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Based on interview and document review, the Critical Access Hospital (CAH) failed to document a timely discharge summary for 2 of 20 patients (P4, P12) whose medical records were reviewed. In addition, the facility failed to obtain the time when surgical consents were signed for 6 of 7 patients (P2, P10, P11, P16, P18 and P13) whose surgical charts were reviewed.

Findings include:

P4 was admitted to the CAH on 2/18/14, with a diagnosis identified in the physician's orders as atrial fibrillation. P4 was discharged on 2/19/14. The physician's discharge summary was dated 4/3/14, 44 days after discharge.

P12 was admitted to the facility on 4/14/14, with diagnoses identified on the physician's orders that included recurrent abdominal pain and generalized weakness and fatigue. P12 was discharged on 4/18/14. The physician's discharge summary was dated 5/28/14, 40 days after discharge.

On 8/14/14, at 8:10 a.m. the vice president of clinical services (VPCS)-A was interviewed and stated discharge summaries should be completed within 30 days of discharge.

The facility was unable to provide a policy and procedure in regards to when discharge summaries are to be completed.


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P2 had an emergency appendectomy procedure on 2/5/2014. Review of the Informed Consent for Surgical/Invasive Procedures for P2, revealed that the time the consent was signed was not documented by the patient's representative and the physician.

P10 had a right total knee arthroplasty procedure on 7/22/2014. Review of the Informed Consent for Surgical/Invasive Procedures for P10, revealed that the time the consent was signed was not documented by the physician.

P11 had a right hemicolectomy procedure on 7/28/2014. Review of the Informed Consent for Surgical/Invasive Procedures for P11, revealed that the time the consent was signed was not documented by the patient or the physician.

P16 had a right total hip arthroplasty procedure on 8/12/2014. Review of the Informed Consent for Surgical/Invasive Procedures for P16, revealed that the time the consent was signed was not documented by the physician.

P18 had a repeat cesarean section procedure on 6/9/2014. Review of the Informed Consent for Surgical/Invasive Procedures for P18, revealed that the time the consent was signed was not documented by the patient or the physician. A witness was not documented on the consent form.

An interview was conducted with the vice president of clinical services (VPCS)-A on 8/13/14, at 1:05 p.m. who verified that all surgical consents should include the time the consent was authenticated by the patient and physician.


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Findings include:

P13 had a right hip hemi arthroplasty procedure completed on 7/17/14. Review of the Informed Consent for Surgical/Invasive Procedures for P13, revealed that the time the consent was signed was not documented by P13 or the physician and the witness.

An interview was conducted with the vice president of clinical services (VPCS)-A on 8/13/14, at 1:05 p.m. verified that all surgical consents should include the time the consent was authenticated.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure physician's orders were timed, dated and/or signed for 17 of 20 patients (P1, P3, P4, P5, P12, P6, P13, P15, P19, P20, P21, P2, P11, P10, P14, P16, & P18) whose medical records were reviewed.

Findings include:

P1 was admitted to the CAH on 6/15/14. Physician's orders dated 6/15/14, 6/1614, and 6/17/14, were not timed when signed by the physician.

P3 was admitted to the CAH on 5/8/14. Physician's orders dated 5/8/14, and 5/9/14, were not timed when signed by the physician.

P4 was admitted to the CAH on 2/18/14. Physician's orders dated 2/18/14 were not timed when signed by the physician.

P5 was admitted to the CAH on 6/3/14. Physician's orders dated 6/3/14, 6/5/14, and 6/6/14, were not timed when signed by the physician.

P12 was admitted to the CAH on 4/14/14. Physician's orders dated 4/14/14, 4/15/14, 4/17/14, and 4/18/14, were not timed when signed by the physician.


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P6 was seen in the emergency department (ED) on 7/17/14. A verbal order received by a registered nurse (RN) on 7/17/14 at 1800 (6:00 p.m.) was not authenticated, dated or timed by the ordering physician. P6 was subsequently admitted to the hospital on 7/17/14 at 1955 (7:55 p.m.) The inpatient admission order to admit P6 to the hospital lacked timing of the order by the physician.

P13 was seen in the ED on 7/16/14 and the following documents had been identified as not being completed:
The ER (emergency room) Physician Impression lacked a date and time when authenticated;
The Radiologist Impression lacked a date and time when authenticated.
P13 was admitted as an inpatient on 7/16/14 at 1724 (5:24 p.m.) and the following documents were noted to be incomplete:
A verbal order was obtained by a registered nurse dated 7/15/14 at 2130 (9:30 p.m.). The date of the verbal order was noted to be incorrect as it was identified to be 1 day prior to P13 being admitted to the hospital. In addition, the verbal order was not dated and timed when signed by the author.
The Total Joint and ORIF (open reduction internal fixation) Hip pre-op (operative) /Admission and Post-op Order set lacked the time the physician signed the pre-op and post-op order set. Physician orders dated 7/17/14 lacked the time the physician authenticated the orders and other physician orders for P13 were noted that were signed but not dated or timed.

P15 was admitted to the hospital on 7/18/14 at 1430 (2:30 p.m.). The following physician orders were noted to be incomplete: A telephone order was obtained on 7/18/14 at 1945 (7:45 p.m.) by a registered nurse (RN) and the telephone order was not authenticated, dated or timed by the physician; Physician orders dated and signed on 7/21/14 lacked a time; a telephone order that was obtained by an RN on 7/22/14 at 0015 (12:15 a.m.) was not signed, dated or timed by the physician who had given the telephone order; a verbal order obtained by an RN on 7/22/14 at 1430 (2:30 p.m.) was not signed, dated or timed by the author; and an anesthesia note dated 7/20/14 lacked the time of the entry.

P19 was seen in the ED on 7/17/14 by a physician and the following was noted to be incomplete: Five physician orders that were noted, lacked the full date (the year was missing) and 1 of the 5 physician order lacked a signature by the physician and 2 of the 5 physician orders were noted as not being signed off by an RN; 2 radiologists preliminary reports lacked a signature, date and time; and the order for admission to observation services lacked the complete date and was not timed when signed by the physician. R19 was admitted to the hospital as an observation (the hospital stay was expected to last less than two midnights) patient on 7/17/14 at 2017 (8:17 p.m.). A PCA (patient controlled analgesia) order for morphine (a strong pain medication) was noted as lacking the date and time the physician wrote the order.

P20 was admitted to the hospital on 7/17/14 at 1941 (7:41 p.m.). The admission order to observation services was not timed when signed by the physician.

P21 was seen in the ED on 7/13/14 and orders for lab work, radiology and ibuprofen lacked a signature, date and time by the ordering physician. In addition the discharge note for P21 was noted as not being signed, dated or timed by the physician who wrote the discharge orders.


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P2 was admitted to the CAH on 2/5/2014. Physician post-operative order set was not dated and timed by the physician when signed. Physician's orders dated 2/5/2014, and 2/6/2014 were not dated and timed by the physician when using a stamped signature. Physician progress notes dated 2/6/2014 were not timed when stamped by the physician.

P11 was admitted to the CAH on 8/6/2014. Pre-op/surgery admission order set and post-op order set was not dated and timed when signed by the physician. Physician's orders (verbal and written) dated by nurses as 8/8/2014, 8/9/2014, and 8/10/2014 were not always dated and timed when signed by the physician. Physician progress notes dated 8/8, 8/9 and 8/10/2014 was not timed by the physician.

P10 was admitted to the CAH on 7/22/2014. Physician's orders (total joint and ORIF hip pre-operative/admission and post-operative order set dated 7/22/2014, were not timed when signed by the physician.

P14 was admitted to the CAH on 5/15/2014. Physician admission order set dated 5/15/2014; Physician ' s orders and progress notes dated 5/16/2014, 5/17/2014, and 5/18/2014, were not timed when signed by the physician.

P16 was admitted to the CAH on 8/12/2014. Preoperative Total Joint Arthroplasty order set dated 8/12/2014 was not timed when signed by the physician.

P18 was admitted to the CAH on 6/9/2014. Physician orders for C-section pre-op and post-op order set dated and timed by the physician. Physician orders and progress notes dated 6/9/2014, and 6/10/2014 were not timed when signed by the physician.


The facility policy for GENERAL DOCUMENTATION GUIDELINES without date and provided by the facility was reviewed. It noted: PHYSICIAN's ORDERS: The attending physician's written or verbal orders direct a patient's diagnostic and therapeutic course in the hospital. All orders must be clear, complete and legible (if handwritten), and should include the time and date. They also must be authenticated by the physician giving them.

On 8/13/2014 at 1:00 p.m., the vice president of patient services was interviewed. The above policy for signing, dating and timing entries only says MD orders but she expected they would do that for all discipline entries.

Information policy titled PHYSICIAN'S ORDERS specified the following: ... The Condition of Participation state that "All entries must be legible and complete, and must be authenticated and dated promptly by the person who is responsible for ordering, providing, or evaluating the service furnished" Verbal orders are to be reviewed and authenticated within 24 hours.

Review of the Medical Staff Bylaws under #26 verified the following: All orders for treatment shall be in writing. Verbal orders received from a practitioner on any outpatient or inpatient in the hospital or nursing home shall be received only by a Registered Nurse, a Licensed practical Nurse, Physical Therapist, X-ray Technician, Pharmacist, Dietician, and Lab personnel... It is the duty of the attending practitioner or practitioner making the order to sign such orders at the time of his next visit to the hospital which should be within 30 days...

An interview conducted with the vice president of clinical services (VPCS) on 8/14/14, at 11:30 a.m. verified that the Health Information policy differed from the Medical Staff Bylaws. The VPCA further added that she was aware that the policy was not the same as the Medical Staff Bylaws related to Physician's orders and the hospital needed to work on this issue.

Based on interview and document review, the Critical Access Hospital failed to document the time pre-anesthesia notes were documented for 7 of 7 (P13, P2, P11, P10, P14, P16, P18) patients whose inpatient surgical records were reviewed. In addition, the CAH failed to document post-anesthesia records in a timely manner.

Findings include:

P13 had a right hip hemi arthroplasty procedure completed on 7/17/14. The PREANESTHETIC EVALUATION form documented on 7/17/14, by certified registered nurse anesthetist (CRNA)-A lacked a time when completing the form on page 1 and lacked CRNA-A's signature and time on page 2 of this form.

During an interview with CRNA-A on 8/13/14, at 10:15 a.m. verified that the PREANESTHETIC EVALUATION form should contain the author's signature, date and time when this form is completed.


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P2 had an emergency appendectomy procedure on 2/5/2014. The Pre-Anesthetic Evaluation form documented on 2/5/2014, by a certified registered nurse anesthetist CRNA-A lacked a time when completing evaluation. The Post Anesthesia Evaluation was dated 2/26/2014 (21 days after the surgery). On 8/13/2014 at 12:45 p.m., CRNA-A was interviewed and indicated a post anesthesia evaluation should be done and a note written after surgery, so the chart was reviewed and a note made.

P11 had a right hemicolectomy procedure on 8/6/2014. The Pre-Anesthetic Evaluation form was documented on 8/5/2014 (surgery was 8/6/2014), by CRNA-B and lacked a time when completing the evaluation.

P10 had a right total knee arthroplasty procedure on 7/22/2014. The Pre-Anesthetic Evaluation form documented on 7/22/2014, by CRNA- B lacked a time when completing evaluation.

P14 had a right hip arthroplasty procedure on 5/15/2014. The Pre-Anesthetic Evaluation form documented on 5/15/2014, by CRNA- A lacked a time when completing evaluation. The Post Anesthesia Evaluation was dated 7/16/2014 (32 days after the surgery). On 8/13/2014 at 12:45 p.m., CRNA-A was interviewed and indicated a post anesthesia evaluation should be done and a note written after surgery, so the chart was reviewed and a note made then.

P16 had a right total hip arthroplasty procedure on 8/12/2014. The Pre-Anesthetic Evaluation form documented on 8/12/2014, by CRNA- B lacked a time when completing evaluation.

P18 had a repeat cesarean section procedure on 6/9/2014. The Pre-Anesthetic Evaluation form documented on 6/9/2014, by CRNA-A lacked a time when completing evaluation.

During an interview with CRNA-A on 8/13/14, at 10:15 a.m. verified that the PREANESTHETIC EVALUATION form should contain the author's signature and the date and time when the evaluation form was completed.