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Based on review of Medical Staff Rules and Regulations and review of medical records, the facility failed to ensure that six (6) of 28 patient's medical records reviewed contained a history and physical examination documented within 24 hours of admission.

Findings include:

Review of the facility's Medical Staff Rules and Regulations revealed that a history and physical examination was required to be documented within 24 hours of admission.

Five (5) medical records discharged from 02-18-11 through 02-22-11, 18 medical records discharged from the last six (6) months, and five (5) inpatient medical records were reviewed for a total of 28 records reviewed.

Six (6) of the 28 medical records reviewed had no documented evidence that the history and physical examination had been documented within 24 hours of admission.

Based on review of Medical Staff Rules and Regulations and review of medical records, the facility failed to ensure that six (6) of 28 medical records reviewed did not have progress notes documented on a daily basis.

Findings include:

Review of the facility's Medical Staff Rules and Regulations revealed that progress notes were required to be written daily.

Five (5) medical records discharged from 02-18-11 through 02-22-11, 18 medical records discharged from the last six (6) months, and five (5) inpatient medical records were reviewed for a total of 28 records.

On six (6) of the medical records reviewed, progress notes were either absent from the medical records or had not been written on a daily basis.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that 11 of 28 records reviewed had physician orders that had been timed when entered into the medical record.

Findings include:

Five (5) medical records discharged from 02-18-11 through 02-22-11, 18 medical records discharged from the last six (6) months, and five (5) inpatient medical records were reviewed, for a total of 28 records.

On 11 of the medical records reviewed, all physician orders had not been timed when entered into the medical record. This included verbal orders taken by a nurse, and orders written by a physician.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that six (6) of six (6) patient's pre-anesthesia evaluations were timed when they were performed.

Findings include:

Record review revealed that on six (6) of the surgery records reviewed, the pre-anesthesia evaluation had not been timed when it was performed.