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Based on record review and review of the hospital policy entitled, "History and Physical Examinations", it was determined that the hospital failed to ensure that the preoperative history and physical examination was updated on the day of surgery or within 24 hours after admission/surgery for 6 of 8 relevant sample patients (ID #'s 2, 3, 5, 15, 16 and 70).

Findings are as follows:

A review of the hospital policy entitled, "Components of the Medical Record", under "History and Physical Requirements" states:

"Same Day Surgery Preoperative History and Physical must be performed within 24 hours of inpatient admission/surgery. In surgery cases in which the surgeons dictate 30 days prior to the surgery, an update must be added to the H&P (History and Physical) on the day of surgery or within 24 hours of surgery. If a H&P is dictated over 30 days prior to surgery, the surgeon would have to redictate a new one."

A review of the medical record for patient ID #'s 2, 3, 5, 15, 16, and 70 revealed that although the H&P was dictated within 30 days of admission/surgery, there was no evidence that the H&P had been updated on the day of surgery or within 24 hours of admission per hospital policy.

1) For patient ID #2, the H&P was dictated on 9/28/11. Surgery was performed on 10/12/11. The H&P was updated on 10/9/11.

2) For patient ID #3, the H&P was dictated on 10/17/11. Surgery was performed on 10/27/11. The H&P was never updated.

3) For patient ID #5, the H&P was dictated on 10/31/11. Surgery was performed on 11/3/11. The H&P was never updated.

4) For patients ID #'s 15 & 16, the H&P's were dictated on 11/9/11. Surgeries were performed on 11/15/11. The H&P's were never updated.

5) For patient ID #70, the H&P was dictated on 9/27/11. Surgery was performed on 9//30/11. The H&P was never updated.

Based on record review, it was determined that the hospital failed to ensure that the Operative Reports include the time of surgery for 6 of 6 relevant sample patients (ID's 2, 3, 4, 5, 6, and 70).

Findings are as follows:

CMS (Center for Medicare and Medicaid Services) Interpretive Guidelines state:

"The Operative Report includes at least:....date and times of surgery".

A review of the Operative Report for patient ID #'s 2, 3, 4, 5, 6, and 70 revealed no evidence that the times of surgery were included in these reports.

Based on record review and staff interview it was determined that the hospital failed to ensure that a post anesthesia evaluation was completed no later than 48 hours after surgery for 3 of 8 relevant sample patients (ID #'s 4, 15 and 16).

Findings are as follows:

1. A review of the clinical record for patient ID #4 revealed a surgical procedure on 11/3/11. A review of the "Post Anesthesia Note" revealed no evidence that a post-anesthesia evaluation was completed and documented within 48 hours after surgery, or completed at all.

2. A review of the clinical record for patient ID #15 revealed a surgical procedure on 11/15/11, with no evidence that a post-anesthesia evaluation was completed and documented within 48 hours after surgery, or completed at all.

3. A review of the clinical record for patient ID #16 revealed a surgical procedure on 11/15/11, with no evidence of a post-anesthesia evaluation completed and documented within 48 hours after surgery, or completed at all.

When interviewed on 11/17/11 at approximately 1:30 PM, the Chief of Anesthesia could not provide evidence that a post-anesthesia evaluation had been completed on these patients.

Based on surveyor observations and staff interview, it was determined that the hospital failed to endure required audits of the Nuclear Medicine Services and performed by qualified personnel in accordance with State laws.

Findings are as follows:

According to C.8.5(b)3 of the Rules and Regulations for the Control of Radiation:

"A licensee shall ensure that only authorized medical physicists perform... radiation surveys described in C.8.57."

On 11/15/11 at approximately 11:00 AM, a tour of the Nuclear Medicine Department, and record review of the hospital's radiation safety program records since December 2010, revealed that although equipment was calibrated, tested, and inspected, there was no evidence that this was performed or reviewed by an authorized Medical Physicist per licensing requirements and radiation control regulations. This included obtaining and counting the sealed source leak test wipes.

Based on surveyor observations and record review, it was determined that the hospital failed to ensure that Nuclear Medicine Services related to brachytherapy treatment were ordered only by a practitioner authorized by the State licensing agency.

Findings are as follows:

According to C.8.2(b) of the Rules and Regulations for the Control of Radiation:

"A licensee shall apply for and receive a license amendment before permitting anyone, ... to work as an authorized user under the license."

On 11/16/11 at approximately 11:30 AM, a tour of the Nuclear Medicine Department and review of the only 2 records of brachytherapy seeds ordering and accountablity forms revealed that although credentialed and Board Certified, the physician ordering Brachytherapy seeds containing Iodine-125 for treatment in the Nuclear Medicine Department was not an authorized for this license. Although an amendment request to the State licensing agency had been submitted by the hospital to authorize a physician user, this amendment had not been approved as additional information had been requested of the hospital by the State agency, and was never received.

Based on record review and staff interview, it was determined that the hospital failed to ensure that services provided were in accordance with orders of the licensed practitioner responsible for the care of 2 of 2 relevant patients in the hospital at the time of the survey (ID #'s 27 and 66).

Findings are as follows:

1. A review of the clinical record for patient ID #27 revealed physician orders dated 11/9/2011 at 0053 for Mechanical Ventilation Support Mode with the following settings: "Breath Rate: 14, Tidal Volume Setting: 450, FIO2 (Fraction of Inspired Oxygen) 100, PEEP (Positive End Expiratory Pressure) 8.0".

On 11/9/2011 multiple ventilator changes were made to the FIO2 settings between the hours of 0035 to 2235 without a physician's order.

Additionally on 11/10/2011, between the hours of 0130 and 2243, and on 11/12/2011, between the hours of 0000 and 0755, multiple changes were made to the FIO2 settings without a physician's order.

When interviewed on 11/16/2011 at 11:25 AM, the Director of the Cardiopulmonary Services reported that ventilator setting changes are only to be made under the direction of a physician order. The Director also reported that the ventilator setting changes made by the respiratory therapist were not in accordance with a physician order.

2. A review of the clinical record for patient ID # 66 revealed physician's orders dated 11/8/2011, at 1916, for Mechanical Ventilator Support Mode with the following settings: Support Breath Rate: 14, Tidal Volume Setting: 450, FIO2: 100, PEEP: 8.0.

On 11/11/2011 between the hours of 0925 and 1345, the Tidal Volume was set at 400 without a physician's order. In addition, between 1830 and 2200 the respiratory rate was changed to 14 without evidence of a physician's order, which continued on 11/12/2011 between the hours of 0000 and 1620.

On 11/12/2011 between the hours of 0104 and 1153 the respiratory rate was set at 14 without evidence of a physician's order. Additionally, on 11/12/2011 between the hours of 1417 and 1620 the respiratory rate was again changed to a setting of 16 without evidence of a physician's order. Multiple ventilator setting changes continued without evidence of an accompanying physician's order until 11/16/2011 when brought to the attention of staff by the surveyor.

During an interview on 11/16/2011 at 12:30 PM, the Director of Cardiopulmonary Services acknowledged that the facility failed to notify the physician of ventilator setting changes and obtain an order for the changes.