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Based on review of Medical Staff Rules and Regulations, review of medical records, and interview with staff, the facility failed to ensure that a physician had reviewed and signed all medical records for patients cared for by nurse practitioners.

Findings include:

Only one patient was hospitalized on the days of the survey. The medical record belonging to this patient, along with medical records of the last 9 discharges from the CAH since January 1, 2010 were reviewed.

On 3 of 10 records reviewed, the only documentation in the record from a physician is a discharge progress note and/or discharge order. The other 7 records contained no physician documentation or signatures.

On interview with personnel, the physician does not routinely review and sign all medical records for patients cared for by nurse practitioners.

Based on review of Medical Staff Rules and Regulations, review of medical records, and interview with staff, the facility failed to ensure that when a patient is admitted to the CAH by a nurse practitioner, a physician on staff of the CAH is notified of the admission.

Finding include:

On 9 of 10 medical records reviewed, the patients were either Medicare and/or Medicaid patients . On 6 of 9 medical records reviewed, there was no documentation in the records from a physician to demonstrate the physician ' s responsibility/care.

Based on review of Medical Staff Rules and Regulations, and interview, the facility failed to ensure that it had maintained a list of authenticated signatures of professional staff.

Findings include:

The administrative staff stated that a current list of authenticated signatures for physicians, nurse practitioners and other licensed personnel was not maintained.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that the physician sign all histories and physical examinations documented by a nurse practitioner.

Findings include:

Only one patient was hospitalized on the days of the survey. The medical record belonging to this patient, along with medical records of the last 9 discharges from the hospital since January 1, 2010 were reviewed.

On 10 of 10 medical records reviewed, the nurse practitioner had documented the history and physical examination. None of these histories and physical examinations had been signed by a physician.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure all physician orders had been timed when entered into the medical record.

Findings include:

On 7 of 10 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included verbal orders taken by a nurse, and orders written by the nurse practitioner.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to carry out a annual evaluation of its total program.

Findings include:

The CAH had not developed policies and procedures for an annual evaluation specifying how the CAH is to conduct the evaluation, who is responsible for conducting the evaluation, and what information is to be included in the evaluation.

The administrative staff stated that they had not conducted an annual evaluation.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to carry out a annual evaluation of its total program to include the utilization of CAH services, including at least the number of patients served and the volume of services provided.

Findings include:

The CAH had not conducted an annual evaluation of it ' s total program that included how the services that the CAH provides are utilized.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to include a representative sample of both active and closed clinical records as part of an annual evaluation.

Findings include:

There was no yearly program evaluation performed by the facility that included
a review of medical records that were representative of the services furnished by the CAH, the method of selection of the records to be reviewed, the criteria to be utilized in the review of the records, and the person(s) responsible for the review.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to include a review of the CAH ' s health care policies as part of an annual evaluation.

Findings include:

The CAH had not demonstrated that the health care policies were evaluated, reviewed, and/or revised as part of an annual evaluation of it ' s total program.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to ensure through an annual evaluation that the utilization of services were appropriate, the established policies were followed, and any changes were needed.

Findings include:

The CAH had not determined whether the utilization of services was appropriate, the established policies were followed and any changes were needed as a result of a program evaluation.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to ensure that it had 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:

The only departments of the CAH that are reporting Quality Assurance data are
Nursing, Lab, X-Ray and ER. However, there has not been any documentation of coordination of Quality Assurance activities of these departments in minutes of committee meetings.

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to ensure that all patient care services and other services affecting patient health and safety are evaluated.

Findings include:

All departments affecting patient health and safety are not reporting Quality Assurance activities. Cross refer to C-0336

Based on review of facility policies and procedures, review of Medical Staff Minutes and Governing Body Minutes, and interview with staff, the facility failed to ensure that the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners are evaluated by a member of the CAH staff who is a physician.

Findings include:

Cross refer to C-0260. A physician member of the medical staff does not routinely review medical records of those patients that are admitted to the CAH to assess the quality and appropriateness of the diagnosis and treatment furnished by a nurse practitioner.

There were no QA meeting notes to review or other types of written evaluations to demonstrate there is an ongoing evaluation of care provided by nurse practitioners.

Based on medical record review and staff interview, the facility failed to ensure that activities were provided for three (3) of three (3) swing bed patients. Affected patients were #1, 2 and #3.

Findings include:

Patient #1 was admitted to the hospital on 2/8/2009. Record review revealed that there was no documentation by the Activity Coordinator on the patient ' s medical record. An interview with the Activity Coordinator on 02/16/2010 from 3:00 p.m. to 3:10 p.m. revealed the following information. She had no activity documentation of the patient for the surveyor to review. There was no activity calendar available for the patient.

Patient #2 was admitted to the hospital on 01/16/2010 and discharged on 01/22/2010. Medical record review revealed that there was no documentation by the Activity Director.

Patient #3 was admitted to the hospital on 12/9/2009 and discharged on 01/29/2010. Medical record review revealed that there was no documentation by the Activity Director.

Findings were confirmed during interview with the Director of Nursing on 02/2/19/2010 from 10:10 a.m. to 10:20 a.m. She reviewed the patients ' records and indicated agreement with surveyor findings.

Based on medical record review and staff interview, the facility failed to ensure that medically-related social services were provided for one (1) of three (3) patients. Patient #

Findings include:

Patient #2 was admitted to the hospital on 01/16/2010 and discharged on 01/22/2010. Medical record review revealed that there was no documentation by the Social Worker.
Findings were confirmed during interview with the Director of Nursing on 02/2/19/2010 from 10:10 a.m. to 10:20 a.m. She reviewed the patients ' records and indicated agreement with surveyor findings.

Based on medical record review and staff interview, the facility failed to ensure that a comprehensive, standardized, reproducible assessment was conducted within fourteen (14) days after admission for one (1) of one (1) patient. Patient #3 was the affected patient.

Findings include:

Patient #3 was admitted to the hospital on12/9/2009 and discharged on 01/29/2009. Record review revealed that there was no comprehensive assessment in the record.

Findings were confirmed during interview with the Director of Nursing on 02/2/19/2010 from 9:10 a.m. to 9:20 a.m. She reviewed the patients ' records and indicated agreement with surveyor findings.