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Based on document review and interview, it was determined for 2 of 3 (Pt. # 2 and #6) clinical records reviewed of patients in restraints, the Hospital failed to ensure physicians' orders were signed within 48 hours as per policy.

Findings include:

1. The Hospital policy titled, "Restraint & Seclusion (revised 9/16/11)" required, "Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. ... A physician shall authenticate the telephone/verbal order within 48 hours."

2. The clinical record of Pt. #2 included that Pt. #2 was an 11 year female admitted on 6/5/13 with the diagnosis of mood disorder. A physician's telephone order for restraint, dated 6/6/13 at 9:02 AM, lacked the physician's signature within 48 hours of the order date.

3. The clinical record of Pt. #5 included that Pt. #5 was a 16 year old male admitted on 6/1/13 with the diagnosis of bipolar disorder. A physician's telephone order for restraint, dated 6/5/13 at 4:12 PM, lacked the physician's signature within 48 hours of the order date.

4. The above findings were discussed and verified with the Director of Nursing during an interview on 6/10/13 at 3:30 PM.

Based on document review and interview, it was determined that the Hospital failed to ensure medical records were completed within 30 days.

Findings include:

1. The Hospital's "Rules and Regulations of the Medical Staff" (revised 9/2012) required, "All sections of the medical record must be completed within thirty (30) days of discharge.


2. The Medical Records Supervisor presented the surveyor with a letter of attestation on 6/12/13 at 12:00 pm that included, "as of 6/12/2013 at 12:00 pm there were a total of twelve delinquent records".


3. The above findings were confirmed with the Medical Records Supervisor on 6/12/13 at approximately 12:00 pm.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation survey conducted on June 10-11, 2013 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation survey conducted on June 10 - 11, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated June 11, 2013