HospitalInspections.org

Based on record review, staff interview, and Medical Staff By-Laws review the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 19 of 30 sampled medical records (#'s 1, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 29).

Findings include:

- The CAH's Medical Staff By-Laws reviewed on 6/13/11 at 4:20pm directed "...All entries (into the medical record) shall be dated, timed, and signed by the appropriate provider..."

- Patient #13's medical record reviewed on 6/13/11 at 12:50pm revealed an admission date of 5/16/11 with a diagnosis of post left hip replacement and discharged on 5/27/11. Record review revealed eight written/verbal/telephone orders lacked the date and time when the practitioner authenticated (signed) the order.

- Patient #14's medical record reviewed on 6/13/11 at 1:30pm revealed an admission date of 5/13/11 with a diagnosis of left total hip arthroplasty (replacement of the left hip) and discharged on 5/26/11. Record review revealed twelve written/verbal/telephone orders lacked the date and time when the practitioner authenticated (signed) the order.

- Patient #15's medical record reviewed on 6/14/11 at 2:00pm revealed an admission date of 5/18/11 for a surgical procedure and discharged on 5/19/11. Record review revealed seven written/verbal/telephone orders and progress notes lacked the date and time when the practitioner authenticated (signed) the entry into the medical record.

- Patient #16's medical record reviewed on 6/14/11 at 2:30pm revealed an admission date of 6/6/11 with a diagnosis of abdominal pain and discharged on 6/12/11. Record review revealed four written/verbal/telephone orders and progress notes lacked the date and time when the practitioner authenticated (signed) the entry into the medical record. The record review revealed four standing orders lacked a date and time the orders were initiated.

Staff A interviewed on 6/13/11 at 4:20pm acknowledged the providers failed to date and time all entries into the medical record and the facility had recently added the requirement for providers to date and time all entries into the medical record to the Medical Staff By-Laws.

This deficient practice also affected patient #'s 1, 11, 12, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 29.