HospitalInspections.org

Based on policy review, medical record review and staff interview the Critical Access Hospital (CAH) failed to ensure providers dated and timed all entries in the medical record when authenticated (signed) for 7 of 34 patient medical records reviewed (#'s 22, 24, 25, 26, 27, 28, and 29).

Findings include:

- Review of Health Information's policy, "Medical Record Entries" on 1/27/11 at 12:00pm directed, each entry in the medical record shall be authenticated (signed) by the person making the entry including date and time of the signature.

- Patient #22's medical record reviewed on 1/25/11 revealed an admit date of 1/17/11 to swing bed. Patient #22's medical record revealed between 1/17/11 to 1/24/11, eight telephone or verbal orders that lacked a date and time when authenticated (signed) by the provider.

- Patient #24's medical record reviewed on 1/25/11 revealed an admit date of 10/1/10 to swing bed. Patient #24's medical record revealed between 10/1/10 to 1/22/11, twenty five telephone or verbal orders that lacked a date and time when authenticated (signed) by the provider.

- Patient #25's closed medical record reviewed on 1/26/11 revealed an admit date of 10/10/10 to swing bed. Patient #25's medical record revealed between 10/10/10 to 10/12/10, four telephone or verbal orders that lacked a date and time when authenticated (signed) by the provider.

Staff A interviewed on 1/25/11 at 2:00pm acknowledged the CAH failed to ensure the providers dated and timed verbal and telephone orders when authenticated (signed).

Staff D interviewed on 1/26/11 at 2:45pm acknowledged the CAH failed to ensure the providers dated and timed verbal and telephone orders when authenticated (signed).

This deficient practice also affected patient (#'s 26, 27, 28, and 29) medical records reviewed.