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Based on interview and record review, the facility failed to ensure when a mid-level provider admitted a patient to the CAH, a physician was notified for 2 (#s 6 and 11) of 23 sampled patients. Findings include:

Review of patient #6's acute CAH admission medical record, dated from 4/29/23 to 5/2/23, showed the patient was admitted to the CAH by a Physician's Assistant. The medical record failed to show a physician was notified at the time the patient was admitted to the hospital.

Review of patient #11's admission medical record, dated 9/8/23, showed the patient was admitted to skilled swing bed status by a Physician's Assistant. The medical record failed to show a physician was notified at the time the patient was admitted to the hospital.

During an interview on 9/13/23 at 1:57 p.m., staff member I, stated he did not always notify a physician when he admitted someone to acute or skilled swing bed status in the hospital. Staff member I stated if the patient's primary care provider was identified, he sent a text to the provider as a courtesy. Staff member I was not aware of the required notification.

During an interview on 9/13/23 at 2:45 p.m., staff member J stated he was one of four physicians who were active members of the medical staff. Staff member J stated he did not know when a patient was admitted by a mid-level provider (Physician's Assistant or Advanced Practice Registered Nurse), a physician needed to be notified at the time of the admission.

Review of the facility's Medical Staff Bylaws, dated January of 2019, failed to show the mid-level provider requirement to notify a physican when a patient was admitted to the hospital.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures which identified hazardous radiation areas in the x-ray and CT machine locations and failed to ensure clear signage associated with the radiation hazards was present in the radiology department. This deficient practice had the potential to affect all patients and staff utilizing radiology services. Findings include:

During an observation and interview on 9/12/23 at 11:50 a.m., staff member E identified the areas where plain film x-rays and CT scans were performed. The doors to each of these locations failed to have hazardous radiation signage. Staff member E was not able to explain why the hazardous radiation signage was not present.

During an interview on 9/13/23 at 8:00 a.m., staff member D stated she was not aware signage identifying radiation hazards was required in the radiology department. Staff member D stated the facility's policy did not contain information regarding the requirement of signage which identified radiation hazards in the facility.

Review of the facility's policy titled Radiation Safety and Protection, dated 5/31/23, failed to describe the requirement for clear signage of the presence of radiation hazards in the radiology department.

Based on interview and record review, the facility failed to ensure the medical record contained a discharge summary for 1 (#5), and failed to show the medical record contained required elements for 2 (#s 17 and 21) of 23 sampled patients. Findings include:

1. Review of patient #5's medical record showed the medical record did not contain a discharge summary outlining the outcome of patient #5's stay at the CAH.

During an interview on 9/14/23 at 10:35 a.m., staff member B stated there was not a discharge summary documented for patient #5 when she was discharged from skilled swing bed services.

Review of the facility policy, titled Medical Staff Medical Record Completion showed, the Discharge Summary is required on all inpatient admissions.

2. Review of patient #17's medical record failed to show a date the form was signed, and witness signature on the Conditions of Admission, which included the consent to treat.

During an interview on 9/14/23 at 10:35 a.m., staff member B stated the Conditions of Admission form should have contained the date and witness signature.

3. Review of patient #21's medical record failed to show a witness signature on the Conditions of Admission form, which contained the consent to treat.

During an interview on 9/14/23 at 10:35 a.m., staff member B stated the Conditions of Admission form should have contained the witness signature.

Based on interview and record review, the facility failed to establish and implement a medical staff policy or rule which ensured when a mid-level provider admitted a patient to the CAH, a physician reviewed and signed the history and physical for 2 (#s 6 and 11) of 23 sampled patients. Findings include:

Review of patient #6's admission History and Physical (H&P), dated 4/29/23, showed the patient's admission examination was completed by a Physician's Assistant. The H&P document failed to show a physician reviewed and signed the form for patient #6.

Review of patient #11''s admission H&P, dated 9/8/23, showed the patient was admitted to skilled swing bed status by a Physician's Assistant. The H&P document failed to show a physician had reviewed and signed the form for patient #11.

During an interview on 9/13/23 at 1:57 p.m., staff member I stated he was not aware a physician must review and sign the H&P completed by a mid-level provider who admitted someone to acute or skilled swing bed status in the hospital.

During an interview on 9/13/23 at 2:45 p.m., staff member J stated he was one of four physicians who were active members of the medical staff. Staff member J stated he did not know when a mid-level provider (Physician's Assistant or Advanced Practice Registered Nurse), completed the H&P, the physician was required to review and sign the patient's H&P form.

Review of the facility's Medical Staff Bylaws, dated January of 2019, failed to show the physican requirement to review and sign the H&P done by a mid-level provider.