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Based on interview and record review, the facility Governing Body had not approved Medical Staff Rules and Regulations.

Findings included:

1) In an interview with the surveyor at 10:00 AM on 03/08/11 the Medical Director (Personnel #5) was asked if the Medical Staff had Rules and Regulations to include requirements for completing medical records. He stated he did not know of any Medical Staff Rules and Regulations.

2) In an interview with the surveyor at 3:00 PM on 03/8/11 the Chief Executive Officer (Personnel #1) was asked if the staff had located any Medical Staff Rules and Regulations. He stated they had not been able to locate rules and regulations for the medical staff. He stated he had asked the credentialed staff and they did not have any copies of rules or regulations.

3) Review of the Medical Staff By Laws, amended 10/16/07, Article XXIII, Rules and Regulations;
"23.01 The Medical Staff shall adopt such rules and regulations as may be necessary to implement more specifically the general principles found within the Bylaws, subject to the approval of the Board of Trustees...Such rules and regulations shall be a part of the Bylaws..."

Based on review of records and interviews, the medical staff did not enforce their own bylaws to ensure their medical records were accurate and complete. The medical records of 18 of 18 patients (Patients #1 through #9, Patients #11 through #14, and Patients #16 through #20), hospitalized after August 1, 2010, were not dated, timed, and/or signed by the physician and/or physician assistant (PA) responsible for providing medical services to the patients. This practice presents a risk of potential harm to patients.

Findings included:

The "History and Physical" was not signed by the physician and/or physician assistant with the date and time of signatures for the following patients:

Patient #8 - Admitted 08/13/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #9 - Admitted 08/20/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #13 - Admitted 10/21/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #17 - Admitted 12/07/10, the Physician did not sign with date and time of signature.

The "Emergency Department (ED) Record Physician's Record" signatures were not dated and timed by the physician and/or physician assistant for the following patients:

Patient #1 - Date of ED visit 08/28/10, signature not dated and timed.
Patient #2 - Date of ED visit 09/10/10, signature not dated and timed.
Patient #3 - Date of ED visit 10/08/10, signature not dated and timed.
Patient #4 - Date of ED visit 11/13/10, signatures not dated and timed.

The "Memorandum of Transfer" physician's signatures were not dated and/or timed for the following patients:

Patient #3 - Accepted by receiving hospital on 10/08/10, Physician's signature was not dated and timed.
Patient #4 - Accepted by receiving hospital 11/13/10, Physician's signature was not dated and timed.

The "Consent To/Referral of Treatment and Transfer" physician and physician assistant signatures were not timed for the following patient:

Patient #4 - Physician and Physician Assistant's signatures dated 11/12/10 were not timed.

The "Outpatient Short Stay Record" physician and/or physician assistant's signatures were not dated and timed for the following patient:

Patient #5 - Patient label admit date 12/15/10, signatures were not dated and timed.

The "Physician's Order Sheet" included orders written by the physician and telephone orders that were not dated and timed by the physician and/or physician's assistant for the following patients:

Patient #5 - Physician's order signature dated 12/15/10 was not timed.
Patient #7 - Telephone order 12/29/10, Physician's signature was not dated and timed, Physician's order signature dated 12/30/10 was not timed.
Patient #8 - Physician's order signature dated 08/14/10 was not timed.
Patient #9 - Physician's order signature dated 08/23/10 was not timed.
Patient #11 - Physician's order signature was not dated and timed. The Nurse noted the order on 10/09/10 at 12:30 PM.
Patient #12 - Physician's order signature dated 10/16/10 was not timed.
Patient #13 - Telephone order 10/21/10, Physician's signature was not dated and timed, and the Physician's order signature dated 10/23/10 was not timed.
Patient #16 - Admit 11/30/10, Physician's order signature was not dated and timed.
Patient #17 - Physician's order signature dated 12/07/10 was not timed.

The "Routine PRN Medication Orders" checklist physician's signature was not dated and timed for the following patient:

Patient #9 - Orders were noted by the Nurse at 08/20/10 11:00 PM, Physician's signature was not dated and timed.

The "Medication Reconciliation Order Form" physician and/or physician's assistant signatures were not entered with the date and/or time of signature for the following patients:

Patient #9 - The Admit Physician's 08/20/10 signature was not timed, and the Physician Assistant did not sign with the date and time of signature. The Discharge Physician's 08/23/10 signature was not timed.
Patient #13 - Discharge Physician's 10/23/10 signature was not timed.
Patient #17 - Admit Physician's 12/09/10 signature was not timed and Discharge Physician's signature dated 12/10/10 was not timed.
Patient #19 - Admit Physician's 12/20/10 signature was not timed. The Discharge Physician's signature dated 12/24/10 was not timed.

The "Operative Report" physician and/or physician assistant's signatures were not entered, dated and/or timed for the following patients:

Patient #5 - Colonoscopy report transcribed 12/15/10, Physician's signature was not dated and timed and the Physician Assistant did not authenticate the report with a signature that was dated and timed.
Patient #7 - Tonsillectomy and Adenoidectomy report transcribed 12/29/10, Physician did not authenticate the report with a signature that was dated and timed.

The "Discharge Summary" was not signed with date and time of signatures for the following patients:

Patient #6 - Elective circumcision, admit date 01/13/11 and discharge date 01/13/11, Physician did not sign with date and time of signature.
Patient #9 - Transcribed 08/23/10, Physician did not sign with date and time of signature.
Patient #13 - Discharged 10/23/10, Physician did not sign with date and time of signature.
Patient #14 - Discharged 11/15/10, Physician did not sign with date and time of signature.
Patient #16 - Discharged 12/02/10, Physician and Physician Assistant did not sign with date and time of signatures.
Patient #17 - Discharged 12/10/10, Physician did not sign with date and time of signature.
Patient #18 - Discharged 12/13/10, Physician did not sign with date and time of signature.
Patient #19 - Discharged 12/24/10, Physician did not sign with date and time of signature.
Patient #20 - Discharged 01/16/11, Physician's signature was not dated and timed. The Physician Assistant did not sign with the date and time of signature.

The "Circumcision Note" was not signed with date and time of signatures for the following patient:

Patient #6 - Elective circumcision report transcribed 01/13/11 was not signed with date and time of signature by the Physician and Physician Assistant.

The "Progress Notes" were not signed with the date and time of signatures and/or the signatures were not dated and/or timed for the following patients:

Patient #7 - Physician's signature dated 12/30/10 was not timed.
Patient #8 - Physician and Physician Assistant notes dated 08/14/10 and 08/15/10 were not signed with the date and time of the signatures.
Patient #9 - Physician and Physician Assistant notes dated 08/21/10 and 08/22/10 were not signed with the date and time of the signatures.
Patient #11 - Physician Assistant's signature was not timed, the Physician did not date and time the 10/10/10 progress note.
Patient #12 - Physician's signature was not dated and timed.
Patient #13 - Physician and Physician Assistant typed notes dated 10/22/10 were not signed with date and time of signatures.
Patient #14 - Physician's signatures for 11/09/10, 11/10/10, and 11/11/10 typed notes were not dated and timed.
Patient #17 - Physician's 12/09/10 typed note was not signed with date and time of signature.
Patient #18 - Physician's signature for 12/12/10 typed note was not dated and timed.
Patient #19 - Physician's signatures for 12/21/10 and 12/22/10 typed notes were not dated and timed. The typed Physician's note dated 12/23/10 was not signed by the Physician with the date and time of signature.

On 03/08/11 at approximately 05:00 PM, the Chief of Medical Staff (Personnel #5) was asked why the physician's entries to the patient's medical records were not always timed. The Chief of Medical Staff (Personnel #5) said that he was not aware of the need to add the time to the medical record entries.

On 03/09/11 at approximately 01:45 PM, the Assistant Chief Nursing Officer (Personnel #3) and Medical Records Director (Personnel #4) reviewed the above medical records of Patients #1 through #9, Patients #11 through #14, and Patients #16 through #20 with the surveyor and agreed that the medial record entries were missing authentication information that included signatures, dates of signatures, and/or times of signatures.

The hospital's "Medical Staff Bylaws" amended 10/16/07 noted that "All members of the Medical Staff shall pledge themselves to maintain such standards and meet such requirements...federal...regulatory agencies...Medical Records/Surgery/Tissue Committee...review summary information on the timely completion of all medical records ..."

The hospital's "Author Authentication" policy dated 02/22/10 noted, "Each person responsible for documentation in the Medical Record shall date and sign each entry...verbal orders must be dated, timed and authenticated by the prescribing practitioner or another practitioner responsible for the care of the patient...within 48 hours."

Based on review of records and interviews, the medical records of 18 of 18 patients (Patients #1 through #9, Patients #11 through #14, and Patients #16 through #20), hospitalized after August 1, 2010, were not complete in that the medical record entries were not dated, timed, and/or signed by the person responsible for providing the hospital services to the patients. This practice presents a risk of potential harm to patients.

Findings included:

The "History and Physical" was not signed with date and time of signatures for the following patients:

Patient #8 - Admitted 08/13/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #9 - Admitted 08/20/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #13 - Admitted 10/21/10, the Physician and Physician Assistant did not sign with date and time of signatures.
Patient #17 - Admitted 12/07/10, the Physician did not sign with date and time of signature.

The "Emergency Department (ED) Record Physician's Record" signatures were not dated and timed by the physician and/or physician assistant for the following patients:

Patient #1 - Date of ED visit 08/28/10, signature not dated and timed.
Patient #2 - Date of ED visit 09/10/10, signature not dated and timed.
Patient #3 - Date of ED visit 10/08/10, signature not dated and timed.
Patient #4 - Date of ED visit 11/13/10, signatures not dated and timed.

The "Patient Post-Care Instructions" nurse's signatures were not dated and timed for the following patients:

Patient #1 - Report dated 08/28/10, Nurse's signature was not dated and timed.
Patient #2 - Report dated 09/10/10, Nurse's signature was not dated and timed.

The "Authorization for Emergency Treatment" witness signatures were not timed for the following patients:

Patient #2 - Witness signature dated 09/10/10 was not timed.
Patient #3 - Witness signature dated 10/08/10 was not timed.
Patient #4 - Witness signature dated 11/13/10 was not timed.

The "Memorandum of Transfer" physician's signatures and/or nurse's signatures were not dated and/or timed for the following patients:

Patient #3 - Accepted by receiving hospital on 10/08/10, Nurse and Physician's signatures were not dated and timed.
Patient #4 - Accepted by receiving hospital 11/13/10, Physician's signature was not dated and timed.

The "Consent To/Referral of Treatment and Transfer" physician, physician assistant, and witness signature were not timed for the following patient:

Patient #4 - Physician and Physician Assistant's signatures dated 11/12/10 were not timed, Witness signature dated 11/13/10 was not timed.

The "Conditions of Admission to ..." witness signatures were not timed for the following patients:

Patient #5 - Witness signature dated 12/15/10 was not timed.
Patient #11 - Witness signature dated 10/09/10 was not timed.
Patient #19 - Witness signature dated 12/20/10 was not timed.

The "Outpatient Short Stay Record" physician and/or physician assistant's signatures were not dated and timed for the following patient:

Patient #5 - Patient label admit date 12/15/10, signatures were not dated and timed.

The "Physician's Order Sheet" included orders written by the physician and telephone orders that were not dated and timed by the nurse, physician, and/or physician's assistant for the following patients:

Patient #5 - Physician's order signature dated 12/15/10 was not timed.
Patient #7 - Telephone order 12/29/10, Physician's signature was not dated and timed,
Nurse's signature was not timed. Physician's order signature dated 12/30/10 was not timed.
Patient #8 - Physician's order signature dated 08/14/10 was not timed.
Patient #9 - Physician's order signature dated 08/23/10 was not timed.
Patient #11 - Physician's order signature was not dated and timed. The Nurse noted the order on 10/09/10 at 12:30 PM.
Patient #12 - Physician's order signature dated 10/16/10 was not timed.
Patient #13 - Telephone order 10/21/10, Nurse's signature was not timed. The Physician's signature was not dated and timed. The Physician's order signature dated 10/23/10 was not timed.
Patient #16 - Admit 11/30/10, Physician's order signature was not dated and timed.
Patient #17 - Physician's order signature dated 12/07/10 was not timed.

The "Routine PRN Medication Orders" checklist physician's signature was not dated and timed for the following patient:

Patient #9 - Orders were noted by the Nurse at 08/20/10 11:00 PM, Physician's signature was not dated and timed.

The "Medication Reconciliation Order Form" physician and/or physician's assistant signatures were not entered with the date and/or time of signature for the following patients:

Patient #9 - The Admit Physician's 08/20/10 signature was not timed, and the Physician Assistant did not sign with the date and time of signature. The Discharge Physician's 08/23/10 signature was not timed.
Patient #13 - Discharge Physician's 10/23/10 signature was not timed.
Patient #17 - Admit Physician's 12/09/10 signature was not timed and Discharge Physician's signature dated 12/10/10 was not timed.
Patient #19 - Admit Physician's 12/20/10 signature was not timed. The Discharge Physician's signature dated 12/24/10 was not timed.

The "Consent to Medical Photographs/Video Pictures" witness signature was not timed for the following patient:

Patient #5 - Witness signature dated 12/15/10.

The "Anesthesia Record" signatures were not timed and dated for the following patients:

Patient #5 - Report dated 12/15/10, signatures of Instrument Nurse, Charge Nurse, and Anesthetist "CRNA" were not dated and timed.
Patient #6 - Report dated 01/13/11, signatures of Instrument Nurse, Charge Nurse, and Anesthetist "CRNA" were not dated and timed.
Patient #7 - Report dated 12/29/10, signatures of Instrument Nurse, Charge Nurse, and Anesthetist "CRNA" were not dated and timed.

The "Operative Report" physician and/or physician assistant's signatures were not entered, dated and/or timed for the following patients:

Patient #5 - Colonoscopy report transcribed 12/15/10, Physician's signature was not dated and timed and the Physician Assistant did not authenticate the report with a signature that was dated and timed.
Patient #7 - Tonsillectomy and Adenoidectomy report transcribed 12/29/10, Physician did not authenticate the report with a signature that was dated and timed.

The "Post-Operative Instructions" nurse's signatures were not timed for the following patients:

Patient #5 - Nurse signature dated 12/15/10.
Patient #6 - Nurse signature dated 01/13/11.
Patient #7 - Nurse signature dated 12/30/10.

The "Perioperative Pre-admission Record" nurse's signatures were not dated and timed for the following patients:

Patient #5 - Nurse signature was not dated and timed.
Patient #6 - Nurse signature was not dated and timed.
Patient #7 - Nurse signature was not dated and timed.

The "Discharge Summary" was not signed with date and time of signatures for the following patients:

Patient #6 - Elective circumcision, admit date 01/13/11 and discharge date 01/13/11, Physician did not sign with date and time of signature.
Patient #9 - Transcribed 08/23/10, Physician did not sign with date and time of signature.
Patient #13 - Discharged 10/23/10, Physician did not sign with date and time of signature.
Patient #14 - Discharged 11/15/10, Physician did not sign with date and time of signature.
Patient #16 - Discharged 12/02/10, Physician and Physician Assistant did not sign with date and time of signatures.
Patient #17 - Discharged 12/10/10, Physician did not sign with date and time of signature.
Patient #18 - Discharged 12/13/10, Physician did not sign with date and time of signature.
Patient #19 - Discharged 12/24/10, Physician did not sign with date and time of signature.
Patient #20 - Discharged 01/16/11, Physician's signature was not dated and timed. The Physician Assistant did not sign with the date and time of signature.

The "Discharge Planning Summary" nurse's signature was not dated and/or timed for the following patient:

Patient #7 - Summary dated 12/30/10 Nurse's signature was not dated and timed.

The "Consent to Operation, Anesthetics and other Medical Services" witness signatures were not timed for the following patients:

Patient #6 - Witness signature dated 01/13/11 was not timed.
Patient #7 - Witness signature dated 12/29/10 was not timed.

The "Circumcision Note" was not signed with date and time of signature for the following patient:

Patient #6 - Elective circumcision report transcribed 01/13/11 was not signed with date and time of signature by the Physician and Physician Assistant.

The "Progress Notes" were not signed with the date and time of signature and/or the signatures were not dated and/or timed for the following patients:

Patient #7 - Physician's signature dated 12/30/10 was not timed.
Patient #8 - Physician and Physician Assistant notes dated 08/14/10 and 08/15/10 were not signed with the date and time of the signatures.
Patient #9 - Physician and Physician Assistant notes dated 08/21/10 and 08/22/10 were not signed with the date and time of the signatures.
Patient #11 - Physician Assistant's signature was not timed, the Physician did not date and time the 10/10/10 progress note.
Patient #12 - Physician's signature was not dated and timed.
Patient #13 - Physician and Physician Assistant typed notes dated 10/22/10 were not signed with date and time of signatures.
Patient #14 - Physician's signatures for 11/09/10, 11/10/10, and 11/11/10 typed notes were not dated and timed.
Patient #17 - Physician's 12/09/10 typed note was not signed with date and time of signature.
Patient #18 - Physician's signature for 12/12/10 typed note was not dated and timed.
Patient #19 - Physician's signatures for 12/21/10 and 12/22/10 typed notes were not dated and timed. The typed Physician's note dated 12/23/10 was not signed with the date and time of signature.

The "Conditions of Admission" witness signatures were not timed for the following patients:

Patient #9 - Witness signature dated 08/20/10.
Patient #13 - Witness signature dated 10/21/10.

The "RN Initial Summary" nurse's signature was not dated and timed for the following patient:

Patient #9 - Admitted 08/20/10, Nurse's signature was not dated and timed.

The "Graphic Chart" that included temperature, respiration, pulse, blood pressure, and diet percentage did not include signatures by the person making the entries for the following patients:

Patient #9 - 08/20/10 11:25 AM through 08/23/10 08:00 AM information was not signed.
Patient #11 - 10/09/10 12:00 Noon through 10/12/10 08:00 AM information was not signed.
Patient #12 - 10/16/10 04:00 PM through 10/20/10 08:00 AM information was not signed.
Patient #13 - 10/21/10 04:00 PM through 10/23/10 08:00 AM information was not signed.
Patient #16 - 11/30/10 02:55 PM through 12/02/10 08:00 AM information was not signed.

The nursing care plan information nurse's signature was not timed for the following patients:

Patient #13 - Nurse signature dated 10/21/10.
Patient #16 - Nurse signature dated 11/30/10.

On 03/08/11 at approximately 05:00 PM, the Chief of Medical Staff (Personnel #5) was asked why the physician's entries to the patient's medical records were not always timed. The Chief of Medical Staff (Personnel #5) said that he was not aware of the need to add the time to the medical record entries.

On 03/09/11 at approximately 01:45 PM, the Assistant Chief Nursing Officer (Personnel #3) and Medical Records Director (Personnel #4) reviewed the above medical records of Patients #1 through #9, Patients #11 through #14, and Patients #16 through #20 with the surveyor and agreed that the medial record entries were missing authentication information that included signatures, dates of signatures, and/or times of signatures.

The hospital's "Author Authentication" policy dated 02/22/10 noted, "Each person responsible for documentation in the Medical Record shall date and sign each entry...verbal orders must be dated, timed and authenticated by the prescribing practitioner or another practitioner responsible for the care of the patient...within 48 hours."

Based on observation, interviews and record review, the pharmacy had not ensured that drugs and biologicals had been properly secured in 2 of 3 patient care areas.

Findings included:

On a tour of the Emergency Department (ED) at 3:55 PM on 03/07/11 with an ED nurse (Personnel #24), the surveyor observed the following drugs, that were unsecured in an unlocked drawer in ER Room #4:
-1 Dexamethasone Sodium Phosphate ophthalmic solution, 5 milliliters (ml.)
-1 Atropine Sulphate ophthalmic solution, 5 ml.

In an interview at 3:55 PM on 03/07/11 with Personnel #24, she verified that these ophthalmic drugs were unsecured in a patient care area, and stated that they did not have room for these drug items in the medication room after the addition of the med-dispense system had been installed.

On a tour of the 2-Bed, Special Care Unit (SCU) at 10:00 AM on 03/08/11 with the Medical/Surgical Unit charge nurse (Personnel #7), the surveyor observed the following biologicals, that were unsecured in an unlocked medication cart located in a public walkway, and just before the entrance to room #118:
-2 Sterile water for injections, 5 ml's.
-2 Normal saline intravenous (IV) flushes, 5 ml's.

In an interview at 10:00 AM on 03/08/11 with Personnel #7, she verified that these biologicals had not been secured and were in a public walkway. Personnel #7 confirmed they should not have been left in an old, unused medication cart.

Based on interviews and record review, the hospital had not ensured that an ongoing program of activities was directed by the activities professional (Personnel #9), to meet the interests, and the physical, mental, and psychosocial well-being of each resident, in that, responsibility for activities had been delegated to the Medical/Surgical (M/S) unit nurse aides for 1 of 1 current Swing Bed resident (Patient #21).

Findings included:

In an interview at 1:00 PM on 03/08/11 with the Swing Bed Activity Coordinator (Personnel # 9), she was asked how she documented activities provided to hospitalized Swing Bed residents. She stated that she did the comprehensive assessment on each resident when admitted to Swing Bed status, but that she had not been providing or directing the activities of these residents. She said that she placed the activity calendar on each Swing Bed chart, but that the M/S unit nurse aides had been providing activities, and documenting on a separate form in the medical record the date and time that activities had been offered to Swing Bed residents. She said that she had not known that this was part of her role as a Swing Bed Coordinator in the hospital. She also said that the hospital had a Patient Activities Consultant (Personnel #25), who came to the hospital once a month to review her initial comprehensive assessment and activity plan, and then signed off behind her signature as approved by him.

Review of personnel records for both Personnel #9 and #25, confirmed that both the Swing Bed Coordinator (Personnel #9), and the Swing Bed Consultant (Personnel #25), were currently certified as activity professionals.

Review of the only current (at time of survey) Swing Bed resident's (Patient #21) medical record, showed that the M/S unit nurse aides had documented twice daily on the "Activities Progress Notes" form, that this resident had refused Swing Bed activities 13 out of the 22 entries, and the remaining 9 entries made no reference to Swing Bed activities at all.

Review of the hospital's "Swing Bed Program, Patient Activities Policy and Procedure," dated 01/18/06, noted the following regarding responsibilities of this role:
-The Swing-Bed Activities Coordinator (Personnel # 9, a Certified Activity Professional): The "duties of (in her role as) the Patient Activities Coordinator"... included that she will "report to the nursing personnel the participation of a patient in activities and particularly any significant change in his/her response to activities in order that these may be documented in the patient's medical record," and "each patient will be visited routinely by the Patient Activities Coordinator to determine that supplies are available and to provide assistance in carrying out activities."

In an interview at 1:00 PM on 03/08/11 with the Swing Bed Activity Coordinator (Personnel #9), she verified that the only documentation in the current Swing Bed resident's (Patient #21) medical record for participation in Swing Bed activities had been recorded twice daily by the M/S unit nurse aides on the "Activities Progress Notes." She also confirmed after review of the hospital's "Swing Bed Program, Patient Activities Policy and Procedure," that she had not performed all duties listed for her role as the Patient Activities Coordinator, in that, she had not routinely visited Swing Bed patients to provide assistance in carrying out activities, or documenting any changes in patient's responses to activities in their plan of care and the medical record.