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Based on observation, interview, and review of the hospital patient rights policy, it was determined that the hospital did not ensure that all patients were informed of their patient rights in advance of furnishing care for 3 out of 7 interviewed patients. (Patient identifiers: 31, 34, and 35)

Findings include:

1. An interview was held with the Corporate Quality Director on 12/10/15. The surveyor asked how the hospital notified patients of their patient rights. The Corporate Quality Director stated that the patients rights form was available online and was posted in the lobby, but that they did not give individual copies of patient rights information to patients.

2. On December 15-16, 2015, surveyors interviewed 7 patients in various hospital units and asked if anyone had explained their patient rights to them or given them patient rights written information. For 3 of 7 patients (patients 31, 34 and 35), no patient rights information had been provided.

A. Patient 31 stated that they might have provided patient rights information earlier in her pregnancy, but no patient rights information was provided at the hospital.

B. Patient 34 stated that no patient rights information was explained or given, to either himself or his spouse.

C. Patient 35 explained that he was transported via EMS, and no patient rights information was provided.

3. On 12/10/15, the surveyor observed the registration process for the emergency room. There was no mention of patient rights. In an interview with the ER registrar, she stated that they do not go through the patient rights information with patients, that they just had them "sign the consent screen on the computer."

4. In interviews held at the 2 main hospital registration desks, one at the main registration desk on 12/15/15 at 10:00 AM, and one at the surgical registration desk at 10:15 AM, the surveyor asked both registrars to explain the registration process exactly as if the surveyor were a patient. Both registrars went through a list of information which included verification of patient identification, date of birth, address, employment, insurance information, physician name, and procedure being done. There was no mention of patient rights at either registration desk. The surveyor (pseudo-patient) was asked to sign an electronic "consent for medical treatment" space, but that was the total explanation given.

5. On 12/16/15, the surveyor requested and reviewed the hospital's patient rights policy. Number two lists the requirement that the hospital, in advance of furnishing care, inform each patient, or patient's representative, of their patient rights at the time of patient admission or prior to receiving care.

Based on observation and interview, it was determined that the hospital did not ensure that all foods were stored appropriately.

Findings include:

On 12/10/2015 at 10:50 AM and 2:50 PM, the surveyor toured the kitchen.

1. The following was found on the 10:50 AM kitchen tour:

a. A kitchen worker was observed tearing plastic wrap from a large roll. The plastic wrap was observed draped over the countertop and down over the edge of the counter. The kitchen worker lifted the plastic wrap off the counter and placed it over the food on the serving table. The side of the wrap that was touching the countertop was placed directly on the food. The countertop had food debris and a splattered, dried-on, unknown substance on it.

b. The following was found in the walk-in refrigerator:

(i) a one-gallon jug of separated buttermilk with the expiration date of 12/8/2015

(ii) a squeeze bottle of thousand island dressing open to air (tip cut off and not capped). It was not labeled or dated

(iii) a two-quart jug of lime juice with the expiration date of 7/29/2015

(iv) a container of cut raw red potatoes in water with a prepared date of 12/2/15

c. The gap between the drain pipe for the steam table/cooling table and the floor drain was less than 1 inch. There needs to be a minimum 2-inch gap

d. A food preparation sink's drain pipe was observed. The gap between the drain pipe and the floor drain was less than 1 inch

e. Freezer - an opened bag of chicken nuggets was observed.

2. The following was found on the 2:50 PM kitchen tour:

a. an opened-to-air 1-pound box of powdered sugar

b. an opened-to-air box of cornstarch

c. a large plastic jar of peanut butter with an expiration date of 3/7/2105

d. an opened-to-air bag of what appeared to be granola, not labeled or dated

e. 2-ounce single-serve plastic containers with what appeared to be granola with no dates or label as to what the food item was

f. on the preparation counter was a plastic bin filled with clear 2-ounce single-serve containers. The containers had an unknown syrup liquid-like substance in them with no label identifying the substance

g. A Vulcan food warmer was observed. It was splattered with food particles and had a grimy glass door.

3. The following staff was interviewed:

a. On 12/10/2015 at 11:00 AM, the Dietary Manager was interviewed. She stated that the dietary staff do inventory every Monday and Thursday. She stated that at that time they are supposed to rotate stock and discard expired food.

b. On 12/10/2015 at 3:20 PM, the hospital's Quality Assurance Manager was interviewed. She stated that the food should be in sealed containers, labeled and dated.

Based on observation and interview, it was determined that the endoscopy reprocessing area did not comply with regulations for infection control.

Findings include:

On 12/10/2015 at 2:45 PM, the endoscopy reprocessing area was observed where an endoscopy technician was cleaning endoscopes. She was observed to have on a protective gown and a mask with a face shield. The surveyors were asked to put on protective gowns and masks, as some "splashing" could occur.

There were two sinks that had submerged dirty endoscopes in each of them. The technician then demonstrated how to manually wash a scope by cleaning one of the scopes. The technician used a small white brush to manually clean some of the ports of the endoscope. The technician also stated that she used the same small white brush to clean multiple scopes and would place the brush in the automatic scope reprocessor with the endoscope. The technician stated that when the brush became visibly worn, she would discard it and replace it with a new brush.

On 12/15/2015 at 3:00 PM, the Endoscopy Manager was interviewed. She stated she was unable to obtain the manufacturer's instructions on the use of the small white brushes used to clean the endoscopes. She stated that she contacted the manufacture and was informed the brushes were for single use only.

Observed within 3-4 feet of the "dirty" sinks was an uncovered multi-tiered cart. There were clean linens and supplies observed on the cart. There was no barrier between the dirty sinks and clean supplies to prevent cross contamination.

Also observed was a dirty linen receptacle placed directly next to the uncovered clean linen cart. There was no barrier between the dirty linen receptacle and the clean supplies to prevent cross contamination.

Based on interview and record review, it was determined that the hospital did not have a complete operating room (OR) registry.

Findings include:

On 12/16/2015 at 2:10 PM, the Corporate Quality Director was interviewed and he presented the OR registry on his laptop computer. Review of the OR registry revealed that the following key information was missing, name of nursing personnel, pre and post operation diagnoses and ages of the patients.