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Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated with a timed and dated signature for 5 of 10 emergency records reviewed (E1, E2, E3, E4, and E5); 17 of 20 inpatient records reviewed (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P18, P19, and P20); and 4 of 4 surgical records reviewed (S1, S2, S3 and S4).

Findings include: Authentication of records by physicians, Registered Nurses (RNs) and Registered Dietician (RD) lacked dated and timed signatures for 17 of 20 (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P18, P19, and P20) inpatient records reviewed. Examples included: Dated and timed physician signatures were lacking on Discharge Summaries, Progress Notes, Operative Reports, Standing Orders and/or History and Physical examinations in records P1, P2, P3, P4, P5, P6, P7, P8, P10, P11, P12, P14, P18, P19, and P20. Initial nutritional evaluations by the Registered Dietician lacked a dated and timed signature. Physician authentication of verbal and/or telephone orders lacked a timed and dated signature. It was noted during record review that physician progress notes had been authenticated via electronic signature, including date and time of authentication having been documented. However, handwritten physician signatures lacked timed and dated authentication.

Four of four same day surgical (SDS) records (S1, S2, S3, and S4 ) reviewed lacked proper authentication of entries by the surgeon and/or the certified registered nurse anesthetist (CRNA). The records for patients S1 (admitted 7/6/10), S2 (admitted 7/6/10), S3 (admitted 7/13/10), and S4 (admitted 7/23/10) lacked timed and dated signatures by the surgeon on entries into the medical record. Examples of entries lacking proper authentication included: operative reports, pre and post operative orders, standing surgical orders, surgical consult notes, and discharge orders. Records for patients S1 and S2 lacked timed and dated signatures on the post anesthesia evaluations by the CRNA.

Authentication of Emergency Room notes by physicians and RN's lacked dated and timed signatures on records for patients E1, seen in the emergency department (ED) 3/5/10; patient E2, seen in ED on 3/20/10, and for patient E3, seen in ED on 4/6/10; patient E4, seen in the ED on 7/13/10; patient E5, seen in the ED on 6/20/10. Documents lacked consistent dated and timed signatures.

Interview with the Health Information Director at 1:30 p.m. on 8/5/10, 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 (performance improvement) program, it remained an ongoing problem.

Based on review of quality assurance information and staff interview, the CAH (Critical Access Hospital) failed to evaluate out patient cardiac rehabilitation services and out patient radiology services provided by agreement as part of the overall quality improvement program.

The findings include: the CAH did not evaluate all patient care services as part of the overall quality improvement (QI) program. During review of the QI information it was noted the contracted radiologic services of magnetic resonance imaging (MRI), nuclear medicine, and ultrasound, as well as the out patient services for cardiac rehab had not been evaluated as part of the CAH QI program for the past year.

Interview was conducted with the Quality Coordinator at 11:30 a.m. on 8/5/10. It was confirmed the out patient radiologic services and services provided by cardiac rehab had not been evaluated by the CAH's QI process as there had been no reporting of quality data from those areas during the past year.