HospitalInspections.org

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 20 of 33 sampled medical records (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20).

Findings include:

- Document review on 1/25/11 of the CAH's policy titled "Medical Records Dismissal Procedures" and "Medical Staff Bylaws Rules and Regulations 2010" lacked direction that medical staff must time and date all authenticated (signed) entries in the medical record.

- Patient #1's medical record revealed an admission date of 11/16/10 to the swing bed unit of the CAH. The medical record revealed a history and physical, a discharge summary, four progress notes between 11/16/10-11/22/10 and 16 physician orders between 11/16/10-11/24/10 lacked a time when authenticated.

- Patient #6's medical record revealed an admission date of 1/10/11 for surgery of the right breast. The medical record revealed a history and physical, the verbal admission orders and two progress notes written on 1/10/11 lacked a date and/or time when authenticated by the physician.

- Patient #7's medical record revealed an admission date of 11/1/10 for surgery of the colon. The medical record revealed orders written on 11/1/10, 11/2/10, 11/3/10, 11/4/10, 11/5/10, and 11/6/10 lacked a date and/or time when authenticated by the physician. The medical record contained four progress notes between 11/2/10-11/5/10 and five verbal or telephone orders between 11/1/10-11/6/10 that lacked a date and/or time when authenticated by the provider.

On 11/25/11 at 11:15am staff B acknowledged all entries into the medical record lacked a date and/or time when authenticated.

This deficient practice also affected patient #'s 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20.