HospitalInspections.org

.
Based on observation, document review and interview, the Critical Access Hospital staff failed to implement preventative maintenance program for medical equipment and facility equipment.

Failure to implement a preventative maintenance program places patients' safety and health at risk.

Findings Included:

1. Document review of hospital's policy and procedures titled, "Preventive Maintenance" Policy number 7050-23, last reviewed 02/04/21, showed that all medical equipment be on the hospital preventive maintenance program.

2. 06/28/22 between the hours of 1:00 PM and 4:30 PM Surveyor #1 observed several pieces of equipment in the hospital missing preventive maintenance stickers or missing facility ID tags. One piece of equipment was an (Electrocardiogram) EKG in the emergency department and 3 pieces of equipment (NuStep, Omni Cycle and Matrix Bike) in the physical therapy department.

During the observation, Surveyor #1 interviewed the plant manager (Staff #101) about the hospital's process for ensuring all patient care equipment received preventive maintenance (PM). Staff #101 provided an preventive maintenance inventory list.

3. On 06/30/22 at 1:00 PM, Surveyor #1 reviewed the preventive maintenance list electronically with Executive Assistant (Staff #105). Staff #105 confirmed that the following equipment was not on the preventive maintenance list provided:

a. GE Mac 5500 HD (l2 LED EKG) Facility ID 232280 PM Sticker Past Due 02/22 (Not on inventory list).
b. NuStep TRS 4000 No Facility ID; Sticker indicated last safety check 08/16 (Not on inventory list)
c. Omni cycle, Facility ID 001474 (Not on inventory list)
d. Matrix Recumbent Bike, Facility ID 001384 (Not on inventory list).
.

.
Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report found at Shell EHFM21."
.

.
Based on record review, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff followed the hospital's policy for the patients placed in restraints for 2 of 3 medical records reviewed (Patient #306, #307).

Failure to follow policies and procedures when caring for patients in restraints puts patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, Use of Restraints in Acute Care & ER," policy number 8721-092, last revised 11/24/20, showed that restraint can only be used in emergency situations if needed to ensure the patient's physical safety and less restrictive interventions have been determined to be ineffective. A written order for physical restraint is limited to 4 hours for adults. The original order may be renewed in accordance with these limits for up to 24 hours.

2. On 06/29/22, Surveyor #3 and the Chief Nursing Officer (CNO) (Staff #301) reviewed the medical records of three patients who were restrained during their care received at the hospital. The reviewed showed:

a. Patient #306 was a 32-year-old who presented to the Emergency Department on 06/07/22 with complaints of anxiety, agitation and worsening of manic behavior. The patient became assaultive toward staff and was placed in soft four-point restraints on 06/07/22 at 1:22 PM. The patient was released from restraints on 06/07/22 at 8:58 PM. Surveyor #3 found no evidence that a provider reordered the continuation of restraints after the initial order had reached its time limit, a period of 3 hours and 36 minutes.

b. Patient #307 was a 54-year-old who presented to the Emergency Department on 05/14/22. The patient was acutely combative, agitated and displaying symptoms of active acute delirium. The patient was immediately placed in four-point restraints on 05/14/22 at 12:51 PM and was later released from restraints on 05/14/22 at 7:11 PM. A provider wrote the initial order for restraints at 05/14/22 at 3:16 PM, a period of 2 hours and 25 minutes after the initial application.

3. On 06/29/22 at 2:30 PM, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the hospital's policy on restraints being placed for violent or self-destructive behavior. Staff #301 verified the missing and/or late provider orders written for the application of restraints.
.

.
Item #1 - IV Fluid Warmers

Based on observation, document review, interview, and review of hospital policy and procedures, the hospital failed to ensure staff follow its policy for storing and monitoring intravenous (IV) fluids stored in the warmer.

Failure to store IV fluids at a proper temperature range puts patients at risk for receiving intravenous fluids with compromised sterility, integrity, or stability.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Warming of IV Solutions," policy number 7050-21, last reviewed, 02/04/21, showed that IV solutions may remain in the warmer in their plastic over-pouches not to exceed 104 degrees Fahrenheit for no more than 14 days.

2. On 06/28/22 at 11:00 AM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the IV fluid and blanket warmer in the Emergency Department. The observation showed several 1000 ml IV four 1000 ml IV bags of 0.9 % normal saline in their protective overwrap in the warmer. The fluid warmer cabinet had a digital temperature reading display of 110 degrees Fahrenheit (F) at the time of the observation.

3. Document review of the warmer cabinet temperature recording sheet for the period of 05/05/22 to 06/27/22 (a period of 54 days) showed the IV solution temperatures ranged from 105 degrees (F) to 112 degrees (F). Surveyor #3 noted that no dates were within the acceptable temperature range of 104 degrees F.

4. At the time of observation, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the storage and temperature monitoring of IV fluids in the warmer cabinet. Staff #301 stated she was unsure of the maximum required temperature for storing IV fluids. She stated that central services stocks and dates the IV fluids placed into the warmer cabinet. Central services is responsible for checking and recording the temperature of the warmer cabinets which is performed every other day during the work week. Staff #301 verified the findings that the IV fluid warmer was out of an acceptable temperature range.

Item #2 - Medication Refrigerator Temperature

Based on observation, document review, interview, and review of hospital policies and procedures, the hospital failed to monitor and maintain medication refrigerator temperatures at the required temperature control range.

Failure to maintain medications under proper conditions of sanitation, temperature, light, moisture, and ventilation puts clients at risk for receiving medications with compromised sterility, integrity, or stability.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Refrigerator Temperatures," policy number 7170-215, last revised 02/10/21, showed that medication refrigerators will be maintained between 36 degrees Fahrenheit (F) and 46 degrees (F).
The West Wing night shift Registered Nurse will record the temperature of the medication refrigerator located in the medication room. If the temperature is not within the specified limits, the nurse will adjust the thermostat and recheck the temperature in 30 to 60 minutes. If adjusting the thermostat does not fix the problem, a help ticket will be submitted by the nursing staff to the maintenance department for repair and will annotate on the medication temperature log that a trouble call has been initiated. The pharmacist will be notified immediately to determine if the stored refrigerated medications are still safe for patient use. The refrigerator temperature log forms will be turned into Nursing Administration at the end of each month for review.

2. On 06/28/22 at 12:40 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the West Wing Medication Room. The medication refrigerator had a digital temperature reading display of 33 degrees Fahrenheit (F) at the time of the observation.

3. Document review of the Medication Refrigerator Temperature Log showed that the within normal range was stated as 32 to 45 degrees F. A review of the period 05/01/22 to 06/27/22 (a period of 58 days) showed the medication refrigerator temperatures ranged from 33 degrees (F) to 35 degrees (F). Surveyor #3 noted that no dates were within the acceptable temperature range of 36 to 45 degrees F and no trouble calls to the maintenance department were annotated on the log sheet.

4. At the time of the observation, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the temperature monitoring of medications stored in the medication room refrigerator. Staff #301 stated the night shift nurse is responsible for recording the medication refrigerator temperature. When asked why the medication temperature log form had an inappropriate temperature range (32 to 45 degrees F) listed as normal limits, Staff #301 stated she was unaware of the discrepancy between the hospital's policy, the medication manufacturer's recommended range (36-to-46-degree F), and the posted medication refrigerator temperature log. She verified the findings described above that the medication refrigerator was too cold for proper storage of medications.

Item #3 - Patient Owned Medications

Based on observation, interview, and review of hospital policy and procedure, the hospital failed to ensure that a pharmacist verified patient-owned medications to identify and verify integrity of the medication.

Failure to verify patient medication brought from home puts patients at risk of harm or death from medication errors.

Findings included:

1. Document review of the hospital policy and procedure titled, "Patient's Own Medication-Storage and Destruction," policy number 7170-218, last revised 10/29/19, showed that a physician must approve the use of the patients' own medications in the physician orders. Medications will be verified by a pharmacist before being placed into the West Wing Medication Cart or Pyxis for patient administration. Medications needing to be administered prior to the arrival of the on-site pharmacist shall be verified by the tele-pharmacist using the patient-owned medication verification form.

2. On 06/28/22 at 12:40 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the West Wing Medication Room. The observation showed the following non-verified patient-owned medications stored in the Pyxis (automated medication dispensing machine) cabinet:

a. 5 boxes of Ipratropium Bromide Inhalation Solution 0.5mg per 3 ml per in a non-hospital prescription labeled bottle for Patient #308

b. Hydroxyzine 25 mg capsules in a non-hospital prescription labeled for Patient #308

c. Spironolactone 25 mg in a non-hospital prescription labeled for Patient #308

d.1 box of Naloxone nasal spray in a non-hospital prescription labeled for Patient #308

e. 2 bottles of Tamsulosin 0.4 mg capsules in a non-hospital prescription labeled bottle for Patient #309

f. 2 packages of Apixaban 5 mg tablets in a non-hospital prescription labeled for Patient #309.

3. On 06/28/22 at 2:30 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the West Wing Medication Cart used for Long Term Swing patients. The observation showed the following non-verified patient-owned medications stored in the cart:

a. Patient #308

Torsemide 20 mg tablets in a non-prescription labeled package
Levothyroxine 100 mcg in a non-prescription package
Metoclopramide 5 mg in a non-prescription package
Potassium Chloride ER 10 mEq in a non-prescription labeled package
Meloxicam 7.5 mg in a non-prescription labeled package
Trazadone 50 mg in a non-prescription labeled package
Ondansetron 4 mg in a non-prescription labeled package
Omeprazole 40 mg in a non-prescription labeled package
Atorvastatin 10 mg in a non-prescription labeled package
Prednisone 20 mg in a non-prescription labeled package

b. Patient #309

Tamsulosin 0.4mg capsules in a non-hospital prescription labeled packages
Metoprolol 25 mg in a non-hospital prescription labeled packages
Nifedipine 30 mg in a non-hospital prescription labeled packages
Latanoprost Ophthalmic Solution 0.005% in a non-hospital prescription labeled package

c. Patient #310

Potassium Chloride ER 20 mEq in a non-hospital prescription labeled package
Levothryoxine 25 mcg in a non-hospital prescription labeled package
Bupropion 100 mg SR in a non-hospital prescription labeled package
Atorvastatin 40 mg tablet in a non-hospital prescription labeled package
Metoprolol 50 mg ER in a non-hospital prescription labeled package
Furosemide 40 mg in a non-hospital prescription labeled package

d. Similar findings of medications in a non-hospital labeled package were observed for Patient's # 311, #312, and #313.

4. On 06/28/22 at 3:25 PM, Surveyor #3 interviewed a Registered Nurse (Staff #302) about the process of verifying patient-owned medications. Staff #302 explained that a patient verification form is sent to the tele-pharmacy and then a label is generated (from the tele pharmacy) after having been verified. It is then attached to the package or bottle. When asked about long-term swing bed patient medications, Staff #302 stated the process is the same except for those medication cards which have a bar code printed on the package, those medications are not verified by the tele-pharmacy.

5. On 06/29/22 at 10:00 AM, Surveyor #3 inspected the hospital pharmacy. In the course of the inspection, Surveyor #3 interviewed the hospital Pharmacist in Charge (Staff #303) about the patient owned medications observations found in the West Wing Medication Room and Long-Term Swing Bed patients medication cart. Staff #303 acknowledged that all outside medications brought into the hospital need to be verified before being used for patients. She was unaware that medications from an outside pharmacy with a barcode were not being verified by the hospital pharmacy service prior to being used.

Item #4 -Controlled Substance Inventory Counts

Based on document review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to follow its policy for controlled substance accountability.

Failure to perform nursing shift counts for controlled substances risks potential diversion.

Findings included:

1. Document review of the hospital policy and procedure titled, "Narcotics: Storage & Disposition," policy number 7170-223, last reviewed 09/10/20, showed that a controlled substance count will be done at the end of each shift and signed by two licensed staff, unless a Pyxis machine (automated dispensing machine) is used.

2. On 06/28/22, Surveyor #3 reviewed the Long-Term Swing Bed controlled substance shift count verification sheets for the months of April, May, and June 2022. The review showed the following:

a. The night shift inventory for controlled substances was not documented as having been completed by two licensed personnel on April 12, 2022.

b. The day shift inventory for controlled substances was not documented as having been completed by two licensed personnel on April 17, 2022.

c. The night shift inventory for controlled substances was not documented as having been completed by two licensed personnel on May 15, 2022.

d. The night shift inventory for controlled substances was not documented as having been completed by two licensed personnel on May 29, 2022.

e. The night shift inventory for controlled substances was not documented as having been completed by two licensed personnel for May 30, 2022.

f. Both the day and night shift inventory for controlled substances was not documented as having been completed by two licensed personnel for June 6, 2022.

g. The night shift inventory for controlled substances was not documented as having been completed by two licensed personnel for June 12, 2022.

h. The night shift inventory for controlled substance was not documented as having been completed by two licensed personnel for June 24, 2022.

i. The day shift inventory for controlled substance was not documented as having been completed by two licensed personnel for June 25, 2022.

3. On 06/28/22 at 3:25 PM, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about inventory shift counts for Long Term Swing Bed controlled substances. Staff #301 stated the expectation is that they are performed at every shift change by the licensed nursing staff. She verified the findings above and could not determine why the counts were not documented on the days described above.

Item #5-Unusable Medications

Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that outdated or unusable medications were not available for administration to patients.

Failure to ensure medication storage areas do not contain outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability, and efficacy.

Findings included:

1. Document review of the hospital policy and procedure titled, "Nursing Unit Inspections," policy number 7170-502, last revised 09/10/20, showed that all areas where medications are stored or used will be inspected by pharmacy. Pharmacy personnel will remove any outdated items, any open multi-dose vial without a date, and any dated, multi-dose vials opened longer than 28 days for insulin, 30 days for other medications.

Document review of the hospital policy and procedure titled "Handling of Vials," policy number 7170-227, last revised 02/10/21 showed that all multiple dose vials need to be dated and initialed when open. All open multidose vials opened and dated need to be discarded no later than 28 days after the open date.

2. On 06/278/22 at 9:30 AM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the Emergency Department medication room. The inspection showed two 10 vials of injectable succinylcholine 20 mg per 10 ml (drug used for intubation) with an expiration date of 05/22.

3. On 06/28/22 at 12:40 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) inspected the West Wing medication room. The inspection showed the following:

a. One vial of Lantus 100 units per ml injectable insulin opened and not dated.

b. One vial of Humulin-N U100 unit per ml injectable insulin opened and dated 02/13/22.

c. One package of Humalog U 100 unit per ml injectable insulin opened and dated 05/28/22

d. One vial of tuberculin purified protein injectable opened and dated 05/26/22

4. At the time of the observations, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the expired or not dated medications. Staff #303 verified the findings and stated the pharmacy technician provides monthly checks and these should have been removed at that time.
.

.
Item #1 Water Management

Based on interview and document review, the Critical Access Hospital (CAH) failed to fully develop and implement their water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30 (6/2/2017): Subject line: "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. The plan must meet the following criteria:

a. Conduct a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system.

b. Implement a water management program that considers the ASHRAE industry standard and/or the CDC toolkit, to include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and/or environmental testing for pathogens.

c. Specify testing protocols and acceptable ranges for control measures and document the results of testing and provide corrective actions taken when control limits are outside of acceptable ranges.

Findings included:

1. Document review of the hospital policy titled, "Waterborne Pathogen Plan," Policy Number 8611-006, last revised 09/09/21, showed the water management plan identified risk points throughout the hospital.

2. On 06/30/22 at 1:00 PM Surveyor #1 interviewed the Facilities Manager (Staff #101) about the water management plan.

3. During the interview, the surveyor determined that the plan was missing the following elements (item c):

c) The hospital did not fully specify protocols and acceptable ranges for control measures and action levels when control levels are outside of the acceptable ranges.

4. At the time of the review, Staff #101 confirmed the missing elements of the plan.
.

Item #2 Hydrocollator Routine Disinfection

Based on interview and document review, the Critical Access Hospital (CAH) failed to follow manufacturer's instructions for cleaning the hydrocollator in the physical therapy center.

Failure to maintain equipment places patients at risk of infections.

Findings included:

1. Document review of the hydrocollator manual, "Chattanooga Hydrocollator," showed on page 5 to regularly clean and drain the tank every two weeks and check water temperature daily. Temperature should be between 160-166 degrees Fahrenheit.

2. On 06/30/22 at 2:00 PM, Surveyor #1 interviewed the office assistant (Staff #102) regarding the process of cleaning and disinfecting the hydrocollator. Staff #102 indicated that the hydrocollator is cleaned monthly.

3. During the interview, Surveyor #1 observed the cleaning logs for 05/22 and 06/22 which indicated monthly cleaning and daily water temperature checks. Surveyor #1 asked for the policy, staff #102 was unable to locate a policy to ensure staff were following manufacturer's instructions for use.
.

Item #3 Therapy Pool Testing and Maintenance

Based on observation, interview, and document review the Critical Access Hospital (CAH) failed to follow nationally recognized guidelines to ensure pool chemistry and equipment are maintained for the health and safety of users using the therapy pool.

Failure to maintain equipment and pool chemistry places patients and staff at risk of injury or illness.

Reference: CDC 2016 Model Aquatic Health Code
5.7.1.8A Flow Meters
Flow meters in accordance with MAHC 4.7.1.9.1 shall be provided and maintained in proper working order.

4.7.1.10A Flow Rates / Turnover Times
Table 4.7.1.10: Aquatic Venue Maximum Allowable Turnover Times; Spa, Therapy*, & Exercise Pools Temperature 72-93F (22-34C) Load > 2500 gals/person (9.46 m3)
Turnover Maximum 4 hours or less.

5.7.5.5 Total Alkalinity (TA) shall be tested weekly at all AQUATIC VENUES
5.7.4.4.1A Total Alkalinity Levels Total alkalinity shall be maintained in the range of 60 to 180 ppm (mg/L)

Findings Included:

1. Document review of hospital's policy and procedures titled, "Therapeutic Pool" policy number 7201 - 022; reviewed date 02/27/20; showed no nationally recognized references and does not indicate alkalinity testing.

2. Document review of hospital's pool chemistry log titled, "Swimming Pool Log Sheet" no policy number; no effective date showed that the form came from Washington State Department of Health and has a column that indicated weekly testing for Alkalinity.

3. On 06/29/22 at 2:00 PM Surveyor #1 inspected the therapy pool with the plant manager (Staff # 101). Surveyor #1 observed that the floater inside the flow meter was stuck and not moving. Staff #101 confirmed that the therapy pool flow meter was malfunctioning.

4. During the observation, Surveyor #1 interviewed the plant manager regarding the maintenance and the pool chemistry for the therapy pool. Staff #101 indicated that the maintenance staff checks the mechanics of the pool and that the physical therapy department does the pool chemistry and records the information in the swimming pool binder. When the surveyor opened the swimming pool binder, there were notes indicating to test for alkalinity weekly. Surveyor #1 reviewed the swimming pool logs for the months of 04/22, 05/22 and 06/22 which showed no documentation of alkalinity testing.
.

.
Item #1 Complete List of Patient Rights

Based on interview and review of hospital documents, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a complete list of their patient rights for 5 of 5 patients reviewed (Patient #301, #302, #303, #304 and #305).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital policy and procedure titled, "Swing Bed Admissions," policy number 6221-001, last revised 04/27/22, showed that on admission, the nursing staff will provide a copy of "Resident Rights" to swing bed patients.

Document review of the hospital document titled, "Patient Rights and Responsibilities," not dated, showed the following rights not annotated in the document:

§483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(6) The right to refuse to participate in experimental research.
§483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician.

§483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;

§483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;

§483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and

2. On 07/01/22 between 9:00 AM and 10:00 AM, Surveyor #3 interviewed the Chief Nursing Officer (Staff #301) about the patient right's document given to swing bed patients. Staff #301 stated that the hospital use the same patient rights documents for all patients admitted regardless of admission status (acute, observation, or swing bed program). She stated that she was unaware that not all the required patients' rights were not included in the current document. Staff #301 acknowledged that previously, the hospital provided swing bed patients with a separate resident rights document/book upon admission.

Item #2 Written Copy of Patient Rights

Based on record review, interview and review of the hospital policy and procedures, the Critical Access Hospital (CAH) failed to provide hospital swing bed patients with a written list of their patient rights for 4 of 5 patients reviewed (Patient #301, #302, #303, and #304).

Failure to notify patients of their healthcare rights risks violation of those rights, which may result in undesired and/or sub-optimal health outcomes.

Findings included:

1. Document review of the hospital policy and procedure titled, "Swing Bed Admissions," policy number 6221-001, last revised 04/27/22, showed that on admission, the nursing staff will provide a copy of "Resident Rights" to swing bed patients.

2. On 06/30/22 at 12:30 PM, Surveyor #3 and the Chief Nursing Officer (Staff #301) reviewed the medical records of five patients who were admitted to the hospital swing bed program. The surveyor found no evidence in the medical record that Patient's #301, #302, #303, or #304 had signed the patient rights document acknowledging having received a written copy of their swing bed patient rights.

3. At the time of the review, Staff #301 verified the findings and stated that a written scanned copy of the patient acknowledging having received a copy of his patient rights should be in their medical records.