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Based on review of the Performance Improvement Plan, Quality Council minutes, and review of quality indicator data, the hospital failed to ensure that Nursing Service and the Laboratory were measuring, analyzing, and tracking quality indicators.

Findings include:

Review of the hospital's Performance Improvement Plan, Quality Council minutes, and review of quality indicator data revealed the laboratory was providing data for Quality Assessment, and Performance Improvement, but was failing to analyze the data, and track quality indicators.

Review of the Performance Improvement Plan, Quality Council minutes, and review of quality indicator data revealed that Nursing Service was not providing quality indicator data to be used in measuring, analyzing and tracking quality indicators.

Based on observation and interview with hospital staff, the hospital failed to ensure on two (2) of two (2) days of survey that the medical record department had adequate filing space to properly file medical records and sufficient work space for the employees of the department.

Findings include:

Interview with the Director of the Department on 04/20/11 revealed that medical records filed in open shelf files in the department go back to the year 2000. All shelves were observed to be full with no available space to accommodate any additional records. There were boxes stacked on the floor of the department being used to store recently discharged medical records.

The overcrowded condition of the department with open shelf files left very narrow aisles to walk from the front of the department to the back. Files were observed with little space between them, making filing medical records difficult. Other than employee desks, there was only one small table situated in a cross space between aisles which could be used as a work space.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries in 22 of 22 medical records were timed.

Findings include:

During record review, 16 discharged records were selected at random from a list of recent discharges from February and March 2011, along with six (6) inpatient medical records and reviewed for a total of 22 medical records. Of the 22 medical records reviewed all progress notes had not been timed when entered in the medical record, all physician's orders were not timed when entered into the medical records. All dictated reports found in the 22 medical records reviewed did not include the time the reports were dictated, or the time that they were transcribed. All x-ray reports reviewed were signed electronically by the reading radiologist. These electronically signed reports did not show the date and time the reports are signed.