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Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all physician orders are timed when they are entered into the medical record, and that all physician orders are signed within 48 hours.

Findings include:

1. Sixteen discharged records were selected at random from a list of discharges for the past 2 months, along with 16 inpatient medical records, and reviewed for a total of 32 medical records.

2. On 12 of 32 medical records reviewed, all physician orders had not been timed when entered into the medical record. These orders included orders written by the physician, those taken by a nurse, and routine order sheets.

3. On 9 of 32 medical records reviewed contained unsigned verbal and/or phone orders that were over 48 hours.

The hospital failed to be constructed, arranged and maintained to ensure the safety of patients.

Refer to A 709 - Failed to comply with the Life Safety Code and A 710- Failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A 710.

The hospital failed to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

1. Refer to K 12- The hospital failed to provide the correct building construction type.

2. Refer to K 17- The hospital failed to provide walls constructed with at least 1/2 hour fire resistance rating.

3. Refer to K 20 - The hospital failed to provide partitions that a fire resistance rating of at least one (1) hour.

4. Refer to K 21- The hospital failed to provide doors that automatically close by zone or throughout the facility upon activation.

5. Refer to K 25- The hospital failed to provide partitions of at least 1/2 hour fire resistance rating and constructed in accordance with 8.3.

6. Refer to K 29- The hospital failed to provide one hour fire rated construction for hazardous areas.

7. Refer to K 51- The Hospital failed to provide all of the approved components, devices or equipment installed in according to NFPA 72.