HospitalInspections.org

Based on record review and staff interview the Critical Access Hospital (CAH) failed to accurately document history and physicals (H & P) within 24 hours of admission for 8 of 24 patient medical records reviewed requiring history and physicals ( record #'s 11, 12, 14, 15, 18, 19, 20, and 26) as directed in the medical staff rules and regulations. The CAH also failed to accurately date, time, and sign verbal and telephone orders for 22 of 34 records reviewed requiring physician signature, date, and time within 24 hrs as directed in the medical staff rules and regulations ( record #'s 1, 4, 6, 10, 11, 13, 14, 15, 16, 17, 18, 22, 23, 24, 25, 26, 28, 29, 30, 32, 33 and 34).

Findings included:

- Rules and Regulations of the Medical Staff (reviewed and approved on 10/20/09) provided by the CAH on 4/13/10 at 11:00am states "Orders dictated to an RN or LPN over the telephone shall be signed by the person to whom dictated and with the name of the physician per his or her own name. The attending physician shall sign, date, and time such orders within 24 hours". The Rules and Regulations also state "A complete history and physical examination shall be written or dictated within 24 hours after admission."

- Patient #11's medical record revealed an admission date of 3/19/10 with History and Physical dictated on 3/28/10. The physician failed to dictate the H & P within 24 hours of admission.

- Patient #12's medical record revealed an admission date of 12/15/09 with History and Physical dictated on 12/31/09. The physician failed to dictate the H & P within 24 hours of admission.

- Patient #14 medical record revealed an admission date of 1/7/10 with History and Physical dictated on 1/23/10. The physician failed to dictate the H & P within 24 hours of admission.

- This deficient practice also affected patient #'s 15, 18, 19, 20, and 26.

- Patient #11's medical record revealed the following: five verbal and/or phone orders written on 3/20/10 and signed, dated and timed by physician on 3/28/10, five verbal and/or phone orders written on 3/21/10 and signed, dated and timed on 3/28/10. Physician failed to sign, date, and time verbal and/or phone orders within 24 hours.

- Patient #13's medical record revealed the following: one verbal and/or phone order written on 10/21/09 and signed, dated and timed by the physician on 11/8/09, one verbal and/or phone order written on 10/22/09 and signed, dated and timed by the physician on 11/8/09. one verbal and/or phone order written on 10/23/09 and signed, dated and timed by the physician on 11/8/09. Physician failed to sign, date, and time verbal and/or phone orders within 24 hours.

- Patient #14's medical record revealed the following: two verbal and/or phone orders written on 1/8/10, one on 1/9/10, and one on 1/10/10, all signed, dated and timed by the physician on 1/12/10, one verbal and/or phone order on 1/11/10, two on 1/15/10, signed, dated and timed by the physician on 1/23/10, one verbal and/or phone order written on 1/12/10, and one verbal and/or phone order written on 1/13/10, all signed dated and timed on 1/15/10. Physician failed to sign, date, and time verbal and/or phone orders within 24 hours.

- This deficient practice also affected patient #'s 1, 4, 6, 10, 15, 16, 17, 18, 22, 23, 24, 25, 26, 28, 29, 30, 32, 33, and 34.

- On 4/14/10 at 4:35pm, staff A acknowledged there is a problem with obtaining timely documentation from medical staff.