HospitalInspections.org

Based on review of medical records (MR) and interview with staff, in 6 of 8 medicare patient (Pt) MR (1, 2, 3, 4, 5 and 9), out of a universe of 10, the facility failed to ensure the Medicare Notice of Their Rights (MNR) is provided to the pt within 48 hours after admission and/or 48 hours prior to discharge.

Findings include:

Pt #1's MR review by surveyor 18816 on 6/9/10 at 9:30 AM revealed Pt #1 was admitted on 4/24/10 and discharged on 4/29/10. There is no evidence in the MR a MNR was given to Pt #1 within 48 hours after admission. This is confirmed in interview with Quality Improvement Coordinator (QI) B on 6/9/10 at 3:30 PM.

Pt #2's MR review by surveyor 18816 on 6/9/10 at 12:00 PM revealed Pt #2 was admitted on 4/14/10 and discharged on 4/23/10. There is no evidence in the MR a MNR was given to Pt #2 within 48 hours of discharge. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #3's MR review by surveyor 18816 on 6/9/10 at 1:00 PM revealed Pt #3 was admitted on 5/22/10 and discharged on 5/26/10. There is no evidence in the MR a MNR was given to Pt #3 within 48 hours of after admission. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #4's MR review by surveyor 18816 on 6/9/10 at 1:35 PM revealed Pt #4 was admitted on 4/22/10 and discharged on 4/25/10. There is one MNR with no readable date. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #5's MR review by surveyor 18816 on 6/9/10 at 12:00 PM revealed Pt #5 was admitted on 3/1/10 and discharged on 3/26/10. There is no evidence in the MR a MNR was given to Pt # 5 within 48 hours of discharge. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 6/9/10 at 12:00 PM revealed Pt #9 was admitted on 5/22/10 and discharged on 5/25/10. There is no evidence in the MR a MNR was given to Pt #9 within 48 hours after admission. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Based on review of medical records (MR), review of policy and procedures, and interview with staff, in 3 of 10 MR (1, 5 and 10), out of a universe of 10, the facility failed to follow up on the patient's desire for an Advance Directive (AD).

Findings include:

Patient (Pt) #1's MR review by surveyor 18816 on 6/9/10 at 9:30 AM revealed Pt #1 was admitted on 4/24/10. Per the Clinical Profile History (CPH) completed by the Registered Nurse (RN) on 4/24/10, Pt #1 has no AD, and was referred to the Social Worker (SW) for assistance developing an AD. There is no evidence in the MR the AD was completed during Pt #1's hospital stay. This is confirmed in interview with Quality Improvement Coordinator (QI) B on 6/9/10 at 3:30 PM.

Pt 5's MR review by surveyor 18816 on 6/9/10 at 1:50 PM revealed Pt #5 was admitted on 3/1/10. Per the CPH completed by the RN on 3/1/10, Pt #5 has no AD, and was referred to the SW for assistance developing an AD. There is no evidence the AD was completed during Pt #5's hospital stay. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt 9's MR review by surveyor 18816 on 6/9/10 at 3:10 PM revealed Pt #9 was admitted on 5/21/10. Per the CPH completed by the RN on 5/21/10, Pt #9 has no AD, and was referred to the SW for assistance developing an AD. There is no evidence the AD was completed during Pt #9's hospital stay. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Based on review of medical records (MR), review of Medical Staff Rules and Regulations (R & R), and interview with staff, in 10 of 10 MR (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) the facility failed to ensure verbal (VO), standing (SO) and/or telephone (TO) orders are authenticated within 48 hours by the MD with a signature, date and time; in 8 of 10 MR (2, 4, 5, 6, 7, 8, 9 and 10) the facility failed to ensure all orders are written with a date and/or time per facility policy.

Findings include:

Facility Medical Staff R & R (n.d.) state under 6.2 d. "All orders must include the date and time the order was issued. e. Verbal or phone orders shall include the name of the Medical Staff Member issuing the order and shall be signed by the appropriately authorized individual who received and records the order. The responsible Medical Staff Member or his covering colleague shall date and authenticate all inpatient orders at the next encounter with the patient's chart, or within 48 hours, whichever is earlier. The authentication must include the date and time the order was signed."

Patient (Pt) #1's MR review by surveyor 18816 on 6/9/10 at 9:30 AM revealed there are VO written between 4/24/10 and 4/29/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #2's MR review by surveyor 18816 on 6/9/10 at 12:00 PM revealed there are VO written between 4/14/10 and 4/23/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 4/14/10 and 4/23/10 that are written without a time, per policy. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #3's MR review by surveyor 18816 on 6/9/10 at 1:00 PM revealed there are VO written between 5/22/10 and 5/26/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #4's MR review by surveyor 18816 on 6/9/10 at 1:35 PM revealed there are VO written between 4/22/10 and 4/25/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 4/14/10 and 4/23/10 that are written without a time, per policy. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #5's MR review by surveyor 18816 on 6/9/10 at 1:50 PM revealed there are VO written between 3/1/10 and 3/26/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 3/1/10 and 3/26/10 that are not signed dated and/or timed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #6's MR review by surveyor 18816 on 6/9/10 at 2:14 PM revealed there are VO written between 3/12/10 and 3/15/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There is a multiple page order form dated 3/12/10 that is no initialed and dated on each page when it was written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #7's MR review by surveyor 18816 on 6/9/10 at 2:30 PM revealed there are VO written between 3/24/10 and 3/25/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 3/24/10 and 3/25/10 that are not signed dated and/or timed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 6/9/10 at 2:40 PM revealed there are VO written between 5/8/10 and 5/25/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 5/8/10 and 5/25/10 that are not signed dated and/or timed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 6/9/10 at 2:55 PM revealed there are VO written between 5/22/10 and 5/25/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 5/22/10 and 5/25/10 that are not signed dated and/or timed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 6/9/10 at 3:10 PM revealed there are VO written between 5/21/10 and 5/25/10 that are not authenticated by the MD with a signature, date and time, and not authenticated within 48 hours per R & R. There are orders written between 5/21/10 and 5/25/10 that are not signed dated and/or timed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Based on review of medical records (MR), review of policy and procedures, and interview with staff, in 10 of 10 MR (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) the facility failed to ensure all progress notes are signed, dated and/or timed by the author.

Findings include:

Facility policy titled Medical Record Documentation, reviewed May 2009, states under F. 2. "Every entry in the medical record will be dated, timed and authenticated by the person making the entry."

Patient (Pt) #1's MR reviewed by surveyor 18816 on 6/9/10 at 9:30 AM revealed there are progress notes written between 4/24/10 and 4/29/10 that are not dated and/or signed when written. This is confirmed in interview with Quality Improvement Coordinator (QI) B on 6/9/10 at 3:30 PM.

Pt #2's MR reviewed by surveyor 18816 on 6/9/10 at 12:00 PM revealed there are progress notes written between 4/14/10 and 4/23/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #3's MR reviewed by surveyor 18816 on 6/9/10 at 1:00 PM revealed there are progress notes written between 5/22/10 and 5/26/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #4's MR reviewed by surveyor 18816 on 6/9/10 at 1:35 PM revealed there are progress notes written between 4/22/10 and 4/25/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #5's MR reviewed by surveyor 18816 on 6/9/10 at 1:50 PM revealed there are progress notes written by a Registered Nurse (RN) for the Medical Doctor (MD), between 3/1/10 and 3/26/10, are not dated and/or signed when written. These progress notes are not authenticated by the MD with a date and time. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #6's MR reviewed by surveyor 18816 on 6/9/10 at 2:14 PM revealed there are progress notes written between 3/12/10 and 3/15/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #7's MR reviewed by surveyor 18816 on 6/9/10 at 2:30 PM revealed there are progress notes written between 3/24/10 and 3/25/10 that are not dated and/or signed when written. This is confirmed in interview with QI Bon 6/9/10 at 3:30 PM.

Pt #8's MR reviewed by surveyor 18816 on 6/9/10 at 2:40 PM revealed there are progress notes written between 5/8/10 and 5/23/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #9's MR reviewed by surveyor 18816 on 6/9/10 at 2:55 PM revealed there are progress notes written between 5/22/10 and 5/25/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.

Pt #10's MR reviewed by surveyor 18816 on 6/9/10 at 3:10 PM revealed there are progress notes written between 5/21/10 and 5/25/10 that are not dated and/or signed when written. This is confirmed in interview with QI B on 6/9/10 at 3:30 PM.