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Based on record review and interview, staff failed to ensure that the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 1 out of 6 (Patient #13) Medicare eligible medical records reviewed out of a total of 24, and failed to document whether patients have advanced directives, or would like information on advanced directives, in 4 of 4 surgical outpatient records reviewed (Patient 1, 2, 3, and 4). .

Findings include:

Review of policy "Important Message from Medicare (IMM)" #2821330, review date 9/21/2016 revealed, "Hospitals must issue the Important Message for Medicare (IM or IMM) within two (2) days of admission and must obtain the signature of the beneficiary or his/her representative. Hospitals must also deliver a copy of the signed notice to each beneficiary not more than two (2) days before the day of discharge. Follow-up notice is not required if delivery of the initial IM falls within two (2) calendar days of discharge, if the beneficiary is being transferred from one inpatient setting to another inpatient hospital setting or when a beneficiary exhausts Part A hospital days. Hospital must retain a copy of the signed notice."

Per interview with Registered Nurse Case Manager G on 7/9/2018 at 2:20 PM regarding obtaining the Medicare discharge appeal notice, Case Manager G stated that registration staff obtain a signed copy upon admission and that it is case management's responsibility to obtain a second signed copy if the patient stays more than 48 hours. Case Manager G stated that if G is not available, then the second signed copy is to be obtained by nursing staff.

Review of Patient #13's medical record on 7/10/2018 at 12:00 PM revealed an admission date of 4/11/2018 and was discharged on 4/15/2018. Patient #13 received the first IMM on 4/12/2018, a second IMM was not given.

Interview on 7/11/2018 at 10:45 AM, Quality Improvement Specialist H stated, "It has been hard to catch patients for the second notice for the Important Message for Medicare, discharge planning moves fast. We need to clarify roles as to who is responsible to make sure the patient receives the second notice."

Interview on 7/11/2018 at 12:15 AM, Director of Nursing A stated , "Case Management is responsible to issue the IMM's, however they are not here everyday."


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The facility's policy titled, "Advance Care planning and Advance Directives," #2658603, dated 1/3/2017 revealed in part, "Initiating advance care planning discussion should be considered at any of the following times: 1. Outpatient or ambulatory care procedures..."

Patient #1's closed surgical outpatient medical record was reviewed on 7/10/2018 at 11:33 AM accompanied by Surgical Nurse D who confirmed the following: Patient #1 was a 60 year old who had a joint injection for pain on 4/9/2018. There was no documentation in Patient #1's record regarding if Patient #1 had an advanced directive, or if not, if Patient #1 would like information on them.

Per interview with Nurse D on 7/10/2018 at 11:53 AM regarding where information about advanced directives can be found in surgical patient medical records, Nurse D stated, "I don't think we ask them about that."

Patient #2's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:06 PM accompanied by Surgical Nurse D who confirmed the following: Patient #2 was a 92 year old who had cataract surgery on 5/8/2018. There was no documentation in Patient #2's record regarding if Patient #2 had an advanced directive, or if not, if Patient #2 would like information on them.

Patient #3's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:27 PM accompanied by Surgical Nurse D who confirmed the following: Patient #3 was a 82 year old who had a colonoscopy and esophagogastroduodenoscopy (EGD, a scope is aseptically guided down the throat to look into the esophagus and other organs) on 6/27/2018. There was no documentation in Patient #3's record regarding if Patient #3 had an advanced directive, or if not, if Patient #2 would like information on them.

Patient #4's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:47 PM accompanied by Surgical Nurse D who confirmed the following: Patient #4 was a 74 year old who had a bladder scope and procedure on 6/28/2018. There was no documentation in Patient #4's record regarding if Patient #2 had an advanced directive, or if not, if Patient #4 would like information on them.

Based on observation, record review and staff interviews, Ascension Eagle River Hospital failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space

Based on observation and interview, staff failed to ensure that equipment that is unusable is identifiable and removed from service in 1 of 1 cafeteria and that wall integrity is maintained in 3 of 8 patient care departments (operating room, post-anesthesia care area, inpatient area).

Findings include:

Cafeteria:
An observation of two coolers was made in the cafeteria with Food Service Supervisor E, Food Service Manager F, and Director of Nursing A on 7/9/2018 at 2:00 PM. Supervisor E stated that one of the coolers was non-functional and was, "Just there for parts because there is no where else to put it." The non-functional cooler was not labeled for being out of service. When asked how staff would know it was non-functional Supervisor E replied, "There are only two of them. They know." There was no identifiable information on the cooler to indicate it was non-functional.

Surgical Suite:
A tour of the surgical suite was conducted on 7/11/2018 between 8:25 AM and 8:35 AM accompanied by Quality Manager C who confirmed the following observations:

At 8:25 AM on 7/11/2018 some of the walls in the operating room were observed to have chipped and missing paint in several areas causing the surface of the walls in those areas to be rough/not smooth.

At 8:35 AM on 7/11/2018 some of the walls in the Phase I recovery room were observed to have chipped and missing paint in several areas causing the surface of the walls in those areas to be rough/not smooth.


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Inpatient Area:
A tour of the inpatient area was conducted on 7/9/2018 between 12:00 PM and 1:00 PM accompanied by Quality Manager C who confirmed the following observations:

At 12:30 PM on 7/9/2018 walls in room 112, 120, and 109 were observed to have chipped and missing paint in several areas causing the surface of the walls in those areas to be rough/not smooth.

Based on observation, record reviews and staff interviews, Ascension Eagle River Hospital failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.


Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0321 - Hazardous Areas
K-0345 - Fire Alarm - Testing And Maintenance
K-0353 - Sprinkler System - Maintenance And Testing
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space

Based on record review, observation, and interview the facility failed to ensure that expired medications are not available for patient use in 1 of 8 areas observed (Inpatient Unit), and failed to label and secure medications used for sedation in 1 of 1 outpatient procedure observed (Patient #21).

Findings include:

Review on 7/11/2018 at 7:00 AM of policy, "Medication Administration" #3763551, dated 11/30/2017 revealed, 2. Before administering a medication, authorized personnel will: b. Verify that the medication is stable based on visual examination for particulates or discoloration and that the medication has not expired. If the medication is expired, the medication will not be administered and will be returned to the pharmacy."

On 7/9/2018 at 12:50 PM observed the code cart to have 3 bags of 5% Dextrose intravenous fluid with expiration date of 3/2018, and 6/2018.

During an interview on 7/10/2018 at 1:00 PM, Pharmacist T stated "Central Supply is responsible to remove expired supplies from the code cart every month and replace the supplies."


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The facility policy titled, "Medication Administration," #3763551, dated 11/30/2017, was reviewed on 7/11/2018 at 7:55 AM. The policy revealed in part, "4. Labeling Medications a. Medications will be labeled when: ...3. The preparer will not be administering the medication directly after preparing it."

The facility policy titled, "Preparation of Sterile Medications and Fluids-Sterile Products Compounding, MM-49 [unknown abbreviation]." #2731167, dated 2/22/2017, was reviewed on 7/11/2018 at 11:56 AM. The policy revealed in part, "10. ...Single Dose Vials shall be used within 1 hour if opened in worse than ISO [International Organization for Standardization] Class 5 air quality and any remaining contents must be discarded."

On 7/11/2018 at 9:15 AM Certified Registered Nurse J was observed removing a pre-filled syringe of propofol from a drawer in the anesthesia cart. This syringe was not labeled for content, time, date, or initials of who prepared the medication. Nurse J then attached the propofol syringe to Patient #21's intravenous line, removed another pre-filled syringe full of propofol and placed it on Nurse J's work area. This syringe was also not labeled.

At 9:20 AM Nurse J returned the second, unused, syringe to the same drawer in the anesthesia cart, and 9:28 AM left the procedure room without securing the cart. The surgical technician remained in the procedure room cleaning and setting up for the next procedure.

At 9:30 AM, upon opening the drawer of the anesthesia cart with the propofol syringe, two opened, undated, single use vials of Xylocaine 2% were observed. The Xylocaine was opened sometime prior to Patient #21 entering the procedure room and was not used for Patient #21.

These observations were discussed with and confirmed per interview by Quality Manager C on 7/11/2018 at 9:50 AM. Manager C stated, "It is not policy to not mark syringes with medication in them."

Based on observation, record review and interview, staff failed to follow policy for hand hygiene/glove use for 2 of 2 surgical procedure patients observed (Patient #20 and 21) and 1 of 1 insulin administration procedure (Patient #12), and failed to complete annual tuberculosis questionnaire for 2 of 11 non-credentialed staff (Certified Nursing Assistant N and Registered Nurse O) and 1 of 4 credentialed staff (Doctor P) personnel records reviewed.

Findings include:

Per interview on 7/10/2018 at 8:06 AM with Infection Preventionist V regarding national standards of practice for hand hygiene and glove use, Infection Preventionist V stated, "APIC (Association for Professionals in Epidemiology and Infection Control), CDC (Centers for Disease Control), and WHO (World Health Organization)."

The facility policy titled, "Hand Hygiene and Gloving Practice, AW [organization identification]," #3666900, dated 7/17/2017, was reviewed on 7/11/2018 at 7:00 AM. The policy revealed in part, "B. Hand Hygiene is required: 1. Hand Hygiene is done according to the WHO (World Health Organization) 5 Moments Before having direct contact with patients-Moment 1; Before clean and aseptic procedures-Moment 2; After body fluid exposure risk-Moment 3; After touching the patient-Moment 4; After touching the patients' environment and surroundings-Moment 5...2. Hand Hygiene must be performed in all 5 moments regardless of glove usage...Therefore, hands are to be washed properly, or a hand sanitizer is to be applied before gloves are donned and after they are removed."

Observation on 7/10/2018 at 7:32 AM of Registered Nurse I administering medication for Patient #12, Registered Nurse I was scanning medication in patient room prior to administering. Registered Nurse I dropped the insulin syringe on the floor , Registered Nurse I picked the syringe off the floor and continued scanning medication for administration. Registered Nurse I administered oral mediation medication, dropped insulin syringe on the floor again, picked up the syringe from the floor and then administered insulin without use of gloves. Registered Nurse I left patient room, completed hand hygiene, returned to medication room to obtain more medication and returned to the patient room without completing hand hygiene prior to administering medication.

On 7/11/2018 at 8:55 AM Registered Nurse K was observed placing an intravenous line in Patient #20's right hand in preparation for an out patient procedure. After performing hand hygiene and applying gloves Nurse K handled intravenous supplies, the bedrail of Patient #20's cot, removed the tourniquet and handled the bedrail again, re-applied the tourniquet, cleansed the insertion site, inserted the intravenous needle/catheter which infiltrated (was not in the vein). Nurse K then removed the catheter, held pressure on the failed site with gauze, handled Patient #20's bare skin several times, then after obtaining more supplies from another nurse in the room, went to Patient #20's left hand and repeated the process of the intravenous needle insertion. Nurse K did not change gloves at any point during this procedure until after the second intravenous attempt, which was successful.

Then Nurse K removed gloves, applied Patient #20's identification band, left the room and performed hand hygiene at the sink, shutting off the faucet with clean hands, thereby potentially re-contaminating Nurse K's hands.

These observations were discussed per interview with Quality Manager C on 7/11/2018 at 9:02 AM. Manager C stated, "I thought there were some missed opportunities there."

Observations in the outpatient procedure room on 7/11/2018 were made with Quality Manager C present, who confirmed the following observations:
At 9:22 AM Certified Registered Nurse Anesthetist J was observed removing one glove after having assisted to hold Patient #21 during an esophagogastroduodenoscopy (EGD, a scope is aseptically guided down the throat to look into the esophagus and other organs). Without performing hand hygiene Nurse J then documented on the anesthesia record. At 9:23 AM Nurse J removed the other glove and continued documenting without performing hand hygiene.

At 9:25 AM, Nurse J was observed removing another pair of gloves, handled Patient #21's skin, cart, and blankets, and removed monitor patches, and left the procedure room with Patient #21 without performing hand hygiene.

Interview on 7/11/2018 at 11:30 AM, Director of Nursing A stated, "Staff should be wearing gloves when providing care that may potentially expose patients to body fluids. Gloves should be worn when administering medications and hand hygiene is completed when entering and leaving the patient room", and "Medication should never be administered to the patient if it falls on the floor".


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The facility policy titled, "Tuberculosis (TB) Control Program Policy, AW," #4834404, dated 4/16/2018, was reviewed on 7/11/2018 at 7:20 AM. The policy revealed in part, "Associates and licensed independent practitioners (LIPs) [credentialed staff] must complete an annual TB Risk Questionnaire and return it to the department specified by each Organization for assessment."

Review of credential files on 7/10/2018 at 9:25 AM revealed that Doctor P did not complete an annual tuberculosis questionnaire since 10/2016. Per interview with Medical Staff Coordinator L on 7/10/2018 at 10:00 AM regarding the missing questionnaire, Coordinator L stated that there was not one in the file for 2017.

Review of personnel files on 7/11/2018 at 8:00 AM revealed Certified Nursing Assistant N and Registered Nurse O did not complete annual tuberculosis questionnaire since 2016.

During an interview on 7/11/2018 at 8:26 AM, Human resource Advisor U stated, "All staff are required to complete tuberculosis questionnaire annually, but it looks like these staff [Certified Nursing Assistant N and Registered Nurse O] were missed in 2017.

Based on record review and interview, staff failed to ensure there were physician orders for medications in 1 of 1 medical record for intravenous conscious sedation out of a total of 4 surgical medical records reviewed (Patient #3).

Findings include:

Patient #3's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:06 PM accompanied by Surgical Nurse D who confirmed the following: Patient #3 was a 82 year old who had intravenous conscious sedation (IVCS) with Versed and Fentanyl (drugs used for sedation during surgical procedures) for a colonoscopy and esophagogastroduodenoscopy (EGD, a scope is aseptically guided down the throat to look into the esophagus and other organs) on 6/27/2018.

The physician order sheet revealed, "5.a. During procedure give: Titration for IVCS Versed_____; Fentanyl_____." There was no dose information provided by the physician for either medication.

The moderate sedation record in Patient #3's electronic health record revealed that Nurse D gave a total of 6 milligrams of Versed and 50 micrograms of Fentanyl during the procedure. Per interview with Nurse D on 7/10/2018 at 12:35 PM regarding where medication dose information comes from if there is no specification in the written orders, Nurse D stated, "[Gender] verbally says 'give this amount' and I give it."

The facility policy titled, "Moderate Sedation," #2416694, dated 10/1/2011, was reviewed on 7/11/2018 at 7:24 AM. The policy revealed in part, "12. Medication a. A physician selects and orders the medication and is present during administration."

Based on record review and interview the staff failed to individualize care plans for 11 of 11 inpatient (Patient #5, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) records reviewed in a total of 24.

Findings include:

Review of policy "Assessment and Reassessment" #1815819, review date 8/31/2016 revealed, "Care planning I. An individualized care plan of care is initiated by the RN within 8 hours of admission."

Patient #5's closed inpatient medical record was reviewed on 7/10/2018 at 1:37 PM accompanied by Quality Manager C who confirmed the following: Patient #5 was admitted with shortness of breath and chronic obstructive pulmonary disease on 7/1/2018 and was discharged on 7/4/2018. Patient #5 has a goal on the nursing care plan which revealed, "Pt [patient] will maintain optimal cardiovascular function." There were no interventions identifying how cardiovascular function would be maintained, or what "optimal" would be for Patient #5.

Per review on 7/10/218 at 8:15 AM, Patient #10's was admitted following alcohol intoxication, alcohol detox, and mouth cancer with g-tube placement. The care plan does not include a problem addressing alcohol intoxication, alcohol detox, or potential for alteration in nutrition.

Per review on 7/10/218 at 10:00 AM, Patient #11's was admitted following syncopal episode due to symptomatic anemia and weakness. The care plan stated, "At risk for falls", there were no goals or interventions listed to prevent falls. The care plan does not address anemia.

Per review on 7/10/218 at 10:19 AM, Patient #12's was admitted following an episode of chest pain. Patient #12 has a goal on the nursing care plan which revealed, "Pt [patient] will maintain optimal cardiovascular function." There were no interventions identifying how cardiovascular function would be maintained, or what "optimal" would be for Patient #12.

Per review on 7/10/218 at 12:00 PM, Patient #13's was admitted due to cellulitis. Patient #13 has a goal on the nursing care plan which revealed, "Impaired tissue integrity". There were no interventions or goals addressing impaired tissue integrity.

Per review on 7/10/218 at 12:30 PM, Patient #14 was admitted for Diabetic Ketoacidosis and a history of aortic stenosis status post aortic valve replacement. Patient #14 has a goal on the nursing care plan which revealed, "Pt [patient] will maintain optimal cardiovascular function." There were no interventions identifying how cardiovascular function would be maintained, or what "optimal" would be for Patient #14.

Per review on 7/10/218 at 12:40 PM, Patient #15 was admitted for possible hypoglycemia episode and alcohol intoxication and detox. The care plan does not include a problem addressing alcohol intoxication/alcohol detox.

Per review on 7/10/218 at 1:30 PM, Patient #16 was admitted due to ongoing wound care with wound vac to right side of neck and right forearm wound. Patient #16 has a goal on the nursing care plan which revealed, "Alteration in skin integrity, skin is intact or integrity improved". There were no interventions or goals addressing wounds on neck or right forearm on the care plan.

Per review on 7/10/218 at 2:10 PM, Patient #17 was admitted for cellulitis, urinary tract infection and congestive heart failure. Patient #17 has a goal on the nursing care plan which revealed, "Pt [patient] will maintain optimal cardiovascular function." There were no interventions identifying how cardiovascular function would be maintained, or what "optimal" would be for Patient #17. Problem on care plan stated, "Alteration in skin integrity", there are no interventions or goals noted.

Per review on 7/11/218 at 9:45 AM, Patient #18 was admitted for complaint of weakness and dizziness. Patient #18 has a diagnosis of congestive heart failure. Patient #18 has a goal on the nursing care plan which revealed, "Pt [patient] will maintain optimal cardiovascular function." There were no interventions identifying how cardiovascular function would be maintained, or what "optimal" would be for Patient #18.

Per review on 7/11/218 at 10:10 AM, Patient #19 was admitted for complaint of low back pain following a fall. There were no problems, interventions, or goals addressing pain.

Interview on 7/11/2018 at 11:20 AM, Director of Nursing A stated, "The care plans should be individualized, the staff have the opportunity to individualize by deleting, changing, or free texting problems, goals, or interventions. I would like to see the staff improve with individualizing care plans for patients."





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Based on record review, observation, and interview, the staff failed to ensure patient's right to privacy of health information for 1 of 1 patient (Patient #27).

Findings include:

Review on 7/11/2018 at 7:00 AM of policy titled, "Patient Privacy Program" #4119169, dated 10/4/2017 revealed, "4. Confidential Information, regardless of the medium, shall be restricted through administrative (e.g. policies and procedures), technical (e.g. unique user ID's, passwords, ID badges, etc.), and physical safeguards (e.g. restricted spaces, data centers, etc.).

Per tour on 7/9/2018 at 12:51 PM of unlocked room labeled "Solarium", Manager of Quality C stated, "The room can be used by guests, patients, and staff. The room has multiple uses, at times the Nurse Practitioners will sit at the desk and dictate patient information, telemedicine is completed in the room, and patient and guests are welcome to use the room." Observed medical information including plan of care for patient #27. Manager of Quality C stated, "Patient information should not be left in this room lying on the desk."

Based on record review and interview, staff failed to ensure that medical records contain all required elements and are completed timely and accurately in 4 out of 24 medical records reviewed (Patient #1, 2, 3, and 5).

Findings include:

The Medical Staff Rules and Regulations, dated 8/4/2017, were reviewed on 7/10/2018 at 7:30 AM. Regarding discharge orders for outpatient/ambulatory patients the rules and regulations revealed, "On discharge. To be completed prior to a follow up appointment but no later than 7 days after discharge. Legible signed, dated and timed order/summary..."

Regarding chart completion the rules and regulations revealed, "Each medical record shall be completed within thrifty (30) days following discharge of the patient."

Patient #1's closed surgical outpatient medical record was reviewed on 7/10/2018 at 11:33 AM accompanied by Surgical Nurse D who confirmed the following: Patient #1 was a 60 year old who had a joint injection for pain on 4/9/2018. There was no discharge order from the physician. Per interview with Nurse D on 7/10/2018 at 11:45 PM regarding the discharge order, Nurse D stated, "There is no order. [Gender] tells me [gender] plan and I write it."

Patient #2's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:06 PM accompanied by Surgical Nurse D who confirmed the following: Patient #2 was a 92 year old who had cataract surgery on 5/8/2018. The anesthesia record had time entries that contained write overs of the times making it difficult to determine what the correct time of anesthesia start and stop times were to be. The physician's dictated operation report was not signed until 6/12/2018, more than 30 days after the procedure.

Patient #3's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:27 PM accompanied by Surgical Nurse D who confirmed the following: Patient #3 was a 82 year old who had a colonoscopy and esophagogastroduodenoscopy (EGD, a scope is aseptically guided down the throat to look into the esophagus and other organs) on 6/27/2018. There were no discharge orders from the physician. Per interview with Nurse D on 7/10/2018 at 12:37 PM regarding discharge orders, Nurse D stated, "I don't think [gender] has discharge orders."

Patient #5's closed inpatient medical record was reviewed on 7/10/2018 at 1:37 PM accompanied by Quality Manager C. Patient #5 was admitted with shortness of breath and chronic obstructive pulmonary disease on 7/1/2018 and was discharged on 7/4/2018. There was no discharge planning evaluation completed for Patient #5. Per interview with case manager/discharge planner G on 7/11/2018 regarding the discharge planning evaluation for this patient, case manager G stated, "When I'm here I put the date and time of the evaluation and where the patient is going. If I'm not here, then nursing does it. But it [the evaluation] is not here."

Based on record review and interview, staff failed to ensure that the history and physical was current within 30 days of a surgical procedure in 1 of 4 surgical medical records reviewed (Patient #4).

Findings include:

The Medical Staff Rules and Regulations, dated 8/4/2017, were reviewed on 7/10/2018 at 7:30 AM. Regarding history and physicals the rules and regulations revealed, "A dictated H&P [history and physical] or legible handwritten H&P form must be completed and documented and placed in the patient's record no more than 30 days before or 24 hours after admission/registration but prior to surgery or procedure requiring anesthesia services (MAC [monitored anesthesia care], regional or general anesthesia)."

Patient #4's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:47 PM accompanied by Surgical Nurse D who confirmed the following: Patient #4 was a 74 year old who had a bladder scope procedure on 6/28/2018. The history and physical in the medical record was dated 11/30/2017. The same day history and physical form was incomplete and did not contain an updated comprehensive examination.

Per interview with Nurse D on 7/10/2018 at 1:00 PM regarding if the history and physical dated for November was the one used for the June procedure, Nurse D stated that it "must have been," and that the same day form should have been completed.

Based on record review and interview, staff failed to ensure that all medical record entries, forms, and reports are authenticated with signature, date, and/or time in 6 out of 24 medical records reviewed (Patient #1, 2, 10, 13, 14, and 15).

Findings include:

Review of policy "Informed Consent", #4803522, last review date 4/5/2018 revealed, "C. Permit: The permit must contain the following elements: 6. Date and time the permit is signed by the patient."

Per interview with Regional Health Information Management Supervisor W on 7/10/2018 at 10:55 AM regarding expectations for medical record entry authentication, Supervisor W stated that providers are expected to date, time, and sign all entries and all other disciplines are also expected to date, time and sign entries.

Patient #1's closed surgical outpatient medical record was reviewed on 7/10/2018 at 11:33 AM accompanied by Surgical Nurse D who confirmed the following: Patient #1 was a 60 year old who had a joint injection for pain on 4/9/2018. The consent for treatment form did not have a time the form was signed.

Patient #2's closed surgical outpatient medical record was reviewed on 7/10/2018 at 12:06 PM accompanied by Surgical Nurse D who confirmed the following: Patient #2 was a 92 year old who had cataract surgery on 5/8/2018. The discharge order from the physician did not include a date or time it was signed.


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Review on 7/10/2018 at 8:15 AM of Patient #10's medical record, the General Consent to Care was signed and dated, the time was not included in the authentication.

Review on 7/10/2018 at 12:00 PM of Patient #13's medical record, the General Consent to Care was signed and dated, the time was not included in the authentication.

Review on 7/10/2018 at 12:30 PM of Patient #14's medical record, the General Consent to Care was not signed, dated, or timed.

Review on 7/10/2018 at 12:40 PM of Patient #15's medical record, the General Consent to Care was signed and dated, the time was not included in the authentication.

Interview on 7/11/2018 at 10:45 AM, Quality Improvement Specialist H stated "It is expected that consents are completed with signature, date, and time."