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Based on record review and staff interview, the facility failed to show evidence of compliance with the advanced directive notice requirement for 26 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26) of 26 patient medical records reviewed. Findings include.

During the review of medical records, the surveyors noted the lack of a written notice to patients regarding the implementation of patients' rights to make decisions concerning medical care.

On 1/16/13 at 11:05 a.m., staff member B, the DON, stated the facility did not have a written notice regarding the patients' right to make decisions concerning medical care, such as the right to formulate advanced directives. The DON stated the facility gave the patients information on the 5 Wishes and POLST if the patient wanted the information. The DON stated there was nothing from the facility in writing to give to the patients.

Based on contract review and staff interview, the facility failed to have an agreement for the credentialing and privileging of teleradiologists. Findings include:


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On 1/15/13 at 2:00 p.m., the contract for the teleradiologist was reviewed. The contract lacked documentation of approved credentialing for the radiologist.

On 1/15/13 at 3:30 p.m., the radiology manager stated there were four radiologists in Missoula who interpreted the radiology films and generated the report. The radiology manager was not aware of who would credential the radiologists.

On 1/16/13 at 4:00 p.m., verification that the radiologists were credentialed by the facility or the contracted company was requested from the interim CEO. The information was not provided by the end of the survey.

Based on observation and staff interviews, the hospital failed to properly store and discard expired supplies; the facility failed to maintain an appropriate schedule for cleaning the autoclave; and the facility failed to keep the equipment in the emergency room and the radiology department clean. Findings include:


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1. On 1/14/13 at 2:30 p.m., the surveyor made the following observations in the emergency room:
-There were seven Portex Provents that had a manufacturer's expiration date of 10/2012;
-There was an IV Burette package that was compromised and was sealed with athletic tape. The tape was peeling away from the package. Noted on the package was "sterile until open."
-The patient suction equipment in the ER and radiology department had a thick layer of dust on the containers. The tubing connected to the containers had a layer of dust and dangled down along the wall.

Staff member F stated that all the supplies in the emergency room were checked monthly and that she was unaware that the IV Burette was compromised.

2. On 1/6/13 at 9:30 a.m., the cleaning schedule for the steam autoclave machine was requested. Staff member H, an RN, stated that she had never cleaned the autoclave machine. The staff member stated she did not know the autoclave machine needed to be cleaned.

On 1/16/13 at 9:40 a.m., staff member G, a maintenance staff member, stated that his department did not monitor the cleaning or maintenance of the autoclave machine. Staff member G stated, "The machine is only used by nurses and maintained by nurses."

Based on record review and governing board bylaws review, it was determined the CAH failed to ensure that the organizational structure requirements were met. The governing body failed to ensure the regulations below were in compliance in order to provide quality of care to all patients. Findings include:

1. CFR 485.627 (a) - C241 - The CAH failed to appropriately credential 2 physicians on staff, 3 midlevel providers, and 4 tele-radiologists.

2. CFR 485.635(a)(3)(vi) - C0278 - The CAH failed to conduct a facility wide infection control program.

3. CFR 42 485.641 - C330 - The CAH failed to conduct a periodic evaluation of the total program and did not have a quality assurance program.

The deficient practices documented in this Statement of Deficiencies describe the failure of the organization and its governing body to effectively manage the CAH's total operation.

Based on record review, governing board and medical staff bylaws reviews, policy review, document review, and staff interviews, the facility's governing body failed to assume responsibility for determining, implementing, and monitoring the policies governing the CAH's total operation. The governing body failed to follow the facility policy for credentialing and privileging for 5 (#s 1, 2, 3, 4, and 5) active providers on staff at the facility and 4 (#s 1, 2, 3, and 4) teleradiologists. Findings include:

1. On 1/14/13 at 3:00 p.m., the surveyor reviewed the governing board minutes for 2012 to the present. The minutes lacked documentation of the governing board's responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies were administered in order to provide quality health care in a safe environment. There was no documentation of the governing board reviewing the annual quality assurance program.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual program review in the past year.


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2. On 1/16/13 at 2:00 p.m., the credentialing records for provider #s 1, 2, 3, 4, and 5 were reviewed and lacked the appropriate approval from the governing board.

On 1/16/13 at 2:00 p.m., verification of the appropriate credentialing was requested for teleradiologist #s 1, 2, 3, and 4. The information was not provided by the end of the survey.

3. On 1/16/13 at 2:00 p.m., the medical staff bylaws were reviewed and noted, "The medical staff through its committees and officers shall investigate and consider each application for appointment or reappointment to the staff...and transmit recommendations thereon to the board... When the recommendation of the medical staff is favorable to the applicant, the Chief Executive Officer shall promptly forward it ....to the board. The board shall, in whole or in part adopt or reject a favorable recommendation of the Staff..."

On 1/16/13 at 4:00 p.m., the interim CEO stated he was unaware that the governing board had not approved the providers' credentials and privileges. The interim CEO stated that the hospital did not have a director of human resources at the time of the survey.

Based on observations and staff interviews, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use. Findings include:

1. On 1/16/13 at 3:15 p.m., during the review of the medication room, the surveyor observed the following expired medications:
-18 syringes of infant 4.2% Sodium Bicarbonate with the manufacturer's expiration date of 12/1/12;
-10 Vials of Gentamicin with the manufacturer's expiration date of 1/1/13; and
-1 open vial of Bacteriostatic 0.9% Sodium Chloride with an open date of 12/13/12.

2. On 1/16/13 at 3:15 a.m., staff member C, a staff nurse, stated the night shift started to look for outdates around the 15th of the month, which allowed time to order the medication and receive before the expiration date. Staff member C stated the Sodium Bicarbonate syringes should have been ordered and destroyed at the end of November 2012.

Based on document review and staff interviews, the facility failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases for all patients and personnel. Findings include:

1. On 1/15/13 beginning at 10:30 a.m., the facility infection control program was reviewed. There was no documentation available of the review of monthly reported infections and the tracking of those infections to establish commonalities or sourcing of those infections.

The infection control program log lacked documentation for the months of July, August, and September of 2012. The log for October to December 2012, contained the Infection Control Report form with the patient's name, signs and symptoms, when symptoms started, and the antibiotic ordered for the patient.

On 1/16/13 at 8:40 a.m., staff member B, the DON, stated he was hired in October of 2012. Staff member B stated in October 2012 he started to put the Infection Control Report form with the patient's name, signs and symptoms, when symptoms started, and the antibiotic ordered for the patient, in the infection control program log. Staff member B stated he was not tracking or trending the infections within the facility.


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2. On 1/14/13 at 2:30 p.m., staff member F, an RN, was asked what cleaning product was used to clean patient care equipment. Staff member F retrieved a container of over-the-counter Lysol wipes and stated, "This is what we use." Staff member F stated she was unaware if the Lysol wipes sanitized the patient care equipment. "This is all we ever used." The surveyor could not locate any information on the container stating that the wipes were to be used in a hospital setting.

Based on observations and staff interview, the facility failed to ensure dietary practices were followed in regards to kitchen sanitation. Findings include:

On 1/15/13 starting at 11:45 a.m., the observation of the lunch meal was conducted. Staff member E was working the tray line for lunch. Staff member E put on gloves, opened the door to the refrigerator, removed a loaf of bread and a tub of butter, and closed the door. The staff member put the bread and butter on the counter near the steam table, went to the prep area of the kitchen for the knife and cutting board, and brought it to the counter near the steam table. The staff member did not change gloves after opening and closing the refrigerator door and going to get the knife and cutting board. Staff member E started to serve the food. While staff member E was cutting the beef patty, he used his gloved fingers to hold the meat in place. Staff member E removed a slice of bread from the bag with his gloved fingers. The staff member placed the bread on the palm of his hand and buttered the bread. Staff member E continued to butter the bread in the same manner for all of the patients trays being served at lunch.

On 1/17/13 at 9:25 a.m., staff member D, the dietary manager stated what the cook did was wrong and the dietician would be conducting education with the cook.

Based on staff interview and review of the list of contracts for services, the facility failed to provide the scope and nature of services for each listed contract. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included a list of contracts with the scope and nature of services provided.

On 1/15/13 at 9:30 a.m., the facility provided a 33-page list of contracts. The list did not contain the scope and nature of the services provided.

On 1/15/13 at 4:30 p.m., during the evening meeting, staff member A stated he was not aware the list of contracts required the scope and nature of the services provided.

Based on review of the governing body bylaws and staff interview, the facility failed to ensure that contracted services met all conditions of participation and standards for contracted services. Findings include:

The Board of Directors Meeting minutes dated from 12/14/11 through 12/19/11 did not contain documentation of a review of the contracted services.

The Board of Directors Meeting minutes dated 1/9/12 contained the following note "[CEO name] told the board that all vendor contracts are being reviewed to insure that they meet Medicare requirements..."

Review of the governing body bylaws indicated that they did not include a requirement for an annual review of contracted services.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated the facility had not reviewed the contracted services in the past. Staff member A stated he was starting the process of reviewing the contracted services.

Based on record reviews and staff interview, the hospital failed to maintain records that were legible and complete for 3 (#s 11, 12, and 17) of 17 patient records reviewed. Findings include:

1. On 1/16/13 at 2:30 p.m., staff member I, medical records, stated she is usually not able to read 100% of the written documentation by provider #2.


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On 1/14/13 at 3:00 p.m., ER medical records were reviewed. The medical records contained illegible documentation from provider #2.

2. Patient #11 was seen in the ER on 12/17/12 Patient #11's physician care documentation form, which contained history and physical results, orders, treatments, diagnoses, and plan for the patient regarding discharge, were illegible.

3. Patient #12 was seen in the ER on 12/11/12. Patient #12's physician's orders and the physician care documentation form, which contained the history and physical, orders, treatments, diagnoses, and plan for the patient regarding discharge, were illegible.

4. Patient #17 was seen in the ER on 10/19/12. Patient #17's physician documentation of care form, which contained the history and physical, orders, treatments, diagnoses, and plan for patient regarding discharge, were illegible.

Based on record review, the facility failed to ensure that properly executed informed consents were obtained for 18 (#s 1, 2, 3, 4, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 23) of 26 patient medical records reviewed. Findings include:

1. Five patients (#s1, 2, 3, 6 and 7) were admitted to the facility on between 11/4/12 and 12/26/12. The Consent of Treatment documents were not timed as to when the consent was obtained.

2. Patient #23, a 91-year-old female, was admitted to the swing bed program on 11/13/12. The Consent to Treat and Privacy Policy Document and the Broadwater Health Center Skilled/Intermediate Care Admission Agreement were not timed, dated or signed.


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3. Twelve patients (#s 4, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) were seen in the ER between 9/6/12 and 1/10/13. The Consent of Treatment documents were not timed as to when the consent was obtained.

Based on record review, the facility failed to ensure that 8 (#s 4, 10, 11, 12, 13, 15, 19 and 24) of 26 sampled patients had records that were properly authenticated. Findings include:

1. Patient #24 a 64-year-old male was admitted to the swing bed program on 11/7/12. The Physician Progress notes dated 12/12/12, 1/8/13, and 1/16/13, were not timed when written by the provider.


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2. Patient #4 was seen in the ER on 1/8/13; the document was not timed or signed as to when medications and/or treatments were administered.

3. Patient #10 was seen in the ER on 1/10/13; the document was not timed or signed as to when medications were administered. The physician care documentation lacked a time as to when the form was signed. The history and physical was not signed.

4. Patient #11 was seen in the ER on 12/17/12; the physician care documentation lacked a time. The discharge instructions lacked a date and time.

5. Patient #12 was admitted on 12/1/12; the discharge instructions lacked a date and time. The laboratory services request lacked signatures, date, and time of the patient and provider. The ER physician care documentation lacked a date. The discharge instruction sheet lacked a signature, date, and time.

6. Patient #13 was admitted to an acute bed on 12/3/12; the physician orders were not timed.

7. Patient #15 was seen in the ER on 11/29/12; the documentation was not timed or signed as to when medications were administered.

8. Patient #19 was seen in the ER on 9/16/12; the documentation was not timed or signed as to when medications were administered. The ER discharge instructions were not dated or timed.

Based on document review and staff interview, the facility failed to meet the condition of participation for the completion, or the arrangement for the completion of the Periodic Evaluation and Quality Assurance Review. Findings include:

1. During the review of the provided documentation beginning on 1/14/13, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included:
-The periodic evaluation itself (C-0331),
-Evaluation of the utilization of the Critical Access Hospital services (C-0332),
-A representative sample of open and closed clinical records (C-0333),
-Evaluation to determine whether the utilization of services was appropriate, established policies and procedures were followed, and if changes were needed (C-0335),
-Evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes (C-0336),
-All patient care services and other services affecting patient health and safety are evaluated (C-0337),
- The evaluation of nosocomial infections and medication therapy (C-0338),
-An evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists, and physician assistants at the critical access hospital (CAH) are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH (C-0339),
-The quality and appropriateness of the diagnosis and treatment furnished by a physician at the hospital are evaluated by a hospital in the network, a Quality Improvement Organization, or other qualified entity (C-0340),
-The findings of the evaluations were considered and corrective actions taken, if necessary (C-0341),
-The facility takes the appropriate remedial action to address deficiencies found through the quality assurance program (C-0342), and
-The facility documents the outcome of all remedial action (C-0343).

2. On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual program review in the past year.

Based on document review and staff interview, the facility failed to complete or arrange for the completion of a periodic evaluation of the total program. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included the periodic evaluation and Quality Assurance program review.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation and Quality Assurance Review on the total Quality Assurance program. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the utilization of CAH services, including at least the number of patients served and the volume of services. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included the periodic evaluation and review of the services provided by the CAH. The review of services needed to include the number of patients served for the year and the volume of services.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation of the services provided by the CAH. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included a representative sample of both open and closed clinical records. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included a representative sample of both open and closed clinical records reviewed for one year.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation of a sample of open and closed clinical records for one year. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the utilization of services was appropriate, the established policies were followed, and if changes were needed. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included a review of the services provided and if they were appropriate, evidence that the facility policies were followed, and documentation of any changes needed.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation if the services provided were appropriate, the facility policies were followed, and if any changes were needed. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to create and maintain an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided staff member A with a list of requested documents and information that included the quality and appropriateness of the diagnosis and treatment furnished in the CAH and documentation of the treatment outcomes.

During the review of the QA binder the surveyor noted QA meeting minutes for 9/29/11; the next set of meeting minutes was for 12/12/12.

On 1/15/13 at 8:15 a.m., staff member A, interim the CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation of all patient care services and other services affecting patient health and safety. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included a determination of whether all patient care services, other services affecting patient health, and patient safety were evaluated.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation of a completed periodic evaluation of patient care services, other services affecting patient health, and patient safety. There also was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation of nosocomial infections and medication therapy. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included a determination whether nosocomial infections and medication therapy were evaluated.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation of nosocomial infections and medication therapy. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

On 1/16/13 at 8:40 a.m., staff member B, the DON, stated he was hired in October of 2012. Staff member B stated he started to complete an Infection Control Report form with the patient's name, signs and symptoms, when symptoms started, and the antibiotic ordered for the patient. Staff member B stated he was not tracking or trending the infections within the facility.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by midlevel practitioners at the CAH were evaluated by a member of the CAH physician staff, or by another physician under contract with the CAH. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included the quality and appropriateness of the diagnosis and treatment furnished by the midlevel practitioners of the CAH were evaluated by a member of the CAH physician staff or by another physician under contract with the CAH.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation of the diagnosis and treatment furnished by the midlevel practitioners in the CAH were evaluated by a member of the CAH physician staff or by another physician under contract with the CAH. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the critical access hospital (CAH) are evaluated by a member of a hospital network, a QIO, or an appropriate and qualified entity identified by the State rural health care plan. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included and evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation as required.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the requirement that CAH staff considered the findings of the evaluations, including any findings or recommendations of the QIO, and took corrective action if necessary. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/12 at 12:00 p.m., the survey team provided a list of requested documents and information that included the requirement for the hospital staff to consider the findings of the evaluations, including any findings or recommendations of the QIO, and take corrective action if necessary.

Beginning on 1/14/13, the surveyor reviewed the documentation provided by the facility. The surveyors did not receive documentation on the completed periodic evaluation of the requirement for the hospital staff to consider the findings of the evaluations, including any findings or recommendations of the QIO, and take corrective action if necessary. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to take appropriate remedial action to address deficiencies found through the quality assurance program. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/13 at 12:00 p.m., the survey team provided staff member A with a list of requested documents and information that included a copy of the facility's QA plan showing the CAH implemented appropriate remedial action to address the deficiencies found through the QA program.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services, and other services affecting patient health and safety. There was no documentation that remedial actions were taken to address deficiencies identified in the quality assurance program. There was no documentation indicating the individual responsible for implementing remedial actions to correct deficiencies identified by the quality assurance program. There was no documentation of the review being reported to the governing board.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on document review and staff interview, the facility failed to document the outcomes identified by the QA plan. Findings include:

During the entrance conference with staff member A, the interim CEO, on 1/14/13 at 12:00 p.m., the survey team provided staff member A with a list of requested documents and information, including the outcome of all remedial action by the QA plan.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety. There was no documentation of the outcomes of any remedial action.

On 1/15/13 at 8:15 a.m., staff member A, the interim CEO, stated he did not think the facility had done an annual CAH program review in the past year.

Based on policy review and staff interviews, the facility failed to have written policies and procedures regarding patient visitation rights. Findings include:

On 1/15/13 at 2:45 p.m., the surveyors requested the policy on the visitation rights of the patient.

On 1/15/13 at 4:30 p.m., during the evening meeting, the surveyors asked the management team if they had a policy for the visitation rights of the patient. Staff member A stated he would have someone look for the policy

On 1/16/13 at 11:05 a.m., staff member B, the DON, stated the facility did not have a policy on the visitation rights of the patients.

Based on policy review and staff interviews, the facility failed to have a policy and procedure regarding the patients' visitation rights, clinical restrictions, consent to visitors, and right to withdraw or deny consent. Findings include:

On 1/15/13 at 2:45 p.m., the surveyors requested the policy on the visitation rights of the patient.

On 1/15/13 at 4:30 p.m., during the evening meeting the surveyors asked the management team if they had a policy on the visitation rights of the patient. Staff member A stated he would have someone look for the policy

On 1/16/13 at 11:05 a.m., staff member B, the DON, stated the facility did not have a policy on the visitation rights of the patients.

Based on policy review and staff interviews, the facility failed to have a policy and procedure regarding the visitation rights of patients which 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. Findings include:

On 1/15/13 at 2:45 p.m., the surveyors requested the policy on the visitation rights of the patient.

On 1/15/13 at 4:30 p.m., during the evening meeting, the surveyors asked the management team if they had a policy on the visitation rights of the patient. Staff member A stated he would have someone look for the policy

On 1/16/13 at 11:05 a.m., staff member B, the DON, stated the facility did not have a policy on the visitation rights of the patients.