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Based on observation, interview, and document review, preventative maintenance and biometric stickers were expired on different equipment and devices within the facility.

Findings include:

On 7/23/18, at approximately 10:30 AM, a tour of the facility was conducted. Biometric equipment stickers were expired on Emergency Room (ER) cardiac monitors with an inspection date on the monitor of 7/13/17 in two different exam rooms.

During interview with the Assets Assistant Manager on 7/23/18 and review of the tracking log, it was discovered that approximately 26 different equipment devices and biometric stickers in the facility were expired as confirmed by a tracking log reviewed with the Assets Assistant Manager. In some instances, the biometric inspections were done timely, but the biometric stickers were not placed on the equipment devices. The cardiac monitors in the emergency department had been inspected annually in July, 2018, but the biometric stickers were not updated on the devices. The reason for this was unknown as per the Assets Assistant Manager. The tracking log indicated that the next scheduled inspection dates for a variety of equipment were due in 2018, but had not been completed and biometric stickers on equipment were unable to be updated until inspections were completed. The maintenance department was tracking and aware of the various equipment and devices without current biometric stickers. In some instances, the equipment was in use without an annual inspection completed or a new biometric sticker in place.

Based on observation, interview, and document review, the facility failed to ensure verbal orders were signed for 11 of 20 sampled patients (Patient #4, #6, #7, #9, #10, #15, #16, #17, #18, #19 and #20) and 3 of 20 had missing postanesthesia note times (Patient #3, #5 and #9).

Findings include:

Patient #1, #2, #3, #4, #6, #7, #8, #10, #11, and #20 all had identified verbal medication orders that were not signed timely by the physician as per policies.

During interview with the Medical Records manager on 07/24/18 at 2:00 PM, it was confirmed all verbal orders for medications should be signed within 48 hours and identified verbal orders were not signed within 48 hours. The current medical records system does not allow the physician to access the medical record from a remote location presently, and the physician must sign orders when on site at the facility.

The policy and procedure, entitled, "Physician Verbal and Telephone Orders" dated 10/29/04, indicated telephone orders shall be countersigned by the physician within 48 hours.

A second policy and procedure entitled, "Physician Order Policy" dated 01/31/17, indicated "A verbal order must be authenticated by the person who issued it at the earliest opportunity but no more than 72 hours after issued".

Review of twenty medical records revealed eleven records contained a verbal order given to the nurse but not signed by the physician within the allotted time.

Review of the "Unsigned Orders Report" evidenced the unsigned verbal orders for 11 of 20 patient records.

Review of the medical records revealed missing anesthesia note times in 3 of 20 patients.

Patient #3 had a Postanesthesia note signed and dated, but not timed in the allotted slot.

Patient #5 had a Preanesthesia/Postanesthesia note signed and dated, but not timed in the allotted slot.

Patient #9 had a Postanesthesia note signed and dated, but not timed in the allotted slot.

During interview with the Medical Records manager on 07/24/18 at 2:00 PM, it was confirmed all notes should be completed appropriately. The current medical records system still utilizes paper records for the anesthesia notes. The "Chart Completion/Deficiency" policy, dated 10/28/04 did not specifically address the time recording on the anesthesia note but completion of the form was an expectation by the facility.