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Based on staff interview and review of facility policies the facility failed to include at least one mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist in the Critical Access Hospital policy developement, execution and periodic revewiew. Findings include:

Interview with the Administrator on 2/22/10, at 1:30 p.m. confirmed the Critical Access Hospital (CAH) utilized physician assistants as part of the orthopedic surgery that was performed at the hospital.

Review of the CAH Advisory Committee Meeting minutes dated 2/19/10, stated, "...The purpose of the meeting was to review the 2009 policy additions and changes and utilization..." Review of the minutes revealed the facility did not have a mid-level practitioner as part of the meeting therefore, the facility policy development and review.

Interview with the Director of Quality Assurance, Utilization Review and Infection Control on 2/23/10, at 1:30 p.m. confirmed the facility did not include mid-level practitioners to advise the facility on policy development and review. It was confirmed that the CAH policies had not been developed or revised with advice from this required group of professionals during the past year.

Based on staff interview and review of facility policies the facility failed to develop or revise policies with the advice of a group of professional personnel that included at least one mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist. Findings include:

Interview with the Administrator on 2/22/10, at 1:30 p.m. confirmed the Critical Access Hospital (CAH) utilized physician assistants as part of the orthopedic surgery that was performed at the hospital.

Review of the CAH Advisory Committee Meeting minutes dated 2/19/10, stated, "...The purpose of the meeting was to review the 2009 policy additions and changes and utilization..." Review of the minutes revealed the facility did not have a mid-level practitioner as part of the meeting therefore, the facility policy development and review.

Interview with the Director of Quality Assurance, Utilization Review and Infection Control on 2/23/10, at 1:30 p.m. confirmed the facility did not include mid-level practitioners to advise the facility on policy development and review. It was confirmed that the CAH policies had not been developed or revised with advice from this required group of professionals during the past year.

Based on record review, policy review, and staff interview the CAH failed to ensure each entry into the medical record was authenticated with a signature, date and/or time of the signature for 22 of 26 (P1, P2, P3, P5, P6, P7, P8, P9, P10, P11, P16, P17, P18, P19, P20, P21, P22, P23, P24, P25, P26, P27) patient medical records reviewed. Findings include:


Twenty two (22) medical records, that included in-patient, surgical, and emergency patient records, lacked authentication with a signature, date and/or time the entry was made in the medical record. Physician signatures were not consistently authenticated with the date and/or time in the following types of documents contained in medical records: physician progress notes, physician orders, discharge summaries, pre and post anesthesia orders and forms, and history and physical exams.

Records P1, P2, P3, P5, P7, P9, P10, and P11 lacked documentation of timed physician signatures to authenticate written orders on the Routine Order forms.

Records P1, P3, P5, P8, P9, and P10 lacked timed signatures by the licensed social worker (LSW) and the physical therapist (PT). Example includes: record P 10 lacked dated and timed signatures to authenticate entries into the medical record made by the LSW and the PT on 12/08/09.

Surgical records P6, P7, P8, P9, and P10 lacked documentation of timed and dated signatures by the physician and the certified registered nurse anesthetist (CRNA). Example includes: record P8 lacked a dated and timed signature by the physician, and lacked a timed signature by the CRNA on the Pre/Post Anesthesia Orders form dated 12/25/09.

Record P8 lacked a dated and timed signature of authentication by the physician on the Pre-Op Cesarean Section Birth order form, and lacked a timed physician signature on the Post -Partum Orders Cesarean Section Birth form.

Record P8 lacked a timed signature on the post anesthesia care notes dated 12/25/09.

Review of the inpatient record for P16 revealed the patient was admitted to the facility on 12/17/09 and discharged on 12/20/09. The history and physical dated 12/17/09, was not dated or timed, the 12/20/09, dictated discharge summary was not dated or timed when signed by the physician, and a physician's progress note dated 12/18/09, was not timed when written.

Review of the inpatient record for P17 revealed the patient was admitted to the facility on 1/4/10 and discharged on 1/5/10. A pre-surgical history and physical completed on 12/28/09, was not timed, a physician's order dated 1/4/10, was not timed, and an informed consent form dated 1/4/10, was not timed when signed.

Review of the inpatient record for P18 revealed the patient was admitted to the facility on 1/27/10 and discharged on 1/29/10. A physician's progress note dated 1/27/10, was not timed, a social service progress note for discharge planning dated 1/28/10, was not timed when written, a physician progress note dated 1/28/10, was not dated or timed, a physician's progress note dated 1/29/10, was not signed and dated, and a second physician progress noted dated 1/29/10, was not signed or timed when written.

Review of the inpatient record for P19 revealed the patient was admitted to the facility on 12/26/09 and discharged on 12/29/09. A history and physical note dated 12/27/09, and a physician's progress note dated 12/27/09, were not dated or timed when signed, a physician's discharge note dated 12/29/09, was not timed when signed, a physical therapy progress note written on 12/28/09, was not timed, two social service discharge planning notes both dated 12/28/09, were not timed, and two occupational therapy progress notes both dated 12/29/09, were not timed when written.

Review of the inpatient record for P20 revealed the patient was admitted to the facility on 2/12/10 and discharged on 2/16/10. The history and physical, an admission progress note and physician's order all dated 2/12/10, were not timed when written, and a social service discharge planning progress note dated 2/16/10, was not timed when written.

The records for 5 of 8 emergency room patients were reviewed (P21, P22, P23, P24, P25) and revealed the emergency room visit summary lacked authentication of a physician's signature.

When interviewed on 2/23/10, at 9:16 a.m. the Medical Records Supervisor confirmed the physician's do not consistently sign the emergency room visit dictation and the physician will instead initial the face sheet from the visit. The Medical Records Supervisor revealed there was no policy development for the use of the physician's initials on the face sheet and the lack of a physician's signature on the emergency room summary documentation.

The records for 3 of 8 emergency room patients reviewed (P23, P26, P27) who were transferred to the CAH for further treatment, failed to have the following entries authenticated with the physician's signature, date and/or time of the entry.

The inpatient record for P23 indicated the patient was admitted to the facility on 2/7/10 and had two physician orders that were not timed.

The inpatient record for P26 indicated the patient was admitted to the facility on 2/18/10, had two physician's orders and one physician's progress note that were not timed.

The record of P27 indicated the patient was admitted to the facility on 1/19/10, had one physician's order on 1/19/10, and one on 1/20/10, that were not timed. In addition, two physician progress notes both dated 1/20/10, were not authenticated with a time of the entry. The record of P29 also failed to have the facility's Routine Medical/Surgical Orders authenticated with a physician's signature, date, and time.

Review of the facility's policy and procedures for Medical Rules and Regulations page 6, stated, "IV. Medical Record Rules A. Medical Record Requirement 1...All entries in the medical record must be dated, timed, and authenticated, and a method established to identify the author..."

When interviewed on 2/24/10, at 2:30 p.m. the Medical Records Supervisor confirmed the lack of authentication of records with consistent signatures, dates and/or times of entries.






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