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Based on emergency room record review, review of policy and procedure and staff interview, the CAH (Critical Care Hospital) failed to ensure arrival of a physician on site within 30 minutes for 1 of 5 emergency room patients (Patient15) reviewed.Census was 3 on the first day of survey. Findings are:

A. Review of ER (emergency room) Record 15 documented the patient arrival time as 1608 (4:08 PM). Physician notification documentation time of Physician A 1615 (4:15 PM) arrival time documented as 1730 (5:30 PM). Arrival being 1 hour and 15 minutes past notification time. Review of the entire ER record lacked documentation by Physician A.

Review of ER Nurse's Notes reveal entry documented at 1758 (5:58 PM) Physician B here. Arrival of Physician B being 1 hour and 50 minutes past the arrival of the patient into the ER. Physician B signed the ER record and dictated the ER Note.

Patient left AMA (against medical advice) at 1800 (6:00 PM).

B. Review of policy and procedure titled Emergency Services dated 11/6/09 revealed "... Hospital offers emergency care twenty-four hours a day, with a physician available to the emergency care area within thirty minutes through medical staff call roster."

C. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirmed that Physicians A and B documented arrival to ER over the 30 minutes and stated due to "confusion regarding why the patient was here and who was on call."

Based on observation and staff interview, the CAH (Critical Access Hospital) failed to keep the following areas clean and in good repair: the CT scanner (computed tomography scanner); area where CT scanner was located; portable X-ray machine; and floor sink in the dietary area. Census was 3 on the first day of survey. Findings are:

A. Tour of the CT scanner on 9/6/11 from 12:05 PM until 12:30 PM with the Radiology Manager revealed the following:
1. The couch area (area where the patient lays) of the CT scanner had a clear sheet of plastic underneath the pillow/cushion that was soiled with a dried white residue. The Radiology Manager during this observation indicated the residue was dried contrast that could not be cleaned off; however, when the Radiology Manager scraped on the residue with fingernail the residue could be scraped off.
2. The following items were observed laying in an area at the end of the couch where the pillow/cushion did not extend to the end of the couch: 2 unopened saline flush syringes; the white plastic top off of a used saline flush and a writing pen.

Interview with the Radiology Manager on 9/8/11 at 2:10 PM revealed the last time the CT scanner was used for a patient was on August 31, 2011 or 6 days prior to this observation.

B. The CT scanner was located in a semitrailer truck parked adjacent to the CAH. Observation on 9/6/11 from 12:05 PM to 12:30 PM revealed the wall to the left of the door to the wheelchair lift had the wall covering torn and loose from the wall. Interview with the Radiology Manager revealed this happened when trying to get the door open which slides to the left across the area with the torn and loose wall covering. The door between the CT scanner and the control room had areas along the edge of the door where the white laminate covering had been chipped off leaving a rough unfinished surface.

C. Tour of the Radiology Department on 9/6/11 from 12:05 PM to 12:30 PM revealed the portable x-ray machine was located in the hallway outside the main x-ray room. The base of the portable x-ray machine and the area around the controls was dusty and had a buildup of lint. Interview with the Radiology Manager on 9/8/11 at 2:10 PM revealed the cleanliness of the portable x-ray machine was the responsibility of the radiology staff. Review of a chest x-ray for Patient 1 revealed the portable x-ray machine was used for Patient 1 on 9/6/11 at 9:30 AM which was 2 and 1/2 hours prior to this observation.

D. Tour of the dietary department on 9/7/11 from 10:45 AM - 11:25 PM with the Dietary Manager revealed a floor sink located between a door to the outside and a door into the kitchen. When the door from the kitchen into this area was opened there was a strong musty odor. The floor and lower wall of the floor sink had a brown, black and white residue and had moisture on about 1/4 of the floor sink area. A drainage pipe was observed coming from the back wall of the floor sink. Interview with the Director of Plant Operations on 9/8/11 from 8:00 AM to 8:30 AM revealed this drain was from the dining room area and is from coffee and other fluids from the drain in the dining room. The paint on the wall close to the floor of the sink and by this drain pipe was starting to peel and chip off. This area was in need of cleaning and repair.

Based on staff interview, review of Administrative documents and review of previous deficiency statements, the CAH (Critical Access Hospital) failed to ensure that 1 of 5 diagnostic imaging services provided through contract utilized technical staff that were licensed as Medical Radiographers or Limited Medical Radiographers as required by the State of Nebraska (Bone Density - Contracted Staff-A). Telephone interview with Radiology Manager on 9/13/11 from 3:05 PM to 3:10 PM revealed the only technologist performing the bone density exams at the CAH for the past year was Contracted Staff-A and that Contracted Staff-A had performed 30 bone density exams from 9/1/10 to 8/31/11. Findings are:

A. During review of Radiology Services on 9/6/11 from 11:30 AM - 12:30 PM the Radiology Manager was unable to provide evidence that Contracted Staff-A was licensed in the State of Nebraska as a Medical Radiographer. Interview with the Radiology Manager on 9/6/11 from 4:00 PM to 4:15 PM revealed the following:
- Provided a copy of a certificate that showed that Contracted Staff-A was a Certified Densitometry Technologist with expiration date of 2/23/12; however, could provide no evidence of a license from the Nebraska Department of Health and Human Services as a Medical Radiographer or Limited Medical Radiographer; and,
- When checking for a license for Contracted Staff-A on the Nebraska Department of Health and Human Services Website no matches were found for this individual.

B. Review of the Diagnostic Imaging Agreement for Mobile Bone Densitometry with an effective date of 6/2/08 revealed the following concerning the responsibility of the contracted service under Personnel:
"Be solely responsible for the hiring, training and compensation of the personnel to properly operate the Equipment."
The contract lacked any requirement for ensuring current licensure of the personnel operating the equipment.

C. Review of the deficiency statement with plan of correction (Form CMS-2567 - Centers for Medicare and Medicaid) dated 9/08/06 revealed a deficiency was cited for the CAH utilizing a contracted service for bone density with the technologist performing bone density exams not being licensed in the State of Nebraska as a Medical Radiographer or Limited Medical Radiographer. A revisit was conducted on 11/14/10 and the facility had corrected the problem and all technical staff providing radiological services had licenses when required by the State of Nebraska.

Based on medical record review, review of Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to ensure patient medical records are complete at discharge as stated in Medical Staff Bylaws for 8 of 27 medical records (Records 5, 7, 8, 10A, 10B, 14, 16 and 17) reviewed. Census was 3 on the first day of survey. Findings are:

A. Review of Medical Record 5 on 9/7/11 at 10:00 AM with an admission date of 5/4/11 and a discharge date of 5/4/11 revealed an Operation Record signed by a physician on 6/15/11.

-Review of Medical Record 7 on 9/7/11 at 10:45 AM with an admission date of 10/6/10 and a discharge date of 10/6/10 revealed an Operation Record signed by a physician on 12/1/10.

- Review of Medical Record 8 on 9/7/11 at 10:55 AM with an admission date of 7/6/11 and a discharge date of 7/6/11 revealed a Surgical Consult signed by a physician 7/20/11.

- Review of Medical Record 10A on 9/7/11 at 11:25 AM with an admission date of 8/4/11 and a discharge date of 8/6/11 revealed the History and Physical signed by the midlevel practitioner on 9/6/11 and an unauthenticated Discharge Summary by a physician.

- Review of Medical Record 10B on 9/8/11 at 10:20 AM with an admission date of 5/28/11 and a discharge date of 5/30/11 revealed a History and Physical signed by a physician on 6/27/11, a Discharge summary signed by a physician on 6/27/11 and a lab ordered on 5/28/11 signed by the midlevel practitioner on 7/6/11.

- Review of Medical Record 14 on 9/7/11 at 1:45 PM with an admission date of 6/27/11 and a dismissal date of 6/27/11 revealed the Emergency Room Record dictated on 6/28/11 signed by the midlevel practitioner on 8/10/11 and a physician on 7/1/11.

- Review of Medical Record 16 on 9/7/11 at 2:15 PM with an admission date of 3/8/11 and a discharge date of 4/25/11 revealed an unauthenticated Podiatry Clinic note, an unauthenticated Surgical Progress Note, a lab ordered on 3/22/11 signed by a physician 5/6/11, a lab ordered 3/24/11 signed by the physician 5/6/11, lab ordered 3/25/11 signed by a physician 5/6/11 and a lab ordered 3/27/11 signed by a physician 5/6/11.

- Review of Medical Record 17 on 9/8/11 at 9:00 AM with an admission date of 6/25/11 and a discharge date of 8/3/11 revealed an unauthenticated Discharge Summary, Operation Record signed by a physician 8/10/11 and a Surgical Consult signed by a physician 8/10/11.

B. Review of Medical Staff Rules and Regulations dated 6/1/09 stated "The patient's medical record shall be complete at the time of discharge, including progress notes, final diagnosis and (dictated) discharge summary."

C. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirmed the above medical records not completed per Medical Staff Bylaws at discharge.

Based on record review, review of policy and procedure and staff interview the CAH (Critical Access Hospital) failed to ensure 1 of 6 surgical medical records (Record 6) reviewed included a history and physical examination. Census was 3 on the first day of survey. Findings are:

A. Review of Medical Record 6 on 9/7/11 at 10:30 AM revealed a surgery date of 11/3/10 with surgery performed Laproscopic Cholecystectomy under general anesthesia. Review of the entire medical record lacked a history and physical examination.

B. Review of the policy and procedure titled Ambulatory Services History and Physical dated 11/10/99 stated "A history and physical must be completed by a physician and a written document placed on the chart prior to any patient going to surgery."

C. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirmed the lack of a history and physical examination in the above chart.

Based on emergency room record review, review of policy and procedure, Medical Staff Rules and Regulations and staff review, the CAH (Critical Access Hospital) failed to obtain treatment and medication orders prescribed by the physicians for 2 of 5 emergency room patients (Patients 9 and 13 ) reviewed. Census was 3 on the first day of survey. Findings are:

A. Review of Emergency Room (ER) Record 9 on 9/7/11 at 11:10 AM revealed patient admitted to ER on 9/3/2010 at 0909 (9:09 AM) unresponsive CPR in progress "see code sheet". Emergency Room Record signed by the physician. Review of the CPR Flow Sheet revealed the charted medications given during the code lacked a signature by a physician.

Review of ER Record 13 on 9/7/11 at 1:00 PM revealed patient admitted to ER on 8/20/11 at 0830 (8:30 AM) lethargic and confused. Review of the Nurse's Notes stated "0950 18 French Foley cath placed under sterile technique." Review of the Emergency Room Record signed by the physician revealed a lack of an order for the Foley catheter.

B. Review of the policy and procedure titled Medication Administration, Transcription & Documentation Revision Date of 4/5/10 stated "Medications may not be given to a patient unless an order is written on the physician's order sheet by a prescriber."

C. Review of Medical Staff Rules and Regulations dated 6/1/09 stated "All orders for treatment shall be in writing."

D. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirmed the above charts did not have written physician orders for medications and treatments prescribed.

Based on record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to ensure physicians and midlevels (physician assistant) included dated signatures in the medical records for 14 of 27 records (Records 4, 5, 6, 7, 8, 9,10A, 10B, 16, 17, 18, 19, 20 and 21) reviewed. Census was 3 on the first day of survey. Findings are:

A. Review of Medical Record 4 on 9/7/11 at 9:30 AM with an admission date of 8/6/11 and a discharge date of 8/6/11 revealed a History and Physical, lab order and a verbal order that lacked dated signatures by health care professionals.

- Review of Medical Record 5 on 9/7/11 at 10:00 AM with an admission date of 5/4/11 and a discharge date of 5/4/11 revealed a History and Physical that lacked a dated signature by a physician.

- Review of Medical Record 6 on 9/7/11 at 10:30 AM with an admission date of 11/3/10 and a discharge date of 11/3/10 revealed a History and Physical, post-operative orders, and DNR & Treatment Limitation Consent Form that lacked dated signatures by a physician.

- Review of Medical Record 7 on 9/7/11 at 10:45 AM with an admission date of 10/6/10 and a discharge date of 10/6/10 revealed History and Physical and a verbal order that lacked dated signatures by a physician.

- Review of Medical Record 8 on 9/7/11at 10:55 AM with an admission date of 7/6/11 and a discharge date of 7/6/11 revealed a History and Physical that lacked a dated signature by a physician.

- Review of Medical Record 9 on 9/7/11 at 11:10 AM with an admission date of 9/3/10 and a discharge date of 9/3/10 revealed the Emergency Room Record lacked a dated signature by a physician.

- Review of Medical Record 10A on 9/7/11 at 11:25 AM with an admission date of 8/4/11 and a discharge date of 8/6/11 revealed Discharge Summary, verbal order and a lab order that lacked a dated signature by a physician or a midlevel.

- Review of Medical Record 10B on 9/8/11at 10:20 AM with an admission date of 5/28/11 and a discharge date of 5/30/11 revealed a lab order that lacked a dated signature by a physician.

- Review of Medical Record 16 on 9/7/11 at 2:15 PM with an admission date of 3/8/11 and a discharge date of 4/25/11 revealed 2 verbal orders, a Surgical Progress Note and a Podiatry Note that lacked dated signatures by physicians.

- Review of Medical Record 17 on 9/8/11 at 9:00 AM with an admission date of 6/25/11 and a discharge date of 8/3/11 revealed 7 verbal orders, Discharge Summary, Physical Therapy Plan of Treatment and a Consent to Operation, Administration of Anesthetics, and the rendering of other Medical Services lacked dated signatures by physicians or a midlevel.

- Review of Medical Record 18 on 9/8/11 at 10:50 AM with an admission date of 3/1/11 and a discharge date of 3/14/11 revealed 2 Speech Therapy Plan of Treatments that lacked dated signatures by a physician.

- Review of Medical Record 19 on 9/8/11 at 11:35 AM with an admission date of 7/15/11 and a discharge date of 7/29/11 revealed an Occupational Therapy Plan of Treatment that lacked a dated signature by a physician.

- Review of Medical Record 21 on 9/8/11 with an admission date of 3/7/11 and a discharge date of 3/8/11 revealed a Chest Pain Standing Orders that lacked a dated signature by a physician.

B. Review of the policy and procedure titled Authentication of Medical Record Entries with Revised Date of 9/16/09 stated "Handwritten Signature: Physician entries shall be deemed authenticated: a) when the physician's name or initials and title are recorded on the entry; and b) the physician understands and acknowledges his/her responsibility for the content of the entry; and c) the physician has not countermanded the entry."

C. Interview with the Director of HIM (Health Information Management) on 9/8/11 at 2:00 PM stated "[gender] thought that dating and timing signature was understood in definition of authentication".

D. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirms the lack of dated signatures by the midlevel and physicians in the above medical records.

Based on review of facility policy and procedure, record review and staff interview, the CAH (Critical Access Hospital) failed to ensure a physician examined and evaluated the patient for the risk of the procedure for 2 of 6 medical records (Records 6 and 17) with surgical procedures performed. Census was 3 on the first day of survey. Findings are:

A. Review of Medical Record 6 on 9/7/11 at 10:30 AM revealed laparoscopic cholecystectomy. Review of the entire medical record revealed the lack of a pre-op evaluation by a physician to evaluate the risk of the procedure to be performed.

Review of Medical Record 17 on 9/8/11 at 9:00 AM revealed incision and drainage of midline abdominal incision. Review of the entire medical record revealed the lack of a pre-op evaluation by a physician to evaluate the risk of the procedure to be performed.

B. Review of the policy and procedure titled Anesthesia Risk and Evaluation with Review/Revised date of December 2001 stated "The surgeon must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed and document this evaluation."

C. Interview with the Director of Nursing on 9/8/11 at 2:45 PM confirmed the lack of pre-operative evaluations by a physician to evaluate the risk of the procedures to be performed in the above charts.