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Based on active and closed patient record reviews and staff interviews, the hospital failed to ensure that 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. Signatures with dates and times validate that the conditions provided by the hospital are agreed upon prior to care, whenever possible. Timing establishes when an activity happened or when an activity is to take place. Timing and dating of entries also establishes a timeline of events and is necessary for patient safety and quality of care. For 20 of 20 patient medical records reviewed, the admission consent form did not have the time listed on the form. In addition, 13 of 20 patient medical records did not either have the patient and/or witness signatures, and/or dates and times documented on the discharge instructions.

Findings include:

On 8/23/13, the SA's clinical record reviews found that for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20, the "Consent To And Conditions Of Treatment And Payment Agreement" (admission consent form) did not have the time listed on the form. Although there were signatures and dates on the admission consent forms, the time entries were all missing.

Also, the record reviews for Patients #3, 4, 5, 6, 8, 10, 11, 12, 13, 14, 15, 16 and 17 found these patients' records did not have the date and time documented next to the patient and/or staff signatures on the emergency department (ED) discharge instruction form.

The facility's electronic medical record (EMR) system was implemented in February 2013. During interviews conducted with the ED Nurse Manager and Chief Nurse Executive (CNE) on 8/23/13, they confirmed the clinical record entries should have the date and time documented on the forms to ensure completeness of each patient's record. The ED Nurse Manager said she would be educating the ED staff on this. In addition, it was revealed with the inception of the hospital wide EMR, the corporate office selected the current admission consent form which omitted the "Time" and only had the signature and date for the patient and witness to sign/complete. The CNE, a clerical staff and the Health Information Management Director verified the absence of the time on the admission consent form. A new form was to be implemented that included the time on the admission consent form.

Based on active and closed patient record reviews, staff interviews and review of the facility's policies and procedures, the hospital failed to ensure that there is appropriate documentation in the patient's treatment record which included information necessary to monitor the patient's condition, such as the pain assessment level and the discharge vital signs for 4 of 20 patient medical records.

Findings include:

1. A review of Patient #1's ED record revealed the ED physician's record entry was incomplete on the T sheet for low back pain/injury for the severity of pain (i.e., mild, moderate, severe (1/10)). On 8/22/13 at 12:00 P.M., during an interview with Physician #1, who was the ED attending physician for the patient's 7/1/13 visit, he stated he missed documenting the pain level on the T sheet, which he said he normally did. A review of Patient #3's ED record revealed that Physician #1 also failed to document the severity of pain for this patient's 7/10/13 visit.

2. A review of Patient #1's and Patient #3's record found the patients' initial pain levels were noted as a 10 on the vital signs report entered by licensed staff. However, the vital signs at discharge for both patients were incomplete. On 8/21/13 at 11:15 A.M., the ED Nurse Manager stated with the implementation of the EMR, it has been a challenge for all the ED staff to know where certain fields resided to ensure clinical documentation was accurately recorded. She stated however, "it's no excuse." Later at 3:30 P.M., the ED Nurse Manager stated with their EMR, the pain assessment resided in the Medication Administration Check (MAC), but that it was not easy to access within the EMR. She related this was an issue which their corporate office still needed to address. The SA also did not have read only access to the MAC during record reviews and had to rely on the availability of the ED Nurse Manager to view this information.

3. On 8/23/13 at approximately 10:30 A.M., during a concurrent record review with the ED Nurse Manager, she acknowledged the vital signs at discharge was missing for Patient #10. In addition, the ED Nurse Manager confirmed that for Patient #17, who came into the ED on 6/30/13 for lower back pain related to a motor vehicle accident, lacked an initial pain assessment that included the level/intensity of pain at triage. The CNE also acknowledged this and verified all licensed staff were to follow the facility's policy and procedure for pain assessment. The facility's policies and procedures stated: 1) "Pain Assessment & Management Documentation" (Policy No. PC 300.3) - Purpose: 1. To accurately document the assessment and management of the patient's pain on admission and throughout the patient's hospital stay. 2. To provide information that enhances continuity of care in achieving an acceptable level of pain control for the patient. Policies: 1. All patients will be assessed for pain on admission using an appropriate pain intensity scale for patient throughout hospital stay;" and 2) "Pain Assessment & Management Principles" (Policy No. PC 300.4) - Purpose: To provide patients with appropriate and timely assessment and management of their pain. Policy: 1. Licensed staff will include pain assessment during the patient admission and throughout the patient's hospitalization. 2. All licensed personnel will assess pain by using a pain intensity scale appropriate for the patient's age, mental status, language skill, etc."