director of Nursing (DON) reported there was not a defined timeframe for the completion of the dietary assessment screening but it should be completed as part of the initial patient interview. During a follow-up interview on 4/3/13 at 3:35 PM the DON acknowledged the nursing staff failed to complete the dietary assessment screening on all patients and reported nursing staff are expected to complete the area, as part of the admission process, and not leave it blank.

During an interview on 4/3/13 at 2:55 PM, Staff H, Registered Nurse (RN), reported the RN and Licensed Practical Nurse (LPN), assigned to the patient, usually worked together to complete the initial patient interview upon admission. She said all of the interview questions would normally be completed at the same time and she would enter some type of response in each section, rather than leaving anything blank. Staff H reported if a patient was unable to answer the interview questions, she would ask an available family member or make an entry indicating the answer was unknown.

During an interview on 4/3/13 at 3:10 PM, Staff I, LPN, reported she normally conducted the initial patient interview questions with the computer in the room and entered the responses immediately. She said she would attempt to ask a family member the questions if the patient was unable to respond and enter something for each one, rather than leave it blank.

Based on observation, document review, and staff interviews, the facility failed to provide a dosimeter badge (radiation detecting device) to all staff exposed to radiation in the operating room during surgical procedures utilizing 1 of 1 portable x-ray machine in the operating room. The facility reported 22 portable x-ray procedures performed in the operating room for the year 2012.

Failure to provide dosimeter badges could potentially result in staff's exposure to unintentional and unknown amounts of ionizing radiation, potentially causing cancer or death.

Findings include:

1. Observation, during tour of the Radiology Department, on 4/2/13 at 10:30 AM, showed the facility had 1 portable x-ray machine.

2. Review of policy/procedure titled "Radiation Protection of Staff", dated 10/07, revealed, in part, "Purpose: To ensure proper radiation protection for all staff. Procedure: Radiation Monitoring: All Radiology personnel (staff and Radiologist) will wear radiation monitors while on duty in the hospital. . . ."

Facility policies/procedures failed to address radiation monitoring for all staff exposed to radiation in the operating room during surgical procedures utilizing the portable x-ray machine.

3. During an interview on 4/2/13 at 10:30 AM, the Radiology Director stated they had not issued dosimeter badges to the operating room staff, including physician and nursing staff, to wear during surgeries when the portable x-ray machine was in use in the operating room. The Radiology Director stated the anesthesia staff remained in the room when the portable x-ray machine was in use in the operating room. The Radiology Director also stated the rest of the staff, including the physician, would leave the room when the portable x-ray machine was in use.

During an interview on 4/3/13 at 11:20 AM, Staff K, Anesthesia Staff, stated they stayed in the operating room when the portable x-ray machine was in use. Staff K also stated the surgeon remained in the operating room approximately one half of the time but the rest of the staff, nursing, would leave the room when the portable x-ray machine was in use. Staff K acknowledged he did not have a dosimeter badge to wear while in the operating room when the portable x-ray machine was in use.

Based on document review and staff interview, the facility failed to ensure the anesthesia staff timed the post-anesthesia evaluation in accordance with the facility policy/procedure for 5 of 5 patients requiring anesthesia for the surgical procedure. (Patients # 13, 14, 15, 16, 17) The facility reported an average of 11 surgical procedures with anesthesia completed per month.

Failure to perform a post-anesthesia evaluation within the designated timeframes could potentially result in patients having unrecognized complications.

Findings include:

1. Review of policy/procedure titled "Post-Anesthesia Responsibilities," dated 2/02, revealed, in part, ". . . A post-anesthetic evaluation/interview of each patient will be conducted by the qualified individual delivery anesthesia who administered the anesthetic (if possible) within 48 hours. This evaluation will be documented in the appropriate location on the anesthesia record and include: . . . Signature of qualified individual delivering anesthesia with date and time. . . ."

Review of medical records for Patients # 13, 14, 15, 16, and 17 revealed no documentation of the time the post-evaluation was completed.

2. During an interview on 4/3/13 at 2:25 PM, the Surgery Director stated the facility policy/procedure required the post-anesthesia evaluation to be timed. The Surgery Director acknowledged the post-anesthesia evaluation for Patients # 13, 14, 15, 16, and 17 lacked documentation of the time the post-anesthesia evaluation was completed.

Based on document review and staff interviews, the facility failed to ensure a system was in place that assured the CAHs periodic evaluation of its total program included review of a representative sample of both active and closed clinical records for all services provided. The facility completes 1 evaluation of its total program per year.

Failure to include review of open and closed clinical records in the periodic evaluation of their total CAH program could result in failure to identify potential changes needed in services and/or patient care provided.

Findings include:

1. Review of the Annual Critical Access Hospital Report, dated 1/22/13, revealed the report lacked evaluation of any active or closed medical records during the process of the Annual Critical Access Report.

2. During an interview on 4/3/13 at 14:00, the Chief Executive Officer (CEO) stated he had not included the review of active or closed medical records in the process of the Annual Critical Access Report. Instead, the CEO had each department only include a historical report on what the department had accomplished or changed during the prior year. The CEO stated the Annual Critical Access Report was primarily a historical document, and the facility did not use the report to improve the care patients received at the facility.

Based on document review and staff interviews, the facility failed to ensure a system was in place that assured the CAHs periodic evaluation of its total program included policy review. The facility completes 1 evaluation of its total program per year.

Failure to include policy review in the periodic evaluation of their total CAH program could result in failure to identify potential changes needed in services and/or patient care provided.


Findings include:

1. Review of the Annual Critical Access Hospital report, dated 1/22/13, revealed the report failed to include the review of the policies as part of the Annual Critical Access Hospital Report.

2. During an interview on 4/3/13 at 2:00 PM, the Chief Executive Officer (CEO) stated the facility did not include any review of policies as part of the Annual Critical Access Hospital Report. The CEO stated he only had the departments perform a historical review of the services they had provided during the prior year. The CEO stated the policies did not receive review during the preparation of the Annual Critical Access Hospital Report. Additionally, the CEO stated the facility did not include any of the policy review performed at the facility as part of the Annual Critical Access Hospital Report.

Based on document review and staff interview, the facility failed to utilize their Annual Critical Access Hospital Reports to determine the appropriate utilization of services at the facility, if the facility followed established policies, and if the facility needed to make changes. The facility performed 1 Annual Critical Access Hospital Report per year.

Failure to utilize the report to determine the appropriateness of utilization of services, if the facility followed policies, and if the facility needed to make changes in their services could potentially result in the facility failing to identify areas that need improvement, and potentially failing to implement improvements.

Findings include:

1. Review of the Annual Critical Access Hospital Review, dated 1/22/13, revealed the facility failed to determine the appropriate utilization of the services at the facility, if the facility followed established policies, and if the facility needed to make changes based on the review.

2. During an interview on 4/3/13 at 2:00 PM, the Chief Executive Officer (CEO) stated the facility did not use the Annual Critical Access Hospital Review to determine the appropriate utilization of services, if the facility followed established policies, or if the facility needed to make changes based on the review. The CEO stated he only had the departments write up a report on what happened to their department during the prior year. He only used the Annual Critical Access Hospital Report as a historical document to show what the facility did in the prior year.

Based on review of documents and staff interview, the facility failed to have a current agreement in place with an Organ Procurement Organization (OPO). The CEO (Chief Operating Officer) identified an average annual death rate of 6 patients.

Failure to have a current OPO agreement could potentially result in a lack of organ donation.

Findings include:

1. Review of Iowa Organ Donor Network agreement dated January 26, 2009 stated in part ...III. Both Iowa Donor Network and Decatur County Hospital agree: 2. This Agreement shall remain in effect for a period of four years from the date of execution and shall replace any and all agreements for organ and tissue procurement between the two parties.

2. During an interview on 4/3/13, at 8:45 AM, the CEO acknowledged the facility lacked a current agreement with the Iowa Donor Network.

Based on document review and staff interview, the facility failed to maintain a current agreement with a dentist to provide routine and 24-hour emergency dental care for swing bed patients. The facility had a census of 2 swing bed patients at the time of survey entrance.

Failure to maintain a current agreement for routine and emergency dental care for swing bed patients could potentially prevent swing bed patients from receiving needed dental care.

Findings include:

1. Review of policy/procedure titled "Swing Bed Program", dated 2/11, revealed, in part, ". . . Patients in the Swing Bed Program will be assisted to obtain routine and emergency dental services. A. A local dentist shall be retained by the facility by maintaining credentialing to provide emergency dental services to patients of the facility. . . ."

Review of a list of providers credentialed to provide services to patients at the facility lacked a dentist with privileges to provide care to swing bed patients at the facility.

Review of policy/procedure titled "Contracted Services Furnished Through Decatur County Hospital", dated 2/15/11, lacked a contract or agreement with a dentist to provide routine and emergency dental services for swing bed patients at the facility.

2. During an interview on 4/1/13 at 2:25 PM, the Director of Nursing acknowledged the lack of a dentist with privileges at the facility or a contract or agreement with a dentist to provide routine or emergency dental care for swing bed patients at the facility.

Based on document review, staff and patient interviews, the facility failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for 1 of 1 acute patient record reviewed. (Patient # 2) The facility identified 1 of 1 Patient Rights policy and 1 of 1 Visitation Policy. The facility identified a current census of 1 acute inpatient at the time of survey entrance.

Failure to inform patients of their visitation rights could potentially result in the staff failing to extend visitation rights to all patient population.

Findings include:

1. Review of the brochure titled, "Your Rights and Responsibilities as a Patient", dated August 2009, provided to the patient upon admission, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of the undated "Patient Bill of Rights and Responsibilities" document, posted in the hallway outside the emergency room entrance, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of policy/procedure titled, "Patient's Rights", dated 10/07, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of policy/procedure titled, "Visitation Policy", dated 12/04, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of documentation in patient #2's medical record, admitted 3/29/13, revealed the patient signed they received a copy of the Patient Rights.

2. During an interview on 4/1/13 at 2:05 PM, the Director of Nursing acknowledged the patient rights information provided to patients did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

During an interview on 4/2/13 at 9:20 AM, Patient #2 reported receiving a brochure upon admit that contained information about patient ' s rights. Patient #2 further stated the facility staff said she could have visitors but nothing about who could or could not visit them.

During an interview on 4/2/13 at 10:00 AM, Staff J, Admit Clerk, stated they provided patients a patient rights brochure when admitted to the facility. Staff J stated the brochures were on the counter and available to all patients entering the facility. Staff J further stated the admitting staff ask the patients if they wanted to have visitors or not but did not ask or tell patients anything else about visitors.