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Based on observation, interview, and record review, the facility failed to have a process to ensure all inpatients received written notice there was no Doctor of Medicine or Osteopathy onsite, in the CAH 24-hours per day. This deficient practice affected 18 of 18 sampled inpatient records and 2 of 2 sampled observation records. Findings include:

Review of the following admission documents provided to inpatient admissions failed to show, in writing, an MD or DO was not present in the CAH 24-hours a day, seven days a week:

- Welcome Letter and Commonly Asked Questions, revised 2/25/22,
- Patient Rights, not dated,
- Your Rights as a Swing Bed Patient, revised 12/2021,
- Conditions and Consent for Services, revised 9/22/20, and
- Information for Prospective Patients, not dated.

During an interview on 8/30/23 at 12:17 p.m., staff member C stated the notice regarding no MD or DO onsite was posted in the emergency room. Staff member C stated she was not aware written notice and a signed acknowledgement from all inpatient admissions and observation stays was required.

A request was made on 8/30/23 at 4:23 p.m., for the facility policy regarding the written notice and signed acknowledgement which was required when the CAH did not have an MD or DO onsite at all times. No policy was received prior to the end of the survey.

Based on interview and record review, the facility failed to implement policies and procedures to ensure physician consultation and supervision was documented in the medical record of inpatients under the care of a mid-level provider for 1 (#15) of 20 sampled patients. Findings include:

Review of patient #15's medical record, dated 11/2/22 through 11/22/22, showed the patient was cared for and discharged by mid-level providers, and failed to show any documentation of attending physician consultation.

During an interview on 8/30/23 at 9:31 a.m., staff member C stated the facility did not have a process in place for documentation in the medical records for co-signing mid-level provider's charts, except during peer review.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures which identified hazardous radiation areas in the x-ray and CT machine locations; and failed to ensure the presence of clear signage associated with the radiation hazard present in the radiology department. The deficient practice had the potential to affect all patients and staff utilizing radiology services. Findings include:

During an observation on 8/29/23 at 8:58 a.m., the doors leading to the x-ray and CT equipment locations did not have signage which identified the areas of radiation hazard. The double doors leading to the radiology department, which were open during regular business hours, and locked when the department was closed, did not have any radiation hazard signage.

During an interview on 8/30/23 at 12:10 p.m., staff member N stated she did not think there had ever been radiation hazard signage on the doors which led to the x-ray and CT machines throughout the department.

Review of the facility's policy titled, Radiation Safety Precautions, not dated, failed to show the placement of clear signage in locations of radiation hazards within the radiology department.