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Based on staff interview, in 2 of 2 (O and Y) interviews, P&P review, the hospital failed to have the full 36 vials of dantrolene within the facility to respond to a malignant hyperthermia (MH) emergency. This deficiency potentially affects 14 In/Swing bed Pts and 44 OutPts on 11/12/14, 5 In/Swing bed Pts and 62 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

During an interview on November 14th with Pharmacy Director Y, the director indicated the facility has half of the supply of dantrolene (18 vials). The other half of the supply is shared with a hospital 20 miles away. The director of pharmacy Y indicated that the facility used to have a procedure to contact police to immediately obtain the shared supply but that may not always be reliable so hospital staff may need to travel to get the supply.

Review of policy titled, Anesthesia Care of the Surgical Patient, origination date 03/10 on 11/13/12 at 3:55 p.m. revealed on page 6 under Malignant Hyperthermia, Phone Protocol to Secure Emergency Supply of Dantrolene Sodium, " Assign a staff person to initiate the following phone calls:
1. Call Jackson County Sheriff's Department.
2. Call Black River Falls Memorial Hospital.
3. Call Tomah Memorial Hospital on call maintenance employee who is on call list."

Per Frequently Asked Questions from the Malignant Hyperthermia Association of the United States (MHAUS) accessed at the following information was reviewed:

Who Should Stock Dantrolene And How Much?
All facilities, including ambulatory surgery centers and offices, where MH triggering anesthetics (isoflurane, desflurane, enflurane, sevoflurane, methoxyflurane, halothane and succinylcholine) are administered, should stock a minimum of 36 vials of dantrolene, along with the other drugs and devices necessary to treat an MH reaction. If none of these agents are ever in use in the facility, then dantrolene need not be kept at hand.

Where Should Dantrolene Be Kept?
Dantrolene should be kept in or very close to the operating room, so that it is available immediately if MH occurs. Dantrolene may be stored at room temperature. A supply of sterile water for injection USP (without a bacteriostatic agent) should be kept nearby to mix with dantrolene before injection (60 ml/vial); the water for diluting dantrolene should not be stored in a refrigerator; it may be stored in a warming cabinet designed to maintain fluid temperatures between 35-40o° C. All anesthesia and surgical team members should be aware of this location.

Are There Any Advantages In Sharing A Supply of Dantrolene?
No. Minutes count in an MH emergency. The Professional Advisory Council of MHAUS strongly recommends that an adequate supply of dantrolene be available wherever general anesthesia is administered. Responsibility for treatment rests with the facility where the surgery is performed. Sharing is not a good alternative.

During an interview on 11/13/12 at 8:50 a.m. Director of Surgical Services O indicated that one-half of the needed dose of Dantrolene was kept at this facility and the other half of the dose would be obtained from another hospital 20 miles away.


14941

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:

K18: The facility did not provide corridor separation doors with doors with positive-latching hardware, self-latching inactive doors, positive-latching hardware, smoke-tight seals at meeting edges, and doors that would close when pushed or pulled.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations.
K29: The facility did not enclose hazardous rooms with closers on all doors, rated wall construction, sealed wall penetrations, sealed wall penetrations, and rated doors.
K38: The facility did not provide egress paths at all times with the required signage, and no obstructions in the path of egress.
K46: The facility did not ensure the generator has emergency lighting.
K51: The facility did not provide a fire alarm system that was installed in accordance with NFPA 72.
K56: Sprinkler system did not meet all minimum requirements per NFPA 13.
K67: The HVAC system did not meet the minimum requirements per NFPA 90A.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K130: The facility did not provide a code compliant environment with miscellaneous deficiencies. The facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with a smoke removal system.
K144: The facility did not equip the emergency electrical generator with a remote stop.
K147: Electrical system did not meet the minimum requirements per NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:

K18: The facility did not provide corridor separation doors with doors with positive-latching hardware, self-latching inactive doors, positive-latching hardware, smoke-tight seals at meeting edges, and doors that would close when pushed or pulled.
K25: The facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations.
K29: The facility did not enclose hazardous rooms with closers on all doors, rated wall construction, sealed wall penetrations, sealed wall penetrations, and rated doors.
K38: The facility did not provide egress paths at all times with the required signage, and no obstructions in the path of egress.
K46: The facility did not ensure the generator has emergency lighting.
K51: The facility did not provide a fire alarm system that was installed in accordance with NFPA 72.
K56: Sprinkler system did not meet all minimum requirements per NFPA 13.
K67: The HVAC system did not meet the minimum requirements per NFPA 90A.
K75: The facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash.
K77: The facility did not provide medical gas piping as required by NFPA 99.
K78: The facility did not provide protection of anesthetizing locations that use medical gases, as required by NFPA 99 with a smoke removal system.
K130: The facility did not provide a code compliant environment with miscellaneous deficiencies.
K144: The facility did not equip the emergency electrical generator with a remote stop.
K147: Electrical system did not meet the minimum requirements per NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.


18816

Based on MR review, review of P&P and interview with staff in 4 of 6 surgery records (4, 12, 22 and 31) out of a total of 30 records reviewed, the facility failed to ensure the MR contains documentation the alcohol skin prep is dry prior to draping. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Per review on 11/14/12 in the PM of facility policy titled Electrosurgical Unit Use, dated 10/11/76, it states under E "If a flammable fluid such as alcohol is used preparatory to surgery, sufficient time for evaporation will be allowed to prevent the possibility of ignition." The policy does not address documenting the dry time in the surgical record, this is confirmed in interview with RN B on 11/14/12 at approximately 10:00 AM.

Pt #4's MR review on 11/14/12 at 1:40 PM revealed Pt #4 had a cesarean section on 10/21/12. Per the NSF the alcohol based Duraprep was used as a skin prep, there is no documentation on the NSF or UPC that the skin prep was confirmed as dry prior to draping. This is confirmed in interview with RN Y on 11/14/12 at 1:40 PM.

Pt #12's MR review on 11/14/12 at 8:20 AM revealed Pt #12 had an appendectomy on 9/28/12. Per the NSF the alcohol based Duraprep was used as a skin prep, there is no documentation on the NSF or UPC that the skin prep was confirmed as dry prior to draping. This is confirmed in interview with RN S on 11/14/12 at 8:20 AM.


29963

Pt #22's MR review on 11/14/12 at 8:40 AM revealed Pt #22 had an cholecystectomy (surgery to remove the gallbladder) on 10/10/12. Per the NSF the alcohol based Exidine was used as a skin prep, there is no documentation on the NSF or UPC that the skin prep was confirmed as dry prior to draping. This is confirmed in interview with Director of Quality Improvement B on 11/14/12 at 8:40 AM.

Pt #31's MR review on 11/14/12 at 8:00 AM revealed Pt #31 had a left wrist open reduction internal fixation on 11/13/12. Per the NSF the alcohol based, Betadine, Chloraprep and alcohol was used as a skin prep, there is no documentation on the NSF or UPC that the skin prep was confirmed as dry prior to draping.

This is confirmed in interview with RN W on 11/14/12 at 8:10 AM.

Based on observation and staff interview the facility failed to ensure drug and biologicals stored in a crash cart are stored securely or under constant supervision, to prevent unauthorized access. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Per tour of the Emergency Department on 11/15/12 at 10:40 a.m. with Director of Emergency Department E and Director of Quality Improvement B, a code cart was stored in an alcove around the corner from the nurses station, has a break away plastic tie, that does not prevent access.

Per interview with Director of Emergency Department E at time of observation, Director of Emergency Department stated that the nurses station may be left unattended for periods of time throughout the day and night.

A second code cart was observed in trauma room 2, has a break away plastic tie, that does not prevent access.

Per interview with Director of Emergency Department E at time of observation, Director of Emergency Department stated that patients may be left unattended by staff in the same room as the code cart.

Based on tours, observations,and interview with staff the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:
On 11/14/12 at 10:30 AM the back of the sterilizer in the sterile porcessing room was dirty and exposed to the room. This was confirmed with Staff M, DON.


18816

Based on tours, observations, review of P&P and interview with staff in 8 of 10 observations the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Review of facility policy on 11/14/12 in the PM, titled Infection Control, dated 8/1/75, it states under Handwashing Recommendations from the CDC A. 2. a. "Decontaminate hands: before direct contact with patients;...e. After contact with body fluids or excretions, mucous membranes, non-intact skin, and would dressings if hands are not visibly soiled; f. If moving from a contaminated-body site to a clean-body site during patient care; g. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and/or h. After removing gloves." Under Shared Equipment it states "...equipment that is used on more than one patient will be cleaned or wiped between each patient as per manufacturer's recommendations..." Under Basic Environmental Guidelines it states A. Ceiling Tiles: If ceiling tiles in patient care areas are soiled they need to be replaced. Wet tiles must be dried with in 24 hours or replaced." Housekeeping states under C. 1. "All upward-facing horizontal surfaces and frequently touched surfaces will be damp cleaned daily with th approved disinfectant. Frequently touched surfaces include, doorknobs, bed rails, call lights, telephones, keyboards and mouse....E. 2. In addition, all flat upward facing surfaces and furniture fronts are cleaned along with insides of drawers, cabinets and closets. Computer equipment is cleaned per training...J Treatment and Special Procedure Areas These areas must be cleaned daily with a germicidal solution, after use with an infected patient, or minor surgical procedure" Anesthesia F. states "Anesthesia machines are cleaned with disinfectant after each use" Under OB F. it states "Personnel caring for patients during delivery, or any other potential risk situations, are to wear personal protective equipment to guard against splashes or sprays of blood or body fluids." Operating Room, Restricted Area #3 B. 2. f. states "Approved protective eyewear is worn whenever activities could place one at risk for splash spray to face or eyes... C. 1. a. "Equipment from outside the surgical suite is damp dusted with germicidal agent in the unrestricted area of th suite prior to being brought into the OR zones." And under PAR E.1.f. states "Spot cleaning of walls and ceilings shall be done as necessary. Walls are washed every three months, ceilings every six months."

Examples of environmental cleaning:

On 11/13/12 at 2: 40 PM Phlebotomist N drew blood from Pt #31 in the Lab draw room, completed labeling the lab tubes, after Pt #31 left, changed the signage from "occupied" to "unoccupied" wearing the same gloves used for the blood draw and entered the lab testing area. Phlebotomist N did not return to clean the room for the next Pt by the end of the observation at 3:00 PM. This is confirmed with Lab Mgr R on 11/13/12 at 3:00 PM.

On 11/12/12 at 10:30 AM a circumcision on Pt #2 was observed in the OB Procedure Room. CNA D cleaned the room after the procedure. There is a rubber mat to prevent the Circumstraint (to hold infants still during circumcisions) from slipping, CNA D stabilized the mat with her left elbow, holding wrapped instruments in her left hand while attempting to clean the mat with her right hand. During this time two instruments that had blood on fell to the carpeted floor. During the circumcision, Betadine had been sprayed on the wall above the counter and by the paper towels, the splatter was not cleaned from the wall by the paper towels.

Per review on 11/13/12 at 4:00 p.m., of policy titled Anesthesia Care of the Surgical Patient, origination date 3/10, under cleaning of anesthesia equipment and restocking of disposable supplies "All horizontal surfaces of anesthesia related equipment shall be cleansed with Sani-wipes after each case. Terminal cleaning after last case of day will be performed using Sani-wipe and include all surfaces of anesthesia related equipment."

On 11/13/12 at 8:35 AM, an anesthesia cart was noted in the hallway of the surgical center outside the door of the CRNA's office. The front of the cart had reddish-brown colored spots on 4 of the 6 drawers. CRNA AA confirmed in an interview on 11/14/12 at 1:30 AM that the cart was used in the obstetrics laboring room on 11/10/12 and was not cleaned prior to bringing back to the surgical center. This was confirmed with Director of Quality Improvement B and Director of Surgical Services O at the time of the tour.

Examples of PPE, handwashing and glove changes:

On 11/12/12 at 10:30 AM a circumcision on Pt #2, performed by CNM C and assisted by CNA D. CNM C did a surgical scrub and proceeded to push the infant bassinet into the Procedure Room, picked up the infant and placed it in the Circumstraint securing the legs and donned sterile gloves. This practice allowed for immediate recontamination of the hands after the surgical scrub. CNA D opened a package of Betadine Swabs to prep the circumcision site, and Betadine splattered on the wall at eye level both to the right of CNM C and behind CNA D. CNM C and CNA D did not have a mask or eye protection on in the event of splatter or spray. CNA D upon completing the circumcision, picked up the baby wearing the same bloody gloves on, swaddled the infant in blankets, removed gloves and left the procedure room without washing.

On 11/12/12 at 11:25 AM a dressing change for a hip repair was performed on Pt #3 by RN E. RN E removed the old dressing, touched Pt #3's skin around the wound with the dirty gloves. After changing gloves, applying the new dressing and assisting Pt #3 with clothing, RN E removed gloves, and handled Pt #3's drinking mug, side table, bedding and raised the head of the bed without the benefit of washing her hands.

On 11/13/12 at 8:40 AM during a tour of the Surgical Department, a personal bag was located in the CRNA's office. In order to get to the office a restricted area must be passed which does not allow personal items. The bag is not a wipeable surface.

Per review of policy on 11/13/12 at 4:00 p.m., titled Standard Precautions, origination date 12/88, 05. Guidelines B. 3. Masks, Eye Protection, Face Shields: a. Are worn to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and/or excretions.

During observation of pt. # 31's repair of a left wrist fracture at 10:05 AM, Surgeon P was observed to be wearing his own eyeglasses which did not have the protection required per facility policy.

Examples of environment:

On 11/12/12 at 10:30 AM there are gouges in the wall in the OB Procedure Room, allowing for an unwashable surface.

On 11/12/12 at approximately 11:00 AM the OB department tour revealed in rooms 111, 115 and 116 there are unsecured drawers containing needles and syringes allowing Pts and visitors access.

On 11/13/12 at 11:35 AM the soiled room in the Med/Surg unit contained a bag of Styrofoam "peanuts" and a bag of cans for recycling next to a Biohazard bin. This practice allows for potential contamination of the recycling products.

On 11/13/12 at 1:45 PM the tour of the off site clinic in Warrens with CNO M revealed glucometer strips were expired on 9/30/12. And there is an unsecured drawer with needles and syringes allowing Pts and visitors access.

On 11/12/12 at approximately 11:00 AM during the Emergency Department tour, revealed the following:

In room 7 there are unsecured drawers containing needles and syringes allowing Pt's and visitors access.

Room 6 in the ED revealed a dusty ceiling vent.

Rooms 1-9 in the ED had ceilings that were not a smooth or cleanable surface.

The soiled utility room was unlocked and located inside the room was a biohazard bin. In the cupboard under the sink was storage including a bucket with cleaning supplies, plastic bags, a bottle of bleach, and cat liter.

The ice machine located in the medication room behind the nurses station had a whitish-yellow colored film on the front of the machine and near the spout for ice.

The above findings were confirmed with Director of ED H and Director of Quality Improvement B at time of tour.

On 11/12/12 at 1:00 PM, during tour of medical/surgical unit revealed the following:

The soiled utility room was unlocked and located inside the room was a biohazard bin.

Examples of breaking sterile field:

During observation of pt. #31's repair of a left wrist fracture at 10:17 AM, Surgical Tech BB turned her back several times to the surgical instrument table while handing supplies to surgeon P.

The above findings were confirmed with Director of Surgical Services O at the time of the observation.

Based on observation, tour, review of P&P and interview with staff, in 2 of 2 staff observation (K and L) the facility failed to ensure safe food handling by staff following gloving and handwashing policy; and in 2 of 2 tour of the kitchen, and kitchenettes, the facility failed to ensure food items are labeled and dated once opened and out of original packaging. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Per review on 11/14/12 in the PM of facility policy titled Infection Control, dated 8/1/75 states under Food handling & Preparation A.1. "Personnel will hand wash when beginning their shift, after handling raw meat and dirty dishes, after touching their face, hair, etc; after touching money, after using the restroom and between tasks as appropriate. Once staff have left the department for any reason, hands will be washed upon re-entry...4. Gloved hands that become contaminated by touching the hair, face, money, etc. need to have the glove discarded, hands washed and new gloves applied...17. Stickers with open date and expired date must be applied to all open foods."

On 11/13/12, between 7:40 AM and 8:00 AM, the following was observed in the kitchen:

Dietary Staff K, while waiting to assemble breakfast trays, used his apron to clean his eye glasses, placed edible garnish on the plates, handled ready to eat toasted bread, and english muffin, and dished up food items without changing gloves and/or washing. Staff K's left sleeve cuff dragged across the plates when reaching for food items. Staff K removed the gloves after the tray line, did not wash, and proceeded to handle several utensils trying to locate a specific item.

Dietary Staff L, after preparing toast, removed gloves, left the kitchen area and returned with new gloves, without washing prior to leaving the kitchen. After placing the breakfast trays in the warmer cart for transport, Staff L removed gloves and proceeded to take the trays to the Pt areas without the benefit of washing.

Per tour of the kitchen on 11/13/12 between 7:00 AM and 8:00 AM the following was found:

The cornstarch container has a Styrofoam bowl inside.

The walk in freezer contains Cranberries, rice bread, 4 packaged of garlic bread out of original container that are not dated.

Open bags of cauliflower, broccoli, carrots and chicken nuggets are not dated.

Another freezer contains meat and potato fries unlabeled with no date.

The refrigerator contains an open bag of spinach that is not dated.

The above was confirmed with Dietary Manager J on 11/14/12 at 8:00 AM.


29963

Per tour of the Medical/Surgical Unit on 11/15/12 at 1:40 PM, revealed in the refrigerator holding snacks and fluids for patients, 3 disposable plastic containers unlabeled and undated as to what was inside. Director of Medical/Surgical Unit CC and Director of Quality Improvement B confirmed findings at the time of the tour.

Based on MR review, review of R&R and interview with staff, in 5 of 30 MR (4, 15, 17, 26 and 27) the facility failed to ensure all VO and TO medication orders are authenticated by the MD with a signature, date and time. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Per review on 11/14/12 at 3:15 PM of facility Medical Staff R&R dated 5/19/09, it states under C on pg 89 "...A verbal or telephone order shall be authenticated by a properly credentialed medical staff member in writing within 48 hours..."

Pt #4's MR review on 11/14/12 at 1:40 PM revealed there is a TO written on 10/22/12 that is authenticated by the MD without a time. This is confirmed in interview with RN Y on 11/14/12 at 1:40 PM.

Pt #15's MR review on 11/14/12 at 10:30 AM revealed the RSF dated 11/9/12 lists medications given during a code. There is no attestation by the MD, confirming the orders were written as verbalized during the code, and the MD did not date and time when signed. This is confirmed in interview with RN W on 11/14/12 at 10:30 AM.

Pt #17's MR review on 11/14/12 at 10:25 AM revealed the RSF dated 2/3/12 lists medications given during a code. There is no attestation by the MD, with signature, date and time confirming the orders were written as verbalized during the code. This is confirmed in interview with RN W on 11/14/12 at 10:25 AM

Pt #26's MR review on 11/14/12 at 7:15 AM revealed there is a VO written on 11/13/12 that is authenticated by the MD without a time. This is confirmed in interview with RN S on 11/14/12 at 7:15 AM.

Pt #27's MR review on 11/13/12 at 10:30 AM revealed there is a TO written on 11/10/12 that is not authenticated by the MD with a signature, date and time within 48 hours per policy. This is confirmed in interview with RN S on 11/13/12 at 10:30 AM.

Based on staff interview and observation, the facility failed to provide safeguards against possible unauthorized access to medical records. This deficiency potentially affects 14 In/swing bed Pts and 84 OutPts on 11/12/14, 5 In/Swing bed Pts and 79 OutPts on 11/13/14, and 6 In/Swing bed Pts and 64 Outpts on 11/14/12 treated during survey.

Findings include:

Per tour on 11/13/12 at 12:30 p.m. with Director of Quality Improvement B and Director of Health Information G revealed a locked room that stored surgical supplies and a partial wall with a locked door housing paper medical records of death patients. The partial wall did not extend to the ceiling leaving a gap between the top of the wall and the ceiling which could allow unauthorized access to medical information.

Director of Quality Improvement B and Director of Health Information G confirmed during the time of the tour that medical records of death patients were stored in a locked room with a partial wall which surgical staff members were able to access due to this room also being used as a storage for surgical supplies.

Per tour of the Medical Records Department on 11/12/12 at 1:00 PM revealed in a locked room, storage of expired patient paper medical records placed on the floor of the room which were labeled may destroy Jan. 2016, and four stacks of patient's medical records were noted.

Director of Quality Improvement B and Director of Health Information G confirmed during the time of the tour that medical records of death patients were being stored on the floor of the room.

Based on review of rights given to swing bed Pts upon admission and interview with staff, in 1 of 1 interview (V) the facility failed to include the right for spouses to be in the same room. This deficiency potentially affects all 3 Swing bed Pts treated at the facility during survey.

Findings include:

Per review of the swing bed rights provided to new swing bed Pts upon admission, the right to be able to share a room with one's spouse was not listed. This is confirmed in interview with SW V on 11/14/12 at 3:10 PM.

Based on review of rights given to swing bed Pts upon admission, review of P&P, and interview with staff, in 1 of 1 interview (V) the facility failed to include the right to allow 30 days for a transfer or discharge notice. This deficiency potentially affects all 3 Swing bed Pts treated at the facility during survey.

Findings include:

Per review of the swing bed rights provided to new swing bed Pts upon admission, the right to have a 30 day written transfer or discharge notice was not listed. The P&P titled Discharge Policy reviewed on 11/14/12 in the PM, did not include language to allow a 30 day notice prior to transfer or discharge. This is confirmed in interview with SW V on 11/14/12 at 3:10 PM.