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Based on review of medical records, medical staff bylaws, medical record quality review data and staff interviews the facility failed to have medical record entries for 5 of 60 sampled records (Records 1, 5, 6, 9 and 10) dated and/or timed. Total sample size was 60. Inpatient census was 165. Findings are:

A. Record review of the following records revealed a lack of time or date with the entry:
- Record review on 6/28/10 of Patient 1's Medical Record revealed Physician Orders written on 6/22/10 and 6/18/10 were not timed. Staff interview with Registered Nurse (RN)-A on 6/28 at 5:00 PM confirmed this finding.
- Record review on 6/21/10 of Patient 5's Medical Record revealed Physician Orders post-cardiac catheterization were noted by nursing on 6/11/10. The physician did not date or time the orders. Physician Orders written 6/13/10 are not timed. Staff interview with the Director of Nursing (DON) on 6/21/10 at 4:10 PM confirmed this finding.
- Record review on 6/23/10 of Patient 6's Medical Record revealed the Physician Operative Report handwritten in in Progress Notes and Physician Orders dated 6/21/10 were not timed. Staff interview with the DON 6/23/10 at 10:40 AM confirmed this finding.
- Record review on 6/22/10 of Patient 9's Medical Record revealed Physician Orders dated 6/18/10 were not timed. These findings were confirmed by the DON on 6/22/10 at 11:50 AM.
- Record review on 6/22/10 of Patient 10's Medical Record revealed the Surgical Consent for a Peripherally Inserted Central Catheter (PICC) signed by the patient's family and witnessed by the RN were not timed or dated. The record shows a PICC line was inserted on 6/21/10. This finding was confirmed by RN-B on 6/22/10 at 2:35 PM.

B. Record review of facility Medical Staff Rules and Regulations last revised 6/17/10 state under the title "Medical Records" states "All entries in the medical record made by members of the Medical/Dental Staff will be legible, dated and timed."

C. Record review of Medical Records Quality focused review dated May of 2010 identified 95% compliance with "All medical record entries are dated" and 76% compliance with "All medical record entries are timed".

Based on review of medical records, medical staff bylaws, medical record quality review data and staff interview the facility failed to have physician orders dated or timed for 4 of 60 sampled records (Records 1, 5, 6 and 9). Total sample size was 60. Inpatient census was 165. Findings are:

A. Record review of Physician Orders revealed the following medical records lacked either the date or time physician orders were written:
- Record review on 6/28/10 of Patient 1's Medical Record revealed Physician Orders written on 6/22/10 and 6/18/10 were not timed. Staff interview with Registered Nurse (RN)-A on 6/28 at 5:00 PM confirmed this finding.
- Record review on 6/21/10 of Patient 5's Medical Record revealed Physician Orders post cardiac catheterization were noted by nursing on 6/11/10. The physician did not date or time the orders. Physician Orders written 6/13/10 are not timed. Staff interview with the Director of Nursing (DON) on 6/21/10 at 4:10 PM confirmed this finding.
- Record review on 6/23/10 of Patient 6's Medical Record revealed Physician Orders dated 6/21/10 were not timed. Staff interview with the DON 6/23/10 at 10:40 AM confirmed this finding.
- Record review on 6/22/10 of Patient 9's Medical Record revealed Physician Orders dated 6/18/10 were not timed. These findings were confirmed by the DON on 6/22/10 at 11:50 AM.

B. Record review of facility Medical Staff Rules and Regulations last revised 6/17/10 state under the title "Medical Records" states "All entries in the medical record made by members of the Medical/Dental Staff will be legible, dated and timed."

C. Record review of Medical Records quality focused reviews dated May of 2010 identified 95% compliance with "All medical record entries are dated" and 76% compliance with "All medical record entries are timed".

Based on record review, staff interview, review of Medical Staff Rules and Regulations and Medical records Quality data the facility failed to ensure 5 of 60 sampled medical records had verbal Telephone Orders authenticated by the practitioner within 48 hours (Patients 3, 4, 7, 8 and 9). The total sample was 60. The census was 165. Findings are:

A. Record review on 6/21/10 of the Medical Record for Patient 3 revealed Telephone Orders taken on 6/8, 6/9 and 6/10/10 were not authenticated by the practitioner. Staff interview with Registered Nurse (RN)-C on 6/21/10 at 11:10 AM confirmed this finding.

B. Record review on 6/21/10 of the Medical Record for Patient 4 revealed Telephone Orders taken on 6/17 and 6/18/10 were not authenticated by the practitioner. Staff interview with RN-C on 6/21/10 at 1:10 PM confirmed this finding.

C. Record review on 6/24/10 of the Medical Record for Patient 7 revealed Telephone Orders taken on 6/18 and 6/19/10 were not authenticated by the practitioner. Staff interview with the Director of Nursing (DON) 6/24/10 at 2:45 PM confirmed this finding.

D. Record review on 6/24/10 of the Medical Record for Patient 8 revealed Telephone Orders taken on 5/15/10 at 3:15 PM were not authenticated until 5/20/10 at 7:30 PM. This exceeded the 48 hour time frame. Staff interview on 6/24/10 at 11:20 AM with RN-A confirmed this finding.

E. Record review on 6/22/10 of the Medical Record for Patient 9 revealed Telephone Orders taken on 6/18/10 were not authenticated by the practitioner. Staff interview on 6/22/10 at 11:50 AM with the DON confirmed this finding.

F. Review of the facility Medical Staff Rules and Regulations last revised 6/17/10 stated under the section titled "Orders" that "Telephone or verbal orders must be authenticated with a date and time within 48 hours by the medical practitioner who is responsible for ordering, providing, or evaluating the service furnished."

G. Record review of May 2010 Medical Records Quality review data titled "All verbal orders are dated, timed and signed within 48 hours" documented a 53% compliance rate when 367 charts were reviewed.

Based on observation and interview, the facility failed to meet Life Safety Code regulations and placed patients, staff and visitors at risk when it failed to comply with the 2000 Edition of the Life Safety Code of the National Fire Protection Association (NFPA) existing and new regulations at 42 CFR 482.41. The Condition of Participation is not met based on the facility failure to comply with these regulations which created a higher potential for fire to spread within the facility. The hospital has a licensed capacity of 356 and a patient census of 165.

Findings include:

1. Based on observation and interview, the facility failed to maintain the building construction type of the facility by not providing fire resistant insulation to cover the steel beams that support the steel deck assembly in accordance with NFPA 101, Life Safety Code. See findings at K012 of the Life Safety Code Survey.

2. Based on observation and interview, the facility failed to have a fire alarm system with the approved components, devices, or equipment installed in accordance with NFPA 72, National Fire Alarm Code. See findings at K051 of the Life Safety Code Survey.

3. Based on observation and interview, the facility failed to have an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. See findings at K056 of the Life Safety Code survey.

4. Based on observation and interview, the facility failed to maintain the Type I essential electrical system requirements installed in accordance with NFPA 99, Standard for Health Care Facilities. See findings at K145 of the Life Safety Code survey.