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Based on medical record review and interview the facility failed to ensure that providers timed all medical record entries. Specifically, four (4) of thirteen (13), (#45, #46, #47 and #50) out patient surgery and endoscopy records, medication reconciliation forms reviewed by survey staff on 3/14/2019 were dated but not timed.

Findings:

1. Chart #45; there was no time on the medication reconciliation form.

2. Chart #46; there was no time on the medication reconciliation form

3 Chart #47; there was no time on the medication reconciliation form

4. Chart #50; there was no time on the medication reconciliation form

This was verified at the exit conference on 3/18/19 at 1:00 PM with the Director of Patient Safety and Quality Improvement

Based on record review and interview, the hospital failed to ensure that physician orders were signed, dated and timed by the physician. Specifically, for five (5) of thirteen (13) out patient surgery and endoscopy medical records reviewed (Medical records #45,#46,#47,#48 and #50) there was no date and time and no authentication by the physician.

Findings include the following medical records:

1. Endoscopy records
#48 and #49 were reviewed on 3/12/19 and 3/14/19, there was no date and time noted on the physician's orders.

2. Surgical records were reviewed on 3/14/19

Chart #45; there was no date and time on the pre-admission physician's order and antibiotic physician's order.
Chart #46; there was no date and time on the pre-surgical anesthesia physician's order, and the order was not authenticated by the physician.
Chart #50; there was no time on anesthesia orders and physician orders.

This was verified at the exit conference on 3/18/19 at 1:00 PM with the Director of Patient Safety and Quality Improvement.

Based on medical record review and interview the facility failed to ensure that an Endoscopy History and Physical was dated and timed and a Pre-Surgical Re-assessment was signed by the Physician. Specifically, this was for two (2) of thirteen (13) medical records reviewed (#18 and #50)

Findings:

1. The patient history and physical for endoscopy record #18 reviewed at the out patient services clinic on 3/12/19 lacked a date and time.

2. The surgical reassessment for surgical record #50 reviewed on 3/14/2019 was not signed by the physician.

This was verified at the exit conference on 3/18/19 at 1:00 PM with the Director of Patient Safety and Quality Improvement.

Based on medical record review and interview the facility failed to ensure that the general consent forms were witnessed, signed and dated and that the physician's signature on the anesthesia consent form was timed. Specifically six (6) medical records of thirteen (13) out patient urgent care and ambulatory surgery records reviewed (#20, #21, #22, #23, #24, #47) did not contain the witness, date and time.

Findings: Medical Records reviewed at outpatient Urgent Care services and the facility's Ambulatory Surgery Center:

1. Medical Record #20 reviewed the general consent form was not witnessed, dated or timed.

2. Medical Record #21 reviewed the general consent form was not witnessed, dated, or timed.

3. Medical Record #22 reviewed the general consent form was not witnessed, dated or timed.

4. Medical Record #23 reviewed the general consent form was not witnessed, dated or timed.

5. Medical Record #24 reviewed the general consent form was not witnessed, dated or timed.

6. Medical Record #47 reviewed the general consent form was not timed at witness signature, and the moderate sedation consent form was not timed at the witness signature.

This was verified at the exit conference on 3/18/19 at 1:00 PM with the Director of Patient Safety and Quality Improvement.

Based on observation and interview, the facility failed to ensure that items held within cold holding were maintained at a temperature of 45 degrees F or below.

Findings include:

1. Observation on 3/15/19 revealed the temperature of 1 of 10 items checked at salad bar held for cold holding was above 45 degrees F. Hummus was determined to be 55-56 degrees F using an EXTECH pocket fold-up thermometer. It was observed that the level of ice used was below the level of the pan holding the hummus.

2. In an interview at time of observation, the chef stated that the mechanical refrigeration had proven to be inadequate.