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Based on staff interview and policy review the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency. This had the potential to affect all patients and staff of the CAH.

The findings include: during review of the CAH's emergency policies it was noted there was an agreement in place for delivery of a water tankard in case of an interruption in normal water supply. However, the policies lacked identification of determination of the need for potable/non-potable water as well as determination of estimated amounts required for use by individual CAH departments.

During interview with Maintenance staff- G at 2:30 p.m. on 7/15/10, he indicated he was not aware of any plan which specified amounts of water required by CAH departments or of the need for potable versus non-potable water in the event of an emergency. Interviews were conducted with the RN (registered nurse) Safety Officer and the RN Risk Manager/Performance Improvement Coordinator at 3:00 p.m. on 7/15/10. They confirmed the CAH lacked a written plan /policy for specific amounts of water that may be required for use during an emergency situation.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated by the physician and/or mid-level provider with a timed and dated signature for 4 of 10 emergency records reviewed (E2, E3, E5, and E6); 18 of 20 inpatient records reviewed (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P18, P19, and P20); and 1 of 5 surgical records reviewed (S1).

Findings include: authentication of records by physicians and mid-level providers lacked dated and timed signatures for 18 of 20 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P18, P19, and P20) inpatient records reviewed. Examples include: Dated and timed physician and/or mid-level signatures were lacking on Discharge Summaries and/or History and Physical examinations in records P1, P2, P3, P4, P5, P6, P7, P8, P10, P11, P12, P14, P15, P18, P19, and P20. Progress notes lacked properly authenticated signatures with time and date for records P4, P5, P7, P9, P12, P13, P14, P15, and P18.

One of five same day surgical records (S1) reviewed lacked proper authentication by the surgeon. The record for patient S1 indicated the patient had been admitted for same day surgery on 6/29/10. The Operative Report had not been authenticated with a timed signature by the surgeon.

Authentication of Emergency Room Notes by physicians lacked dated and timed signatures on records for patients E2, seen in the emergency department (ED) 6/3/10; patient E5, seen in ED on 4/17/10, and for patient E6, seen in ED on 5/10/10. The record for patient E3, seen in the ED on 6/25/10, lacked dated and timed signature on the physician orders.

Interview with the RN/Performance Improvement (PI) Director at 3:00 p.m. on 7/15/10, verified that entries in the medical records reviewed lacked consistent authentication of the time and/or date the entries had been made by the author. It was further indicated that although this had been addressed by the CAH's PI program, it remained an ongoing problem.