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Based on observation and staff interview, the facility failed to prominently post notices which stated that no physician (MD/DO) was present in the Critical Access Hospital at two of two entrances of the facility. Findings include:

During the initial observations of the facility on 7/29/13 beginning at 4:15 p.m. and again on 7/30/13 at 7:30 a.m., the surveyor was unable to locate signage which stated that no physician (MD/DO) was available in the facility 24 hours per day 7 days per week.

Regulatory language of 42 CFR 489.24(b) required that "The posted notice must state that the CAH does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition."

During an interview with staff member A, the DON, and staff member E, the ADON, on 7/30/13 at 2:15 p.m., they stated that patients were provided with a written notice in the clinical record, but there were no signs posted in the building.

Based on document review and staff interview, facility staff failed to ensure that clinical records were complete and accurate for 16 (#s 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 14, 15, 17, 19, 22, and 24) of 25 reviewed patient records. Findings include:

During the review of clinical records for emergency room, swing bed, and hospital patients beginning at 10:30 a.m. on 7/30/13, the surveyor noted the following incomplete clinical records.

1. Patient #1 came to the emergency room on 8/13/12. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment, Patient Bill of Rights, Emergency Service Notice, and Emergency Room Instructions" The forms were signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

2. Patient #2 came to the emergency room on 8/8/12. The record included facility forms labeled "Patient Bill of Rights and Emergency Service Notice" The forms were signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

3. Patient #3 came to the emergency room on 9/23/12. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment, Patient Bill of Rights, Emergency Service Notice, and Emergency Room Instructions" The forms were signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

4. Patient #4 came to the emergency room on 11/6/12. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment and the Emergency Service Notice. Both forms were blank." The form labeled Emergency Room Record was signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

5. Patient #5 came to the emergency room on 12/4/12. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment, Patient Bill of Rights, Emergency Service Notice, and Emergency Room Instructions" The forms were signed and dated by the patient's family member, but did not include the required documentation of the time that the signature of the family member was obtained.

6. Patient #8 came to the emergency room on 1/19/13. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment and the Emergency Service Notice. Both forms were blank." The form labeled Emergency Room Record was signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

7. Patient #9 came to the emergency room on 2/7/13. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment, Patient Bill of Rights, and the Emergency Service Notice" were signed and dated by the patient, but did not include the required documentation of the time that the signatures of the patient were obtained.

8. Patient #10 came to the emergency room on 3/4/13. The clinical record included the facility discharge instruction form signed and dated by the parent of the patient. The time that the signature was obtained was not documented.

9. Patient #11 came to the emergency room on 4/3/13. The record included facility forms labeled "Patient Bill of Rights and Emergency Service Notice". The forms were signed and dated by the patient, but did not include the required documentation of the time that the signature of the patient was obtained.

10. Patient #12 came to the emergency room on 4/17/13. The record included facility forms labeled "Authorization for Medical and/or Surgical Treatment, Patient Bill of Rights, and Emergency Service Notice". Verbal consent of an authorized person was documented and dated on the forms, but did not include the required documentation of the time that the verbal consent of the authorized representative was obtained. The facility emergency transfer form did not include the documentation of the time when the verbal consent to transfer the patient was obtained. The nursing progress note dated 4/17/13 did not include documentation of the time when the note was created.

11. Patient #14 came to the emergency room on 6/11/13. The facility form labeled "Authorization for Medical and/or Surgical Treatment" was signed and dated by a family member of the patient but did not document the relationship of the person granting consent or the time when the signature of consent was obtained.

12. Patient #15 came to the emergency room on 6/15/13. The facility forms labeled "Patient Bill of Rights and Authorization for Medical and/or Surgical Treatment" did not include documentation of the time that the signatures of the patient were obtained.

13. Patient #17 was admitted to a facility swing bed on 8/14/12 after a 3 day stay in a hospital. The facility form labeled "Authorization for Medical and/or Surgical Treatment" did not include the documentation of the time that the signature was obtained.

14. Patient #19 came to the hospital on 4/30/13. The facility form labeled "Uniform Code Level Directives For Cardiopulmonary Resuscitation" was signed and dated by the patient's representative, the provider, and a witness. The form did not include documentation of the times when the signatures were obtained. The facility Discharge Summary, Emergency Room Observation Progress Note, and Emergency Room Note and Emergency Room Observation Notes" did not include the times when the notes were dictated or created.

15. Patient #22 was admitted to the hospital 12/26/12. The facility form labeled "Authorization for Medical and/or Surgical Treatment" did not include the documentation of the time that the signature was obtained.

16. Patient #24 came to the hospital on 2/5/13. The facility form labeled "Authorization for Medical and/or Surgical Treatment" did not include the documentation of the time that the signature was obtained.

During an interview with staff members A and B on 7/30/13 at 4:30 p.m. both staff members stated that they were not aware that the times of consents were not being documented. Staff member A stated that she thought that there was no space dedicated for times on some of the consent forms.

Based on document review and staff interview, the facility staff failed to ensure that all entries into the record by the providers were properly authenticated with dates, times, and signatures of the provider for20 (#s 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 18, 19, 20, 21, 22, 23, 24, and 25) of 25 reviewed patient records. Findings include:

During the review of clinical records for emergency room, swing bed, and hospital patients beginning at 10:30 a.m. on 7/30/13, the surveyor noted the following incomplete clinical records.

1. Patient #3 came to the emergency room on 9/23/12. The emergency room note dictated on 9/23/12 did not include the time when the note was created.

2. Patient #4 came to the emergency room on 11/6/12. The emergency room note dictated on 11/6/12 did not include the time when the note was created.

3. Patient #5 came to the emergency room on 12/4/12. The emergency room note dictated on 12/4/12 did not include the time when the note was created.

4. Patient #6 came to the emergency room on 12/26/12. The emergency room note dictated on 12/26/12 did not include the time when the note was created.

5. Patient #7 came to the emergency room on 4/10/13. The handwritten provider progress note dated 4/10/13 did not include the time when the entry was created.

6. Patient #8 came to the emergency room on 1/19/13. The emergency room note dictated on 1/19/13 did not include the time when the note was created. The facility form labeled "Emergency Room Record" was signed by the provider, but the time that the form was signed was not documented.

7. Patient #9 came to the emergency room on 2/7/13. The emergency room note dictated on 2/7/13 did not include the time when the note was created.

8. Patient #10 came to the emergency room on 3/4/13. The emergency room note dictated on 3/4/13 did not include the time when the note was created.

9. Patient #11 came to the emergency room on 4/3/13. The emergency room note dictated on 4/3/13 did not include the time when the note was created. The handwritten provider progress note dated 4/3/13 did not include the time when the entry was created.

10. Patient #12 came to the emergency room on 4/17/13. The nursing progress note dated 4/17/13 did not include documentation of the time when the note was created.

11. Patient #13 came to the emergency room on 4/29/13. The emergency room note dated 4/29/13 did not include the time when the note was created. The handwritten physician progress note dated 4/29/13 did not include documentation of the time when the note was written by the provider.

12. Patient #15 came to the emergency room on 6/15/13. The emergency room report dated 6/15/13 did not include documentation of the time when the note was created.

13. Patient #18 was admitted to the hospital on 3/19/12. The dictated hospital discharge summary/CAH swing bed history and physical dictated 3/22/13 did not include documentation of the time that the note was dictated or created. Provider orders dated 3/22/13 for a physical therapy consult and medications, and discharge orders dated 3/27/13 did not include documentation of the time when the orders were written by the provider.

14. Patient #19 came to the hospital on 4/30/13. The facility form labeled "Uniform Code Level Directives For Cardiopulmonary Resuscitation" was signed and dated by the patient's representative, the provider, and a witness. The form did not include documentation of the times when the signatures were obtained. The facility Discharge Summary, Emergency Room Observation Progress Note, and Emergency Room Note and Emergency Room Observation Notes" did not include documentation of the times when the notes were dictated or created.

15. Patient #20 was admitted to the hospital 5/18/13. CAH Admission orders dated 5/18/13, two additional sets of written provider orders dated 5/18/13, treatment and lab orders dated 5/19/13, and discharge orders dated 5/20/13 did not include documentation of the time when the orders were written by the provider. The provider dictated Emergency Room Note dated 5/18/13, Emergency Room Addendum & CAH Admission History and Physical dated 5/18/13, and the Discharge Summary dated 5/20/13 did not include documentation of the time that the notes were dictated or created.

16. Patient #21 was admitted to the hospital on 5/27/13. The provider admission orders dated 5/27/13, notification and oxygen orders dated 5/27/13, medication and lab orders dated 5/27/13, medication and activity orders dated 5/28/13, additional medication and lab orders dated 5/28/13, 5/29/13, and discharge orders dated 5/30/13 did not include documentation of the time when the orders were written by the provider. The provider dictated Emergency Room Addendum & CAH Admission History and Physical dated 5/27/13, CAH Progress notes dated 5/28/13 and 5/29/13, and the CAH Discharge Summary dated 5/30/13 did not include documentation of the time that the notes were dictated or created.

17. Patient #22 was admitted to the hospital on 12/26/12. Provider admission orders dated 12/26/12, medication orders dated 12/26/12, 12/27/12, and discharge orders dated 12/28/12 did not include documentation of the time when the orders were written by the provider. The dictated CAH Progress Note dated 12/27/12 did not include documentation of the time that the note was dictated or created.

18. Patient #23 was admitted to the hospital on 1/9/13. The admission orders dated 1/9/13 and additional orders for skin care dated 1/9/13 did not include documentation of the time when the orders were written by the provider. The facility documents labeled "Emergency Room Note and CAH Admission History and Physical and CAH Discharge Summary" did not include documentation of the time that the notes were dictated or created.

19. Patient #24 was admitted to the hospital on 2/5/13. The admission orders dated 2/5/13 and additional orders for medications and IV fluid additives dated 2/5/13 did not include documentation of the time when the orders were written. Medication and lab test orders dated 2/6/16, 2/7/13, and 2/8/13 did not include documentation of the time when the orders were written. The facility documents labeled "CAH Admission History and Physical" dated 2/5/13, and "CAH Discharge Summary" dated 2/8/13 did not include documentation of the time that the notes were dictated or created.

20. Patient #25 was admitted to the hospital on 6/10/13. The initial admission orders were signed by the provider but dated 6/10/12. The time that the orders were written was not documented on the order sheet. Additional care and medication orders dated 6/10/13, 6/11/13, 6/12/13, 6/13/13, 6/14/13, and discontinue medications and treatment orders dated 6/18/13 did not include documentation of the time when the orders were written. The facility documents labeled "Emergency Room Note and CAH Admission History and Physical" dated 6/10/13 and "CAH Discharge Summary" dated 6/19/13 did not include documentation of the time that the notes were dictated or created.

During an interview with staff members A (DON), B (Administrator), and D (Med. Rec) on 7/31/13 at 4:30 p.m., staff members A and D stated that they were not aware providers had not documented the time of their orders and entries into the clinical record.

Based on document review and staff interview, the facility failed to create written policies addressing patient visitation rights for all patients receiving care in two of two care areas of the hospital. Findings include:

During the review of CAH policies and procedure manuals beginning on 7/30/13 at 3:30 p.m., and continuing on 7/31/13 at 3:30 p.m., the surveyor was unable to locate a facility policy for visitation rights of the patients.

During an interview with staff member A, the DON, on 7/31/13 beginning at 4:00 p.m., staff member A stated that she was aware of the policy requirement, but had not written the policy as of that time.

Based on document review and staff interview, the facility failed to create written policies addressing patient visitation rights and possible restrictions of those rights for all patients receiving care in two of two care areas of the hospital. Findings include:

During the review of CAH policies and procedure manuals beginning on 7/30/13 at 3:30 p.m., and continuing on 7/31/13 at 3:30 p.m., the surveyor was unable to locate a facility policy for visitation rights of the patients. There was no policy that addressed restrictions of those rights or informing patients of their visitation rights.

During an interview with staff member A, the DON, on 7/31/13 beginning at 4:00 p.m., staff member A stated that she was aware of the policy requirement, but had not written the policy as of that time.

Based on document review and staff interview, the facility failed to create written policies addressing patient visitation rights for all patients receiving care in two of two care areas of the hospital. Findings include:

During the review of CAH policies and procedure manuals beginning on 7/30/13 at 3:30 p.m., and continuing on 7/31/13 at 3:30 p.m., the surveyor was unable to locate a facility policy for visitation rights of the patients. There was no policy that addressed the basis for visitation rights or restrictions, and that enforcement of those rights was equal, and consistent with the patients preferences.

During an interview with staff member A, the DON, on 7/31/13 beginning at 4:00 p.m., staff member A stated that she was aware of the policy requirements, but had not written the policy as of that time.

Based on observation and staff interview, the facility failed to properly post EMTALA signs in two of two emergency room treatment areas and two of two potential patient entry points to the hospital. Findings include:

During the initial tour of the facility on 7/29/13 at 3:45 p.m., the surveyor did not observe posted EMTALA signs at the main entrance or the emergency room door.

During the review of the emergency room on 7/30/13 beginning at 7:30 a.m., the surveyor noted that there were no signs explaining the EMTALA requirements in the two emergency room treatment areas. A further examination of the main entrance to the hospital and the emergency room door failed to reveal the presence of any EMTALA signage.

During an interview with staff member E, the ADON, on 7/30/13 at 8:15 a.m., the staff member verified that there were no signs posted. Staff member E stated that the sign used to be posted next to the financial message in the hallway next to the emergency room and the radiology area.