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Based on record review, review of hospital policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure a doctor of medicine (MD) or osteopathy (DO) periodically reviewed and signed the records of all inpatients cared for by a mid-level (nurse practitioner (NP) or physician assistant (PA) provider) for 2 of 9 closed inpatient records (Patient #14 and #15) reviewed. Failure to periodically review and sign records of inpatients cared for by a mid-level provider limited the CAH's ability to ensure the quality and appropriateness of patient care provided.

Findings include:

Review of the hospital policy titled "Mid-Level Review" occurred on 05/04/17. This policy, dated 02/01/2013, stated, "Patients admitted or seen on the floor by a Mid-Level will have a Mid-Level Chart Review that is signed and acknowledged by a MD/DO. This form is released to the MD/DO by HIM [health information management]."

A form in the electronic medical record titled "Mid level Chart Review", stated, "The CAH MD/DO (s) must review and sign all medical records for patients cared for by mid-level practitioners at the CAH. By signing below the CAH MD/DO acknowledges that he/she has reviewed the admission by a mid-level provider."

- Review of Patient #14's medical record occurred on 05/03/17 and showed an NP admitted the patient on 02/23/17. The CAH MD/DO failed to sign the form titled "Mid level Chart Review.

- Review of Patient #15's medical record occurred on 05/03/17 and showed an NP admitted the patient on 03/23/17. The CAH MD/DO failed to sign the form titled "Mid level Chart Review."

During an interview on 05/03/17 at 2:30 p.m., an administrative nurse (#2) stated she expected the doctor to sign off on the medical records of patients cared for by mid-levels within 30 days.

Based on observation, record review, review of medical staff bylaws, rules, and regulations, review of hospital policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure patients received a complete history and physical (H&P) examination within 24 hours of admission for 1 of 1 acute patient (Patient #2) reviewed and failed to complete a consent form for 1 of 1 observation patient (Patient #3) reviewed who underwent a procedure. Failure to complete an H&P placed the patient at risk for avoidable complications. Failure to complete the consent form for a procedure placed the patient at risk of receiving unwanted procedures and/or treatment.

Findings include:

Review of the medical staff bylaws, rules, and regulations occurred on 05/04/17. The rules and regulations, approved 09/26/13, stated, ". . . 18. Medical Records . . . The record shall include identifications data, complaint, personal history, family history, history of present illness, physical examination, . . . a complete admission History and Physical examination or an interval admission note shall be recorded within 24 hours of admission. This report should include all pertinent findings resulting from an assessment of the systems of the body. . . ."

Review of the CAH policy titled "Dictation" occurred on 05/04/17. This policy, dated 02/01/13, stated, "History and Physicals shall be dictated within 24 hours of admission. . . ."

Review of the CAH policy titled "Consent" occurred on 05/04/17. This policy, dated 10/16/15, stated, "Purpose: To ensure the patient or patient representative is given the information, explanations, consequences, and options needed in order to consent to a procedure or treatment. . . . A properly executed consent form contains at least the following: . . . Name of procedure(s); . . ."

- Review of Patient #2's medical record occurred on May 02-03, 2017 and showed the CAH admitted the patient on 04/30/17. The patient discharged from the CAH on 05/03/17. The practitioner failed to complete an admission H&P.

- Review of Patient #3's medical record occurred on May 02-03, 2017 and showed the CAH admitted the patient for observation on 05/02/17 in preparation for a colonoscopy on 05/03/17.

Observation on 05/03/17 at 10:55 a.m. showed a nurse (#1) preparing to take Patient #3 to the procedure room. Upon review, the consent form failed to describe the procedure (colonoscopy with possible biopsies) but showed the patient had signed the consent earlier that morning. The nurse (#1) failed to ensure the consent form identified the name/type of procedure prior to obtaining the patient's signature of consent.

During an interview on the afternoon of 05/03/17, an administrative nurse (#2) stated she expected staff to complete the consent forms before the patient signed.