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Based on a review of the surgical roster of procedures performed at the hospital compared with the privileges granted to practitioners, the Governing Body failed to ensure all Medical Staff who performed procedures were granted privileges to do so.

The Critical Access Hospital Active Medical Staff consisted of 3 family practitioners, 2 physician assistants and 1 nurse practitioner. Findings are:

A. Physician A performed a removal of a ganglion cyst on 8/2/10.

B. A review of the clinic privileges granted by the Governing Body on 2/26/09 for Physician A lacked approval for performing this procedure.

C. Interview with the Administrator on 8/26/10 at 2:30 PM confirmed Physician A did not have current privileges to perform the procedure.

Staff interviews, record reviews and review of the Medical Staff Rules and Regulations revealed the Critical Access Hospital (CAH) failed to ensure medical records are completed for a total of 19 patients within the 30 days as directed by the Medical Staff Rules and Regulations. The CAH is licensed for 18 beds and had a census of 1 swingbed patient upon entrance. Findings are:

A. Review on 8/26/10 of the Rules and Regulations Section F: Medical Records #18, amended on 10/9/08 reads: "Amends to read: Medical records shall be completed within fifteen (15) days after discharge of the patient. When a Physician's medical records are not completed within this time period, the medical record department will notify the Committee of the Whole Medical Staff, which functions as the Credentials Committee of this infraction. A letter will be sent to the physician giving the physician at least five (5) days prior notice that his/her admitting and surgical privileges, excluding emergencies, will be temporarily suspended if his/her medical records are not completed within thirty (30) days of a patient's discharge. If the physician still does not comply within the (30) day period, a second letter will be sent following the first notification informing him/her that his/her admission and surgical privileges have been suspended, effective 10 days from date of the second letter.

Section F: Medical Records #7 shall be amended to read: All clinical entries in the patients' medical record shall be accurately dated, timed, and authenticated. Authentication means to establish authorship by written signature, identifiable initials, or computer key. Amendment date 7/26/07."

B. Interview on 8/26/10 at 1:00 PM identified 19 patient medical records delinquent as of entrance date of 8/24/10 due to:
- Lack of physician signatures on Physician Orders on 11 patient records;
- Lack of a discharge summary and physician signatures on 2 patient records;
- Lack of nurses signatures on 4 patient records;
- Lack of documented times and dates on physician telephone orders. The interview also identified the actual count of the missing dates and times would be difficult to ascertain "as there were so many."

Further interview with the Director of Medical Records revealed the issue of delinquent medical records and ensuring that the physicians are entering the date and time of all physician orders have been an ongoing issue with the Quality Assurance program for an extended period of time.