HospitalInspections.org

Based on hospital document review, policy and procedure review, and staff interview, the hospital failed to:


a. Protect the patients from all forms of abuse and harassment

b. Provide patient care in a safe setting

c. Establish a clearly defined grievance process for prompt resolution of patient grievances and failed to ensure each patient grievance was responded to in writing.

Based on hospital document review, hospital grievances review, and staff interview, the hospital failed to establish a clearly defined process for the resolution of patient grievances and failed to ensure all patients knew whom to contact to file a grievance.

Findings:

1. On the morning of July 17, 2015, upon entrance to the hospital surveyors requested all hospital grievances and responses to grievances for the last 6 months, the grievance policy and procedure, and the patient admission packet with complaints and grievance information.

2. Surveyors were provided 2 different grievance policies and procedures. One grievance policy was titled, "Grievance-Adult/Geri Patient" and the second grievance policy provided was titled, "Adolescent/ID Grievance Policy & Procedure." Both policies provided documented a different grievance process. Staff T told surveyors that the hospital did utilize both grievance policies and procedures and that one policy was for the Adult and Geriatric population and the other grievance policy was for the Adolescent and ID (intellectual disability) population.

3. The policy titled, "Adolescent/ID Grievance Policy and Procedure,"documented,"...a grievant files a grievance by obtaining from the PATIENT ADVOCATE a copy of OCA's {Office of Client Advocacy} pre-numbered grievance form or an equivalent (hospital name deleted) pre-numbered grievance form..."

The policy did not address that a patient may file a grievance in other ways than writing a grievance on the grievance form.

4. The policy titled, "Adolescent/ID Grievance Policy and Procedure," documented, "...In order to be processed for action and resolution, a grievance must be filed within 15 business days of the date of the incident..."

The policy did not address that a patient may file a grievance at any time.

5. On the morning of July 20, 2015 surveyors reviewed the patient admission packet to include the complaint and grievance information. The admission packet, documented "...patients may obtain a Grievance Form from any staff or Grievance Box... patients have a right to request assistance from an employee in completing the Grievance Form..." The admission packet did not contain information that a patient my also file a grievance in other ways such as verbally.

6. On the afternoon of July 20, 2015 surveyors reviewed the patient "welcome packet." The Welcome packet, documented "...patients may write their complaint on the Patient Concern Notification form..."

The welcome packet did not address that a patient may file a grievance in other ways.

7. The patient welcome packet documented that the patient may also forward their grievances to the following: Quality Improvement Organization, State Agency, and The Joint Commission.

The patient welcome packet did not address that a patient may file a grievance with the State Agency regardless of whether the patient first used the hospital's grievance process.

8. On the morning of July 20, 2015, Staff T told surveyors that all patient's complaints and grievances are written on the "patient concern notification form." Staff T told surveyors that not all written complaints were recognized as a grievance and that the grievance process was not followed on all written complaints.

Based on hospital grievances and complaints review, policy and procedure review, and staff interview, the hospital failed to ensure the governing body was responsible for the effective operation of the grievance process and the governing body reviewed and resolved all grievances.

Findings:

1. On the morning of July 17, 2015, surveyors were told that Staff H was the patient advocate and patient H was responsible for grievances and complaints. Surveyors were told that it depended on the nature of the complaint as to who would do the investigation of the grievance.

2. On the afternoon of July 17, 2015, surveyors reveiewed a hospital policy titled, "Grievance-Adult/Geri Patient" The policy documented, "The Governing Board is responsible for the effective operation of the grievance process, which includes the hospital's compliance with all the CMS {Center for Medicare/Medicaid Services}grievance process requirements."

3. On the afternoon of July 17, 2015, and the afternoon of July 21, 2015, surveyors reviewed all grievances for the last year. There was no documentation of the Governing Board involvement in the grievance process. Not all grievances contained documentation that the patient advocate had reviewed or investigated the grievance.

4. On the afternoon of July 21, 2015, Staff D told surveyors that she was on the Governing Board. During the course of the survey, surveyors identified 2 patient grievances that alleged verbal abuse. Staff D told surveyors she was not aware of the 2 grievances.

Based on hospital grievance review, grievance policy and procedure review, and staff interview, the hospital failed to provide each patient with a written notice of its decision that contained the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

Findings:

1. On the morning of July 17, 2015, surveyors requested the hospital grievance policy, and all grievances for the past year with responses to the patient.

2. The hospital used a form titled, "patient concern notification form" for the patients to write down any complaints and grievances. The patients were requried to write their grievances out on this form and if they needed assistance writing the patient advocate or another staff member would write it for them.

3. Most grievances reviewed did not contain a letter written to the patients on the steps taken to investigate the grievance, the results of the grievance process and the date of completion.

4. Surveyors reviewed a small number of grievances that did contain a letter that was sent to the patient but the letter sent to the patient did not contain the steps taken to investigate the grievance, the results of the grievance process and the date of completion.

A policy titled, "Grievance-Adult/Geri patient, documented "...all patient grievance will be investigated and the results of the investigation reported back to the complainant..."

5. Staff H told surveyors that it depended on the nature of the complaint as to who investigated the complaint. Staff H told surveyors that she did not send a letter to all complainants regarding the steps taken to investigate the greivance, the results of the grievance process and the date of completion.

Based on observation, hospital document review, and staff interviews, the hospital failed to ensure patients received care in a safe setting.

Findings:
1. On July 17, 2015 at 11:00 a.m. surveyors toured the adolescent unit with Staff E. The following observations were made:

~The Anteroom outside of the seclusion room had plywood mounted on the walls with sharp edges. The plywood was secured with metal screws. The top of the metal screws were sharp and not recessed or flush with the plywood.

~The seclusion room door was lined with a thin plastic/foam coating. A large area of the door had missing plastic/foam coating. The plastic/foam coating came to a point which was sharp. According to the hospital's policy, a seclusion room is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.

~An area of the door larger than basketball size had missing plastic/foam coating that exposed sharp wood.

~Filing cabinets, racks, and charts, blocked the window in the nursing station area for viewing seclusion patients. According to the hospital's seclusion policy, "...The patient shall be monitored and reassessed thorough continuous in-person observation. Continuous means ongoing without interruption..."

~Hanging off the wall was a soap dispenser in the bathroom near the seclusion room.

~Plywood boards with sharp edges were mounted on the walls in several locations in the adolescent unit. The plywood was secured with metal screws. The top of the metal screws were sharp and not recessed or flush with the plywood.

~Door handles and door hinges throughout the adolescent unit were not anti-ligature safe hardware.

~Pieces/sections of vinyl/plastic baseboard trim were missing throughout the unit.

~Multiple dirty food trays with breakfast items were left in the nursing station on top of copier machine.

~A Water cooler dispenser in the nursing station was broken according to Staff II and Staff JJ. Towels and sheets were placed at bottom of water cooler dispensing unit to absorb water leaking.

~Patient room number 400 bathroom shower curb/lip had unsealed wood fastened with screws or nails. The unsealed wood cannot be sanitized and cleaned. The unsealed wood is not water resistant and not secured.

~All patient rooms have different heights of shower curbs/lips. A patient with any physical disability should be able to be placed in any room regardless of the height of the shower curb/lip. Not all patient bathroom showers can accommodate patients with physical disabilities requiring assistance (i.e. wheelchairs).

~A dirty plastic rolling cart that contained and stored several metal screws, washers, nuts, bolts, and zip ties were stored next to clean linens and patient hygiene supplies.

~The nutrition room contained a refrigerator and cupboards that were dirty.

~The nutrition room was missing upper cabinets directly above the sink and lower cabinet area. Paint and drywall were missing in the area that the cabinets had been removed.

~There were 7 patients on the unit. The nutritional room had minimal snacks. There were 2 popsicles, 2 ensure plus nutritional supplements, 1 individual jello cup, 7 one ounce bags of animal crackers, 1 can Campbell chunky soup, and a pitcher with liquid that was not labeled/timed and dated.

~The activity/hygiene room contained multiple shelves with puzzles, movies, books, as well as patients personal belongings. There were multiple clear plastic bags covering the floor with a patient's belongings. A few of the clear plastic bags that contained a patient's belongings were split and the patient's belonging were directly on the floor. This area was cluttered and dirty. Staff II and Staff JJ told surveyors that the patients belongings are stored in the activity/hygiene room when coming from another facility.

2. On July 17, 2015 at 12:50 p.m. surveyors toured the Adult unit with Staff E. The following observations were made:

~Door handles, bathroom fixtures, and door hinges throughout the adult unit were not anti-ligature safe hardware.

~A doorway between the adult unit and intellectually disabled (ID) unit did not lock and was not secure.

The clean linen room was cluttered and dirty. There was a large oscillating fan coated in dust. There was a portable keyboard laying against the wall in the corner. There was a large storage cabinet that contained storage for multiple patient's belongings which was not separated or labeled. There was an oxygen concentrator stored next to the clean linen cart. There was sugar free pudding snack paks next to cleaners and a flash light. There was fruit snacks stored next to antiseptic cleaner.

~There were many patient bathroom shower fixtures that were leaking water.

~There were many patient rooms that contained patient soaps, shampoo,conditioner, lotions, and deodorants. Hygiene items were only to be available inpatient rooms during shower times. According to Staff W and hospital policy, all hygiene items were to be stored and locked in the nursing station during non-shower times.

~Room 300 was a seclusion room and converted to a nursing station, according to Staff E. The nursing station was dirty and cluttered. On top of the filing cabinets there was a coffee pot/maker, shaving cream, radio, metal hangers, two orange juices stored next to the hand sanitizer. Sitting on top of the automated medication dispensing machine was a pitcher of unidentified liquid. There was a medication refrigerator that contained medicines and food.

~There was a water cooler dispenser in the hallway that was dirty.

~There were empty unsecured plastic water cooler bottle jugs left beside the water cooler.

~There were multiple stained ceiling tiles. There were ceiling plant hooks in the ceiling tiles.

~The tub room was wet. There was a laundry bucket in the tub room that contained dirty linen. According to Staff E and Staff J, the tub room was not used.

~The laundry room had a stacked washer/dryer unit. There was a patient's clothing piled in the hand washing sink.

~Patient room number 304 had a hole larger than the size of a quarter in the wall.

3. On July 17, 2015 at 1:30 p.m. and 5:25 p.m. surveyors toured the Intellectually Disabled (ID) unit with Staff E. The ID unit was for patients with intellectual disabilities. The following observations were made:

~There were two seclusion rooms on the ID unit. Neither seclusion room was identified with signage. Both seclusion rooms were used. According to the hospital's policy, a seclusion room is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.

~Both seclusion room windows in the doors were placed so high that surveyors were not able to see in. According to the hospital's seclusion policy, "...The patient shall be monitored and reassessed thorough continuous in-person observation. Continuous means ongoing without interruption..."

~The seclusion rooms on the ID unit had metal framing around the windows on the inside of the door. The metal framing was bent, pulled up, and extremely sharp.

~The seclusion rooms on the ID unit had metal bolts/screws that were not flush or recessed. The metal bolts/screws were sharp.

~The metal door frame had separated from the wall in one of the seclusion rooms. Surveyors were able to slide their hand inside the metal frame up to the knuckles. The metal door frame was sharp.

~An adolescent patient was placed in one of the two seclusion rooms in the ID unit which is meant for adult patients, intellectually disabled patients, and geriatric patients.

~Throughout the survey, multiple staff members told surveyors that the facility rarely uses one of the seclusion rooms in the ID unit. The seclusion room identified as rarely used had an adolescent patient in that seclusion room.

~There was no staff member directly observing the secluded patient. According to the hospital's seclusion policy, "...The patient shall be monitored and reassessed thorough continuous in-person observation. Continuous means ongoing without interruption..."

~There was no medication room/cart on the unit. Nursing staff left the unit to get patient medications.

~All patient rooms had different heights of shower curbs/lips. A patient with any physical disability can be placed in any room regardless of the height of the shower curb/lip.

~ Adult and geriatric patients without intellectual disabilities were placed on this unit when other units were full. On July 20, 2015 at 3:30 a.m. surveyors observed 1 adult male patient on the ID unit and 3 geriatric patients on the ID unit.

~Multiple rooms had plastic cover plates secured with sharp metal screws that were not flush/recessed.

~Patient room 204 bathroom sink, counter, and cabinet surface had material that was sharp, cracked, and had missing pieces. The cabinet surface material could be easily lifted up to crack off.

~Some patient showers contained shower chairs ordered for one of the two patient's that shared a room. Surveyors asked Staff E if the shower chair was removed before the other patient (who did not need the shower chair) entered the shower. Staff EE told surveyors she did not know.

~Some patient rooms contained bedside commodes placed near the foot of patient beds. One of the patient's (rooms were double occupancy) that used the bedside commode had no privacy/provisions in place.

4. On July 17, 2015 at 1:40 p.m. surveyors toured the geriatric unit with Staff E and Staff OO. The following observations were made:

~The geriatric unit is a 22 bed unit. On July 17, 2015, there was a census of 24 geriatric patients. Two geriatric patients were located on the intellectually disabled (ID) unit. The two geriatric patients were not intellectually disabled.

~Door handles, bathroom fixtures, and door hinges, throughout the geriatric unit were not anti-ligature safe hardware.

~Patient beds had wheels and were moveable. The patient doors to the bedroom swing inwards. There was no pass through to enter the patient room. According to national standards of psychiatric practices and building design, patient doors should be out-swinging to prevent a patient from barricading themselves into a room.

~Multiple patient rooms had broken and chipped bathroom cabinets.

~Multiple patient bathrooms had blue tape marked on the ceiling. Surveyors asked what the blue tape was for. Staff E and Staff OO said that the blue masking tape was place before painting started.

~Multiple patient bathrooms had peeling paint hanging from the ceiling.

~Multiple patient bathroom toilet sensors had a wad of toilet paper placed in front of the sensor inhibiting the toilet sensors to work as designed.

~Patient room number 105 did not have a shower curtain. This room had double occupancy and no provision for privacy.

~Patient room number 110 bathroom had dark brown caulking around the commode. The dark brown caulking was different than the caulking from the other patient bathrooms. Surveyors asked Staff E and Staff OO about the brown caulking. Staff E told surveyors that the commode was leaking.

~Multiple patient rooms had a larger than a dollar size chunk of unsealed wood exposed.

~On July 20, 2015 at 3:30 a.m. three geriatric patients were assigned to a geriatric nurse yet was housed on the ID unit. The geriatric unit was full and there were no beds therefore the three geriatric patients were placed on the ID unit.

5. On July 17, 2015 at 6:45 p.m., surveyors requested a policy on incident reporting. The Risk Manager provided a hospital document titled, "Incident Reporting-Risk Management Program." The policy documented, "...If the incident involves a resident, staff must chart relevant information in the patient's medical record..." and "...The responsibility for completing an Incident Report rests with any facility staff member who witnesses, discovers, or has direct knowledge of and incident. An incident is an unanticipated happening which was not consistent with the routine care..."

6. Staff members throughout the survey told surveyors unless someone (either patient or staff) was seriously hurt no incident report was documented.

7. Throughout the survey, multiple staff members acknowledged that they do not follow hospital policy for reporting and recording incidents.

8. On July 17, 2015 at 11:00 a.m. Staff E told surveyors that one physically aggressive adolescent patient had caused the large amount of damage on various areas of the adolescent unit in one day. Surveyors reviewed hospital documents and there was no documented evidence of the incident reported.

9. On July 17, 2015 Staff II and Staff JJ told surveyors that a physically aggressive adolescent reached into the nursing station and broke with water dispensing machine. Staff II and Staff JJ told surveyors neither staff member filled out an incident report.

10. On July 17, 2015 Staff W told surveyors that she does not fill out incident reports unless someone is seriously hurt.

11. Staff members throughout the survey told surveyors that all falls should be reported, documented, and if a patient had a guardian/power of attorney then the patient representative would be notified.

12. One (#5) of one patient's medical records reviewed did not contain nursing documentation of a patient fall.

13. One (#5) of one medical records reviewed did not contain documentation that the patient guardian/power of attorney was notified of the patient fall.

14. Surveyors reviewed hospital incident report documents. There was no documented evidence of patient #5 and patient #15's fall documented. The Risk Manager verified this at the time of review.

15. On July 17, 2015 at 11:00 a.m. Staff E, Staff W, Staff II, and Staff JJ told surveyors that adolescent patients that needed intervenous (IV) hydration infusions were not continuously monitored by a nurse. Staff E told surveyors that adolescent patients that needed IV hydration infusions were allowed to go back to their rooms.

16. On July 17, 2015 at 5:05 p.m. surveyors walked through a door that was suppose to be secured and locked. Surveyors were able to open that door multiple times. Staff B and Staff I observed surveyors being able to open a secure door multiple times.

17. On July 17, 2015 at 5:05 p.m. Staff I told surveyors he was aware of the problem.

18. Throughout the survey, multiple staff members told surveyors that the facility rarely uses one of the seclusion rooms in the ID unit. This seclusion room was currently occupied by an adolescent patient.

19. On the afternoon of July 20, 2015 Staff M, and Staff R told surveyors that geriatric patients utilize the seclusion room if needed.

20. On the afternoon of July 20, 2015, Staff A and Staff D told surveyors that geriatric patients are never placed in seclusion or seclusion rooms. Surveyors reviewed the hospital's policy regarding seclusion rooms. There was no policy in place that geriatric patients are not secluded.

Based on hospital grievance review, policy and procedure review, and staff interview, the hospital failed to protect patients from all forms of abuse.

Findings:

1. On the morning of July 17, 2015, surveyors requested all patient grievances and all grievance responses and investigations for the last year.

2. On the afternoon of July 17, 2015 and through the course of the survey, surveyors reviewed the grievance log and all documentation that was provided.

3. On the afternoon of July 17, 2015, surveyors identified a grievance in the grievance log that alleged verbal abuse to patient #5. The grievance was lodged by patient #5's roommate, patient #9. In the grievance, patient #9 alleged that staff P had yelled at patient #5 during a time when patient #5 needed assistance with Activities of Daily Living (ADL's).

The grievance filed by patient #9 contained documentation from staff P of staff P's version of what happened. Staff P wrote that "I did have to raise my voice."

Staff P was still working at the hospital at the time of the survey. Staff P had not been removed from patient care after the allegation of yelling at patient #5. Staff P admitted raising her voice to the patient.

On July 17, 2015 at 3:50 p.m., the Risk Manager told surveyors that if a staff member was alleged to have abused a patient that they would be suspended until an investigation is done.

4. A hospital policy titled, "Patient Abuse" documented, "if any employee or contractor of the facility is reasonably suspected of abuse, neglect or exploitation, the employee or contractor will be suspended immediately and an investigation conducted by the Risk Manager."

There was no further documentation of investigation and outcome of investigation of the grievance.

On July 17, 2015 at 3:40 p.m., surveyors interviewed the Risk Manager and the Patient Advocate. The Risk Manager told surveyors that she had not investigated the grievance from patient #9. The Risk Manager told surveyors that the Patient Advocate investigated the grievances unless it was something serious. Surveyors asked the Risk Manager what was considered serious and she told surveyors "abuse."

Surveyors reviewed the hospital's abuse training curriculum. The training curriculum defined verbal abuse as, "the use of offensive and/or intimidating language that can provoke or upset an individual." The training curriculum gave an example of abuse as "assaultive behavior physically or verbally."
The training curriculum documented, "...it is NEVER appropriate to...yell at a patient..."

On July 17, 2015 at 3:50 p.m., the Patient Advocate told surveyors that the only investigation that was done for the grievance of patient #9 was the statement of the Behavioral Health Tech (BHT) was obtained and the information had been sent to Adult Protective Services (APS). When the patient advocate was asked why this case was turned over to APS she told surveyors because she thought it might be abuse.

5. On July 20, 2015 at 5:40 p.m., Surveyors interviewed Staff X. Staff X told surveyors that Staff L had recently yelled at a patient. Staff X told surveyors that it was reported to the BHT supervisor but there was no written documentation about it.

On July 21, 2015 at 1:00 p.m., Surveyors interviewed the BHT supervisor. The BHT supervisor told surveyors that he had been made aware of Staff X yelling at a patient. The BHT supervisor told surveyors that he had not talked with Staff X and had not investigated the allegation. The BHT supervisor told surveyors that Staff X was still working in patient care areas.

6. On the morning of July 20, 2015, surveyors reviewed another grievance from patient #3. Patient #3 alleged Staff N had yelled at the patient and had told the patient that if she did not take a shower that Staff N would call the patient's husband and the doctor and the patient would not be able to go home.

There was no documentation of any investigation for the grievance from patient #3. The Risk Manager told surveyors that the BHT supervisor would investigate all complaints involving the BHT's.

Based on observation, seclusion policy and procedure review, and staff interview the hospital failed to ensure patients in seclusion were continously monitored in accordance with the hospital's policy on seclusion.

Findings:

1. On the morning of July 20, 2015 at 9:35 a.m., surveyors observed an adolescent patient in a seclusion room.

2. The seclusion room was located behind 2 doors. There was an anteroom with a door outside the seclusion room and there was a door to the seclusion room.

3. Surveyors observed a Behavioral Health Technician (BHT) right outside the door of the anteroom. Surveyors observed the door to the seclusion room was open. The BHT would not be able to see the patient from the door to the anteroom.

4. Surveyors reviewed a policy titled, "Seclusion." The policy documented, "..The patient shall be monitored and reassessed through continous in-person observation. Continous means ongoing without interruption..."

5. Staff A told surveyors the adolescent patient in seclusion was in the seclusion room voluntarily to calm down and the facility does not consider that to be seclusion.

The policy titled, "Seclusion" documented, "...patients whom use the seclusion room voluntarily to decompress from emotions such as high anxiety, stress, or anger must also be monitored on a continous basis."

Based on document review and staff interview, the hospital failed to:

a. involve all hospital departments and include all contracted services that impacted patient care in the Quality Assessment Performance Improvement (QAPI) program;

b. focus QAPI indicators on improving patient heath outcomes and the prevention and reduction of falls;

c. provide adequate documentation to demonstrate evidence the QAPI committee reviewed valid and relevant data;

d. ensure the QAPI committee reviewed and responded to patient complaint/grievances;

e. ensure the QAPI committee identified opportunities for improvement and recommended changes that would lead to improvement; and

f. the governing body failed to provide adequate oversight of the QAPI program and failed to ensure the hospital's QAPI program conformed to the requirements for the Condition of Participation.

Findings:

1. QAPI meeting minutes had no documentation all departments were included in the QAPI program.

2. There was no documentation all contracted services impacting patient care were evaluated through the QAPI program.

3. Documentation the QAPI committee reviewed through patient complaints and grievances were graphs and charts that documented, "60%" and "6 Total Grievances: 6 grievances regarding a patient concern."

4. Surveyors reviewed the hospital grievances/patient concerns and QAPI meeting minutes. The QAPI meeting minutes included vague data. Surveyors asked Staff J what the grievance/patient concerns QAPI data meant. Staff J was not able to tell. Staff J told surveyors to ask Staff H.

5. Surveyors asked Staff H what the grievance/patient concerns QAPI data meant. Staff H told surveyors she did not know. Multiple times throughout the survey, surveyors asked the Patient Advocate, Risk Manager, and Chief Nursing Officer for all data, analysis, outcome, and action plan for patient grievance/patient concerns. No other documentation was provided to surveyors.

6. There was no documentation the QAPI committee focused on the reduction and prevention of falls.

7. Surveyors reviewed a log regarding patient falls. There were numbers entered into a fall log. Surveyors asked Staff J what the patient fall log data meant. Staff J could not elaborate and could not explain the data.

8. There was no documentation the QAPI committee focused on capturing, collecting, analyzing, and acting on accurate incident reporting.

9. There was no documentation in the QAPI committee meeting minutes that indicated the committee identified opportunities for improvement and recommended changes to be made in response to any of the information presented to the committee. There was no clear documentation of actual actions taken by the committee.

10. There was no documentation the QAPI committee set priorities for improvement based on relevant data that identified high-risk, high-volume and problem-prone areas. There was no documentation the QAPI committee prioritized health outcomes, patient safety and quality of care.

Based on hospital medical record review, policy and procedure review, and staff interview the hospital failed to ensure physician verbal orders were used infrequently and failed to ensure there was a read-back verification process in place. This occurred in 7 of 7 open records reviewed, and in 12 of 12 closed medical records reviewed (#1 through #19)

Findings:

1. During the course of the survey, surveyors reviewed 19 patient medical records. All patient medical records reviewed contained multiple entries of verbal orders used. All 19 medical records reviewed contained multiple entries of verbal orders not signed by the physician.

2. All 19 medical records reviewed contained multiple physician verbal orders that did not contain documentation of a read-back verification process.

3. On July 20, 2015 at 5:33 p.m., surveyors were provided a policy titled, "Authentication and timely entry of medical records." The policy did not address a read-back verification process to be used when obtaining verbal orders.

4. On July 20, 2015, at 5:33 p.m., Administrative staff told surveyors that staff were supposed to use a read-back verification process when they obtained verbal orders.