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Based on review of the Medical Staff Rules and Regulations, review of medical records, and interview with staff the hospital failed to ensure that the surgeon documents a history and physical examination prior to the patient undergoing a surgical procedure.

Findings include:

1. On 3 of 10 surgical records reviewed, the patient had undergone a surgical procedure without the surgeon documenting his findings on physical examination of the patient. On two of these records a handwritten history and physical exam had been documented by an unidentified person. On interview with medical record staff, the person documenting the physical exam was the surgeon ' s office nurse. On one record the physician had signed and dated the history and physical exam documented by the nurse, and on the other record the history and physical was not signed, nor was it dated. On the 3rd surgery chart the surgeon had written on a consult form " OK for EGD and colonoscopy " and had done these procedures, but he had also performed a bowel resection without documenting a history and physical exam prior to the surgery.

1. Twenty-one medical records were selected at random from a list of discharges from May 1 to June 15, 2010, and reviewed along with 12 inpatient medical records for a total of 33 medical records.

2. On 15 of 33 records reviewed, all physician orders had not been timed and/or dated when they were entered into the record. This included orders written by the physician, verbal orders taken by the nurse, and routine and/or standing order sheets when placed in the record.

Based on review of the Medical Staff Rules and Regulations, and review of medical records the hospital failed to ensure that all physician orders were signed within 48 hours.

Findings include:

Verbal/phone orders had not been authenticated by the physician within 48 hours on 3 of 12 inpatient records reviewed.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

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 A710.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:


1. Refer to K17 -- The hospital failed to provide the required 1/2 hour fire-resistance rating for smoke barrier walls.

2. Refer to K20 -- The hospital failed to provide partitions that have a fire resistance rating of at least one (1) hour.

Based on policy review, observation, clinical record review and staff interview the facility failed to ensure that it had provided an activities program to meet the needs of two (2) of two (2) patients, Patient #1 and #2.

Findings:


A copy of the facility ' s policy was reviewed, " Swing Bed Program-Patient Activities Policies and Procedures. " It revealed " General Hospital Swing Bed provided for an activities program appropriate to meet the individual needs and interests of each patient, to encourage self care, to resume normal activities and maintain an optimal level of psychosocial functioning ...EACH PATIENTS PLAN OF ACTIVITIES PRIOR TO BEING IMPLEMENTED, MUST BE APPROVED BY ATTENDING PHYSICIAN AND IS NOT IN CONFLICT WITH THE PATIENT ' S MEDICAL TREATMENT PLAN. "

A tour of the Swing Bed unit was made on 06/29/10 at approximately 2:25 p.m. with the Director of Nursing. There was no posting of an activities calendar on the unit

Clinical record review for Patient #1 revealed that he/she had been admitted to the facility on 06/24/10. There was no documentation that revealed that the patient had received an activities assessment or that the patient had participated in an activities program.

Clinical record review for Patient #2 revealed that he/she had been admitted to the facility on 06/18/10. The patient had received an activities assessment upon admission but there was no documentation that on going activities had been provided.

The Nurse Manager of the Swing Bed Unit was interviewed on 06/29/10 at approximately 2:50 p.m. He/She stated " Our patients are elderly and don ' t participate in activities. "

During an interview with the Social Worker on 06/30/10 at approximately 10:15 a.m. a copy of the activities calendar was provided. It indicated that a different discipline of the facility was responsible for the activities program each day of the week. It did not include the specific activities that were planned.

These findings were discussed with the Administrator during the exit conference on 06/30/10 at approximately 2:00 p.m. No additional documentation was provided.