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Based on record review, policy review and staff interview, the Critical Access Hospital (CAH) failed to ensure the doctor of osteopathy (DO) periodically reviews and signs the records of inpatients cared for by the certified nurse practitioner (CNP) and/or the certified physician assistant (PA-C) for 4 of 5 records reviewed (IP1, IP3, IP9 and IP13).

Findings include: Four (4) inpatient records reviewed lacked the signature of the DO to indicate a review had been conducted for patients cared for by the mid-level practitioner.

IP1, discharged on 7/2/11, lacked a signature by the DO on the discharge summary dictated by the PAC-C ; IP3 lacked the DO signature on the H & P dictated 6/16/11 by the PA-C and lacked DO signature on the CNP progress notes dated 6/17, 6/18 and 6/19/11; and IP13 lacked DO signature on the H & P dated 5/4/11. IP9 lacked countersigning by the DO for a discharge summary and progress note written by the RNC-FNP dated 4/26/11.

During review of medical staff bylaws/policy and procedure manual dated 7/11, the following was noted: "All orders and progress notes for inpatients by the physician assistant and/or nurse practitioner are cosigned by the physician". Interview with the Director of Clinical Services at 11:00 a.m. on 9/8/11, verified the required cosignature was lacking. She further indicated the DO had been delayed in the mid-level reviews since he had become the sole physician at the CAH in May 2011.

Based on interview, record review and policy review, the Critical Access Hospital (CAH) failed to ensure services were provided in accordance with written policies for documentation of dry time for the use of alcohol based skin preparations for 3 of 3 (SDS2, SDS3, SDS6)surgical patients' records where an alcohol based skin preparation had been utilized.

Findings include: The CAH did not implement their policy and procedure to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in anesthetizing locations in CAHs. The use of an alcohol based skin preparation in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to prevent surgery related fires.

Review of the Surgical Skin Preparation policy and procedure effective date of 6/10, identified the following: Chloraprep, DuraPrep and Prevail all contain a small amount of alcohol so the following steps must be completed on all patients..."The circulator will document on the Nursing Operative Report: Three minutes of drying time completed."..

During record review it was noted that an alcohol based skin preparation had been utilized for 3 same day surgical procedures reviewed: (SDS2) 7/12/11, (SDS3) 8/9/11, (SDS6) 8/9/11. Review of the Nursing Operative Report for each of these three records confirmed that an alcohol based skin preparation had been utilized as indicated by the surgical staff. However, there was no documentation evident that the alcohol based skin prep had been allowed to dry for the proper timeframe.

During interview with the scrub nurse/infection control nurse at 8:45 a.m. on 9/8/11, she stated the circulator (Circulating RN) in surgery signs the dry time prior to any incision being made by the provider and further stated that when the case is completed, she (Scrub Nurse) is also supposed to sign off on the dry time on the Operative Report.

On 9/8/11 at 9:50 am, the Circulator/Outreach Surgery Manager verified that an updated checklist had been added to the nursing Operative Report so that documentation reflected the verification of "no pooling" and "drying time" for all alcohol based skin preps utilized. The Circulator/Outreach Surgery Manager stated that following the surveyor's findings, she had learned that some of the "old" Operative Report forms had mistakenly been stored with the updated forms that had been implemented in June 2010. She said that she had now "tossed" the old forms so only the proper documentation forms would be available so no further mix up could occur. In addition, she verified the CAH had been using the alcohol based skin preps: DuraPrep, Chloraprep, and Prevail as preferred by the surgeon. Although the staff indicated they routinely checked to assure the alcohol had completely dried, she verified they had not documented in the 3 mentioned patient records verifying that appropriate procedures were followed ensuring the proper use of the alcohol based skin preparation prior to the surgical procedures.

During interview with the Director of Clinical Services at 11:00 a.m. on 9/7/11, she verified that the two core registered nurses who work in surgery had been aware of the need to document the dry time. The Director also confirmed that they do an average of 3 surgical cases per month, verified the lack of documentation on Operative Reports for SDS2, SDS3 and SDS6, and stated it had been an oversight.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the History & Physical (H & P) had been signed by the surgeon for 2 of 2 records (S1 and S4) reviewed in which the nurse practitioner had performed the H & P.

Findings include: Two (2) surgical records reviewed (S1 and S4) lacked a signature by the surgeon on the pre-operative physical examination and medical history (H & P) to indicate he/she had assumed full responsibility for the H & P. It was noted the certified nurse practitioner (CNP) had performed the pre-operative H & P on 6/6/11, prior to the tonsillectomy performed on 6/9/11 for S1; and had performed a pre-operative H & P on 8/5/11, prior to a tonsillectomy on 8/11/11 for S4. Both records (S1 and S4) lacked a signature by the surgeon who performed the surgical procedures to indicate he/she had assumed full responsibility for the mid-level's H & P.

The Director of Health Information Management confirmed at 10:30 a.m. on 9/7/11, that S1 and S4 required a signature by the surgeon on the H & P.

Interview with the Director of Clinical Services at 2:00 p.m. on 9/8/11, confirmed the co-signature by the surgeon was lacking in both records and indicated it had been the expectation that physical examinations with medical histories performed by the mid level practitioners be signed by the responsible surgeon prior to surgery.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry had been properly authenticated with a timed and dated signature for 14 of 20 inpatient records reviewed (IP1, IP3, IP4, IP5, IP7, IP9, IP10, IP12, IP13, IP14, IP16, IP18, IP19, and IP20); and 5 of 6 Same Day Surgery (SDS) records reviewed (S2, S3, S4, S5 and S6).

Findings include: Five of six surgical records (S2, S3, S4, S5 and S6) reviewed lacked proper authentication of entries by the surgeon and/or the pathologist. Records S2, S3, S5 and S6 lacked timed and dated signatures by the surgeon on the operative reports and the history and physical examinations. Records S1 and S4 lacked a timed electronic signature by the pathologist on the pathology reports. During an interview with the Director of Clinical Services at 11:00 a.m. on 9/7/11, it was verified the noted reports lacked the proper authentication of entry which included the time and date with physician signature.

Fourteen (14) of twenty (20) inpatient records (IP1, IP3, IP4, IP5, IP7, IP9, IP10, IP12, IP13, IP14, IP16, IP18, IP19, and IP20) reviewed lacked proper authentication of entries by the physician, mid-level, occupational therapist (OT) and/or the physical therapist (PT). Reports that lacked dated and timed signatures included the following: physician progress notes, medical history and physical examinations (H & P), and/or OT, PT and physician discharge summaries.

Interview with the Director of Clinical Services at 2:00 p.m. on 9/8/11, confirmed the CAH had been aware of the noted problem.