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1. Based on inspection of the medication storage areas, staff interviews, and review of facility policies Cuero Community Hospital failed to follow acceptable standards of practice regarding medication administration and the use of multidose vials. These requirements were not met as follows:

The findings included:

a. An inspection of the medication refrigerator in the Intensive Care Unit on 09/16/10 at 10:32 a.m. revealed an open vial of Humulin R insulin with a date of 8/20/10 and an open vial of Humalog insulin with a date of 08/20. The label did not include the initials of the person opening the vial, the time the vial was opened, or the expiration date for the vial to be discarded.

b. During an interview with staff #3 on 9/16/10 at 10:33 a.m. in the Intensive Care unit she acknowledged the findings of the opened multidose vials with no initials, time opened, or expiration date. In an interview with intensive care unit staff member#15 he said the expiration date for multidose vials opened was 90 days.

c. A review of the facility policy, Disposal of Unusable Drugs and Supplies, on 9/16/10 at 11:10 a.m. in the second floor nurses station revealed a date of six months for vials to be discarded after being opened. This policy was confirmed by staff member #9, at 11:10a.m. on 9/16/10 as being the current policy. This is outside the standards of practice being 28 days for discarding multidose vials after being opened. The staff in the facility failed to know their own policies in regard to labeling and discarding opened multidose vials for use in patient care.

1. Based upon review of inpatient medical records verbal orders were not used infrequently. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) There were 9 out of 26 medical records reviewed (35%) (MR# 9,10,11,12,16,17,19,20, 23 and MR# 26) that showed the use of frequent verbal orders.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.

1. Based upon review of inpatient medical records and interview with hospital staff all medical record entries reviewed were not legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) 14 out of the 26 medical records (MR) (54%) (MR# 8,9,10,11,12,13,14,15,16,17,18,23,24 and MR#26) were incomplete and either were not dated and or timed by the person responsible for providing or evaluating the services provided. There were 7 out of the 26 medical records reviewed (27%) (MR# 9, 11, 12,13,15,18 and MR#23) that had discharge summaries that were not dated and timed within 30 days of the patient's discharge. There were 12 out of 26 medical records reviewed (46%) (MR# 8,9,10,14,15,16,18,19,20,22,24 and MR# 26) that had verbal orders that were not dated and or timed within 48 hours of being given by physician. There were 5 out of 26 medical records (19%) (MR# 11, 12, 13, 15, 21) that had history and physical examinations that were in the patient medical records within 24 hours. There were 6 out of 26 medical records (23%) (MR# 8, 10,11,14,18 and MR # 24) that had miscellaneous medical entries on progress notes, operating room reports and informed consents that were either not dated and or timed.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.

1. Based upon review of inpatient medical records all verbal orders were not authenticated within 48 hours. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) There were 12 out of 26 medical records reviewed (46%) (MR# 8,9,10,14,15, 16,18, 19,20, 22,24 and MR# 26) that had verbal orders that were either not dated and or timed , authenticated within 48 hours of being ordered by the physician.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.

1. Based upon review of inpatient medical records all verbal orders were not authenticated within 48 hours. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) There were 12 out of 26 medical records reviewed (46%) (MR# 8,9,10,14,15, 16,18, 19,20, 22,24 and MR# 26) that had verbal orders that were either not dated and or timed , authenticated within 48 hours of being ordered by the physician.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.

1. Based upon review of inpatient medical records. All medical records reviewed did not have history and physical examinations placed in the patient's medical record within 24 hours after admission or registration. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) There were 5 out of 26 medical records (19%) (MR# 11, 12, 13, 15, 21) that had history and physical examinations that were not placed in the patient's medical records within 24 hours.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.

1. Based upon review of inpatient medical records and interview with hospital staff dated and/or timed discharge summaries with authentications are not being placed in the patient's medical record within 30 days following discharge. This requirement was not met as follows:

Findings:

a. In review of 26 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 ,20,21, 22, 23, 24, 25 and MR#26) there were 7 out of the 26 medical records reviewed (27%) (MR# 9, 11, 12,13,15,18 and MR#23) that had discharge summaries that were not dated and timed within 30 days of the patient's discharge.

b. Interviewed staff # 3 chief nursing officer and staff #5 health information management director at 1:30pm on Sept. 16, 2010 in a classroom at Cuero Community Hospital. The medical records that had discrepancies were reviewed with staff # 3 and staff #5 who agreed that these deficiencies did not meet the requirements of this regulation. The staff members interviewed could not provide evidence that these discrepancies met requirements.