Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531311 (X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0307 RECORDS SYSTEMS
CFR(s): 485.638(a)(4)(iv)

[For each patient receiving health care services, the CAH maintains a record that includes, as applicable-] dated signatures of the doctor of medicine or osteopathy or other health care professional.


This STANDARD is not met as evidenced by:
Based on medical record review, staff interview and review of QAPI data, the facility failed to ensure dated signatures of various health care professionals for 6 of 22 sample patient records (#2, #9, #10, #14, #16, #22). The findings were: Review of the following medical records showed signatures of various health care professionals were not dated: a. The history and physical examination, the discharge summary, and the nursing assessments for patient #2. b. The history and physical examination for patient #9 was transcribed on 11/4/11 and remained unsigned by 11/17/11. In addition, all the daily nursing assessments and the 1/8/11 discharge summary lacked dated signatures. c. The 10/25/11 and 10/29/11 radiology interpretations for patient #10 were not signed, and the daily nursing assessments lacked dated signatures. d. The history and physical examination and discharge summary for patient #14. d. The discharge summary for patient #16. e. The history and physical examination for patient #22 was dictated and transcribed on 10/21/11; it remained unsigned on 11/16/11. The QA process for the HIM department was reviewed with HIM clerk #1 on 11/15/11 at 10 AM. The summarized data showed selected QA indicators, such as timely completion of history and physical examinations and dated/timed physician signatures, were consistently below the quality baseline established by the hospital. During the interview, the records clerk stated the low compliance rate was presented to the physicians at medical staff meetings. However, there was no documentation to show improvement of the quality indicators.