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Based on observation and interview, the critical access hospital (CAH) failed to ensure signage was posted in all visible areas of the Emergency Department (ED) and at the front clinic entrance identifying a medical doctor was not on duty 24 hours a day, 7 day a week. This had the potential to affect all patients seen in the ED and/or admitted to the CAH.

Findings include:

On 3/10/25, at 3:00 p.m., registered nurse (RN)- A identified two trauma rooms, divided by a curtain, and two adjacent rooms, located behind the nursing station and room with cardiac monitors. These two rooms had glass sliding doors and curtains were utilized for ED patients needing more intensive monitoring, but neither contained signage identifying the absence of a physician (MD or DO), present in the facility for 24 hours 7 days per week. The main entrance which was identified as the Emergency Entrance did not have prominent signage of the lack of physician in the facility 24/7. A laminated 8 x 11 notice was taped to the surface of the registration desk, away from the area a person entering the ED and registering would normally observe.

Observation on 3/11/25, at 8:00 a.m., of the West clinic entrance which could also access the hospital areas, did not have posted signage identifying lack of MD coverage 24 hours per day, 7 days per week.

Interview on 3/10/25 at 3:30 p.m., with RN-A confirmed the absence of posted notification in the above referenced locations, and reported she was not aware of the lack of postings. She reported the admission paperwork contained the notice but was not aware of the need to have notices posted in areas visible to patients and persons entering the identified areas.

Interview on 3/11/25 at 10:30 a.m., with the director of nursing (DON) identified she was not aware of the requirement for posting of notice of the lack of 24/7 MD presence in prominent areas of the facility such as the ED and main entrance areas.

A policy was requested, and the DON reported the facility did not have a policy for posting of 24/7 lack of MD/DO presence in the facility.

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0225, K0353, and K0374 for additional information.

Based on interview and document review, the facility failed to ensure a discharge summary was completed within 30 days after the day of the surgical procedure for 2 of 7 patients (P28 and P31) reviewed for surgical procedures.

Findings include:

P28's operative note dated 2/12/25, indicated P28 had a tonsillectomy (removal of the tonsils) on 2/25/25. P28's electronic medical record (EMR) lacked a discharge summary for P28.

P31's operative note dated 1/15/25, indicated P31 had a adenoids (removal of the adenoids) and right myringotomy (draining of fluid from the middle ear) and ventilation tube placement on 1/15/25. P31's electronic medical record (EMR) lacked a discharge summary for P31.

During an interview on 3/12/25 at 4:24 p.m., operating room manager (ORM) and director of nursing (DON) confirmed the above findings and indicated discharge summaries were not completed for surgical procedures other than scopes. ORM indicated the surgeons only placed discharge orders when the surgical procedure was completed. ORM and DON stated they both understood the importance of discharge summaries.

Requested facility policy on discharge summaries however, ORM stated they did not have one.