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Based on document review, medical record review and staff interview, the facility failed to provide the Medicare discharge rights form, "An Important Message from Medicare About Your Rights" for 3 of 8 (N2, N5 and N6) closed patient medical records reviewed requiring letter.

Findings:

1. 42 CFR 405.1205(b) states: "Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:"

2. Policy No. 11.2.003 M, titled "Admission/Continued Stay/Exclusion Criteria", reviewed on 2/9/11 at 12:03 PM, indicated on pg. 8, under section F. Role of the Clinical Associates in Acute Care Admissions, point 2.a.(10), "Every client who is on Medicare signs "An Important Message from Medicare about Your Rights (CMS-R-193)."

3. Review of closed patient medical records on 2/8/11 at 12:09 PM indicated patient:
A. N2 was a Medicare recipient and lacked "An Important Message from Medicare About Your Rights" letter within two days of admission and not more than two calendar days before the patient's discharge.
B. N5 was a Medicare recipient and lacked "An Important Message from Medicare About Your Rights" letter within two days of admission and not more than two calendar days before the patient's discharge.
C. N6 was a Medicare recipient and lacked "An Important Message from Medicare About Your Rights" letter within two days of admission and not more than two calendar days before the patient's discharge.

4. Personnel P7 was interviewed on 2/8/11 at 1:20 PM and indicated the above mentioned patient medical records were lacking documentation of "An Important Message from Medicare About Your Rights" letter within two days of admission and not more than two calendar days before the patient's discharge as required per facility policy and procedure.

Based on document review, medical record review and staff interview, the facility failed to ensure the right to personal privacy for 6 of 8 (N1-N6) closed patient medical records reviewed and 2 of 8 (N7 and N8) open medical records reviewed.

Findings:

1. Document, titled "Client Rights and Responsibilities", reviewed on 2/8/11 at 12:03 PM, indicated on pg. 1, under Clients have the right section, point 9., "To know, with prior written consent, of involvement in any special observation, treatment procedures and audio/visual recording."

2. Review of closed patient medical records on 2/8/11 at 12:09 PM, indicated patient N1-N6 signed and/or refused to sign the Client Rights and Responsibilities document, lacked written consent to be video monitored, was a patient on the ACU (Acute Care Unit), and was being video monitored during their length of stay.

3. Review of open patient medical records on 2/9/11 at 12:30 PM, indicated patient N7-N8 signed and/or refused to sign the Client Rights and Responsibilities document, lacked written consent to be video monitored, was a patient on the ACU, and was being video monitored during their length of stay.

4. Personnel P7 was interviewed on 2/8/11 at 1:20 PM and indicated the above mentioned patients on the ACU were being video monitored without prior written consent as required per facility policy and procedure.

Based on document review, personnel record review and staff interview, the facility failed to ensure documentation of qualification of individuals providing staff training for 1 of 1 (P8) restraint/seclusion trainer personnel records reviewed.

Findings:
1. Job Description, titled "Community-Mental Health Worker", reviewed on 2/8/11 at 1:58 PM indicated, on pg. 3, under Scope of Practice section, Mental Health Worker Trainer Duties, point 5., "Provide quarterly Seclusion and Restraint inservices for all ACU (Acute Care Unit) staff."

2. Review of personal records on 2/8/11 and 2/9/11 at 3:20 PM and 9:15 AM, indicated:
a. personnel P8 lacked documentation of qualification to train personnel in restraint/seclusion.

3. Personnel P7 was interviewed on 2/8/11 at 1:20 AM and confirmed the above-mentioned personnel lacked documentation indicating qualification to train personnel in the use of restraint/seclusion.

Based on policy and procedure review, personnel record review and staff interview, the facility failed to ensure documentation of training and demonstration of competency for 6 of 11 (P1, P4-P6, P8 and P9) personnel records reviewed.

Findings:
1. Policy No. 11.2.050L, titled "Special Treatment Procedure/Seclusion/Restraint", reviewed on 2/8/11 at 1:38 PM indicated, on pg. 134, under section V. Competencies in Safe Use of Seclusion and Restraint will be Monitored on Every ACU (Acute Care Unit) Employee, points B. and C., "ACU staff will attend an in-service at orientation and at least quarterly to observe and demonstrate safe and effective restraint application, removal, and physical/psychological assessment...Bi-annual updates in Therapeutic Intervention (TI) must be maintained in each employee's file."

2. Review of personal records on 2/8/11 and 2/9/11 at 3:20 PM and 9:15 AM, indicated:
a. personnel P1, P6, and P9 lacked documentation of bi-annual competency in (TI) training.
b. personnel P4, P5, P6, and P8 lacked documentation of quarterly in-service for restraint/seclusion training.

3. Personnel P7 was interviewed on 2/8/11 at 1:20 AM and confirmed the above-mentioned personnel provide direct care to patients and are required per facility policy and procedure to maintain current TI training bi-annually and documentation of quarterly restraint/seclusion competency.

Based on document review and interview, the governing board failed to follow the Medical Staff By-laws/Rules and Regulations by performing annual review/revision.

Findings include:

1. Review of facility document titled Bylaws of the Staff on 2-9-11 indicated the following on page 53, Article XII: These Bylaws shall be reviewed at least annually and revised as necessary. Amendments so made shall be effective when approved by the Board of Directors.
2. Review of the "Bylaws of the Staff" on 2-9-11 indicated the most current review/revision/approval by the Governing Board is dated 6-21-06.
3. Interview with #S1 and #S3 on 2-9-11 at 1110 hours confirm the document titled "Bylaws of the Staff" is the Medical Staff Bylaws/Rules and Regulations; 6-21-06 is the most recent documentation of review/revision/approval by the Governing Board; and confirm the bylaws require annual review/revision approved by the Governing Board.

Based on observation and interview, the facility failed to ensure the safety and well-being of staff and patients in the maintenance area.

Findings include:

1. While touring the maintenance area on 2-8-11 at 1025 hours with #B1, two (2) unsecured fire extinguishers were observed on the floor and one (1) unsecured fire extinguisher was observed on the work bench in the maintenance area.
2. Interview with #B1 on 2-8-11 at 1025 hours confirmed three (3) unsecured fire extinguishers, two (2) on the floor and one (1) on a work bench were unsecured in the maintenance area creating potential harm to patients and staff.