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Based on record review and staff interview the critical access hospital (CAH) failed to ensure emergency services met the needs of 2 of 11 closed emergency room records reviewed (Patient ID # ' s 1 and 3) in that Physician Assistant (PA) ID# M was not onsite within 30 minutes of the patients presenting to the emergency department (ED). This deficient practice had the potential to cause delays in treatment for patients presenting to the ED.

Findings include:

Closed record review of emergency records as follows:

Patient ID# 1 presented to the emergency room on 7/27/15 at 1:25 a.m. with complaints of Syncopy (passing out). Physician Assistant ID# M was notified by the nurse at 1:30 a.m. The Physician Assistant gave the nurse verbal orders over the telephone at this time and did not present to the emergency room unit 2:45 a.m. (One-hour and fifteen minutes after being notified). The patient was subsequently transferred to a higher level of care.

Patient ID# 3 presented to the emergency room on 7/23/15 at 8:10 p.m. with complaints of Chest Pain. Physician Assistant ID# M was notified by the nurse at 8:20 p.m. The Physician Assistant gave the nurse verbal orders over the telephone at this time and did not present to the emergency room until 9:30 p.m. (One-hour and 10 minutes after being notified).

The Administrator (ID# A) acknowledged 8/5/15 at 3 p.m. the hospital has previously experienced problems with Physician Assistant ID# M not meeting the 30 minute requirement.

Record review of the credential file for Physician Assistant ID# M revealed a letter dated 11/6/14 from the Administrator stating " Please consider this a formal reminder of the items discussed at the Medical Staff meeting on October 30th, 2014. On Call Response Time: The Critical Access Hospital Condition of Participation state that the ER System must ensure that a practitioner with training and experience in emergency care is on call and immediately available by telephone or radio, and available on site within 30 minutes. "

Based on personnel record review and staff interview the Governing Body failed to ensure 4 of 4 members of the Professional Staff (ID# ' s K, L, M, N) were reappointed to the medical staff every two years according to the Hospital ' s Bylaws.

Findings include:

Record review of the " Bylaws, Rules and Regulations of the Professional Staff " dated 4/22/13 stated in Section E. " Terms of Appointment or Reappointment " 1. Appointments or reappointments shall be made by the governing body of the Hospital after recommendation of the Medical Staff and shall be for the period of two years ... "

Findings include:

Record review of credential files as follows:

ID# K is a Doctor of Osteopathy. The CAH last reappointed the physician to the medical staff on 4/22/13. The appointment expired 4/22/15.

ID# L is a Physician ' s Assistant (PA). The CAH last reappointed the PA to the medical staff on 4/22/13. The appointment expired 4/22/15.

ID# M is a Physician ' s Assistant. The CAH last reappointed the PA to the medical staff on 4/22/13. The appointment expired 4/22/15.

ID# N is an Advanced Practice Registered Nurse (APRN). The CAH last reappointed the APRN to the medical staff on 4/22/13. The appointment expired 4/22/15.

Interview 8/5/15 at 3 p.m. with the Administrator revealed he was not aware the reappointments had expired. The Administrator stated he would discuss further with the person responsible for credentialing medical staff once she returns from vacation.

Based on record review, Bylaws review, and staff interview the critical access hospital (CAH) failed to maintain clinical records in accordance with written policies in that 7 of 7 closed in-patient records reviewed were incomplete after 30 days (Patient ID# ' s 14, 15, 16, 17, 18, 19 and 20).

Findings include:

Review of the CAH's " Bylaws, Rules and Regulations of the Professional Staff " dated 4/23/13 stated " Article XIII, Rules and Regulations, 19. Medical Records shall be completed within 30 days after discharge of the patient. "

Record review of closed electronic medical records revealed the following:

Patient ID# 14: This patient was admitted 6/3/15 and discharged 6/8/15 by Nurse Practitioner ID# N. Diagnosis listed Pneumonia. The Discharge Summary was not signed by the Nurse Practitioner.

Patient ID# 15: This patient was admitted 6/20/15 and discharged 6/23/15 by Physician ID# K. Diagnosis listed Trauma with multiple lacerations. This record did not contain a History and Physical or a Discharge Summary.

Patient ID# 16: This patient was admitted 5/21/15 and discharged 5/25/15 by Nurse Practitioner ID# N. Diagnosis listed Hypoxia and Shortness of Breath. The Discharge Summary was not signed by the Nurse Practitioner.

Patient ID# 17: This patient was admitted 5/15/15 with Respiratory problems and expired on 5/16/15. Diagnosis listed respiratory problems. The History and Physical and the Discharge Summary were not signed by Nurse Practitioner ID# N.

Patient ID# 18: This patient was admitted 4/18/15 and discharged 4/21/15. Diagnosis listed respiratory problems. The History and Physical and the Discharge Summary were not signed by Nurse Practitioner ID# N.

Patient ID# 19: This patient was admitted 4/20/15 and discharged 5/15/15. Diagnosis listed fractured wrist. The Discharge Summary was not signed by Nurse Practitioner ID# N.

Patient ID# 20: This patient was admitted 3/24/15 and discharged 3/27/15. Diagnosis listed Bowel Obstruction. The History and Physical was not signed by Nurse Practitioner ID# N.

Interview 8/6/15 at 11 a.m. with a medical records staff member (ID# Q) stated the above records were incomplete. The medical records staff member stated the Manager of Medical Records is currently on vacation.

Record review of a delinquent medical record list provided by medical records staff member ID# Q revealed Nurse Practitioner ID# N had 186 records that were past due greater than 30 days needing signatures.

Based on record review, Bylaws review, and staff interview the critical access hospital (CAH) failed to ensure 1 of 7 closed inpatient records reviewed (Patient ID# 15) contained a completed History and Physical and a Discharge Summary.

Findings include:

Review of the " Bylaws, Rules and Regulations of the Professional Staff " dated 4/23/13 stated " Article XIII, Rules and Regulations, 15. A complete history and physical examination shall be written within 24 hours after admission of the patient by the admitting physician.

Closed record review of patient ID# 15 revealed the patient was admitted 6/20/15 and discharged 6/23/15. Diagnosis listed Trauma / Multiple Lacerations. The electronic medical record did not have a History and Physical or a Discharge Summary.

Nurse ID# R verified that patient ID# 15 ' s electronic record lacked a History and Physical and a Discharge Summary.

Based on policy review and staff interview the critical access hospital failed to ensure the Skilled Nursing Facility activities program is directed by a qualified professional. This deficient practice had the potential to affect all current and future patients admitted to a swing bed.

Findings include:

Interview 8/6/15 at 2 p.m. with the Director of Nursing revealed the hospital does not have a person qualified / trained in activities to direct the activities program. The Director stated a home health aide comes to the hospital and assists patients with nails / hair and grooming and the certified nurses ' aide adheres to the activity schedule.

Review of a policy titled " Swing Bed Policy and Procedure: Activities and Recreation " (no date) stated " The program will be directed and supervised by a person who is qualified under applicable law or regulation to do so ... "