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Based on record review and staff interview, the facility failed to ensure the medical records contained the consent for medical care and treatment for 5 of 20 records reviewed in the case sample.

Finding includes:

Clinical record reviews found for Patients #2, 5, 8, 11 and 14, the "Consent To And Conditions Of Treatment And Payment Agreement" was not found in their electronic health records (EHR). On the afternoon of 10/21/14, the Assistant Director of Nursing (ADON) verified this consent form, which was the responsibility of the patient access services personnel to obtain from patients seen in the emergency department, was not found for these five patients. The ADON acknowledged their process was being reviewed to ensure the consent forms were not missed or incomplete.

Based on record review and staff interview, the facility failed to ensure all patient medical record entries must be complete, dated, timed, and/or authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, as 8 of 20 medical records were incomplete in the case sample.

Findings include:

1. For Patients #1, 6 and 18, the "Consent To And Conditions Of Treatment And Payment Agreement" were incomplete. For Patients #1 and 18, the age of the minor was not documented, and the individual providing the consent was also not documented. For patient #6, the date and time the patient signed the form was not documented.

2. For Patients #1, 4, 5, 8, 11 and 14, the patients' discharge instruction sheets were incomplete. These records either did not have the patient or the responsible party's signatures, or were missing the dates and/or times the patient/representative signed the form.

3. For Patients #1 and #11, it was found the ED nursing disposition note departure times did not coincide with the visit information record departure time. The Director of Nursing and ADON verified this and also stated their EHR system, implemented in March 2014 still had "bugs" to work out. They stated it may also be related to when the nurse completes his/her clinical documentation in the EHR, such that for 2 of the 20 records, there was an approximate two hour time difference in the patients' documented departure time.

On the afternoon of 10/21/14, the ADON re-validated these findings for the ED patient medical records reviewed.