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Based on record review, policy review, and staff interview the CAH failed to ensure each entry into the medical record was authenticated with a signature, date, and/or time of the entry for 11 of 30 (P6, P10, P8, P12, P16, P17, P18, P19, P20, P21, P22) patients medical records reviewed. Finding included:

Eleven medical records, that included in-patient,surgical, and emergency patient records, lacked authentication with a signature, date and or/time the entry was made in the medical record.


Review of the inpatient record for P6 revealed the patient was admitted to the facility on 6/15/09, and discharged on 6/18/09. A physicians order dated 6/17/09, was not timed.

Review of the inpatient record for P10 revealed the patient was admitted to the facility on 02/17/10, and discharged on 2/22/10. A telephone order on 2/20/10, and a verbal order on 2/21/10, lacked a physicians signature. In addition a verbal order dated 2/19/10, lacked a nurse practitioners signature.

Review of the inpatient record for P8 revealed the patient was admitted to the facility from the Emergency Room on 10/30/09, and discharged on 11/02/10. The physician admission orders lacked a date and time of the physician's signature.
Review of the orders with the Acute Care Director (ACD) on 3/17/10, at 10:15 a.m. verified that the date and time of the admission orders were added by licensed staff at a later time. ACD stated it was the facilities protocol to have the licensed staff date and time physician's orders if the physician fail to do so.
In addition P8's Thromboembolism Prophylaxis Order and a Adult Insulin Order form lacked the date and time of the physician's signature.

Review of the inpatient record for P12 revealed the patient was admitted to the facility on 09/19/09, and discharged on 9/21/09. A physician's order dated 9/21/09, was not timed.

P16 Physician's orders to discontinue a medication dated 2/26/10, was not timed.

P17 Physician's telephone order had an unclear date indicated the patient was to be discharged to a larger hospital, dated 2/?/10, and this order also, did not include a time to when this order was written.

P18 Physician's verbal order dated 3/11/10, timed 1110 had not been signed by the physician.

P18 Physician's verbal order's dated 3/11/10, had not been signed by a physician.

P19 Physician's discharge medication orders dated 3/4/10, had not been timed by the physician.

P20 Physician's order for physical therapy evaluation dated 3/2/10, did not have the time noted on the physician's order. P20's physical therapy outpatient's, Plan of Treatment, dictation on 3/5/10, by the therapist had not been signed by the physician as of 3/18/10.

Surgical records P16 and P21 lacked documentation of timed signature by the physician. Examples included:
P16's Venous Thromboembolism Prophylaxis Orders form dated 2/25/2010, lacked a timed signature.
P21 verbal Physician's Orders form to administer a medication dated 3/11/10, had not been signed by the physician.

Record review for emergency room patients indicated 3 of 10 patients (P16, P17, P22) failed to have the following entries authenticated with the physician's signature, date and /or time of the entry.
P16 Emergency Room Record Chest Pain Protocol form dated 2/25/10, did not have a physician's signature, date or time.
P17 Emergency Room Record with an orders for laboratory tests, X rays and EKG dated 2/24/10, was not signed by the physician.
P22 Emergency Room Report dictated on 1/10/01, had not been signed by the physician as of 3/17/10.

The facility "Complete Legible ,Organized Records" policy and procedure last reviewed 2010 stated:
Record Completion
- Upon admission, history and physical examinations shall be completed within 24-48 hours.
- Upon discharge, records shall be completed with 24 hours.
- Operative reports shall be completed within 24 hours.
- All orders will be properly documented.
- All entries will be signed by the author of the entry and any other co-signer.

The facility "Maintenance of Health Care Record Policy" reviewed 2010 stated: All dictated reports will be electronically authenticated by the provider responsible for the diction.

Review of the Medical Staff bylaws last reviewed 2010 verified the medical record policies were current.

The medical records manager stated on 3/17/10, at 2:30 p.m. that the hospital had a large amount of "delinquent" charts.

Based on interview and record review the facility failed to develop a Quality Assurance (QA) program that evaluated the quality and appropriateness of the facility's anesthesia services. Findings include:

The facility did not have a QA program for their anesthesia program.
At 11:00 a.m. on 3/18/10, the certified nurse anesthetist (CRNA) stated she knew of no QA projects in the last year for the anesthesia program.

Interview with the Surgical Manager at 11:20 a.m. on 3/18/10, indicated the only thing they had done in anesthesia was to add a lock to the anesthesia cart so controlled substances would have a double lock. He verified no other QA had been completed.

Based on interview and record review the facility failed to develop a Quality Assurance (QA) program that evaluated he quality and appropriateness of the facility's Swing Bed services. Findings included,

The facility failed to have a QA program for their Swing Bed (SB) program.

At 3:10 p.m. on 3/17/10, the acute care director (ACD) stated there was no other QA project for the SB unit other than testing newly admitted residents for methicillin resistant staphylococcus aureus (MRSA).
ACD verified that there was not system in place to evaluate the swing bed program.