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Based on record and policy review and staff interview the facility did not ensure that three of twelve records reviewed (#8, #11 and #12) had Physician's orders that were signed timely, nor were the records completed within the required time frame, per hospital policy.
The findings are:
Patient #8 closed record had verbal orders (VO) dated 1/22/13 that have not been signed to date. This patient was discharged on 1/22/13.
Patient #11 closed record had VO dated 11/25/12 and 11/26/12 that have not been signed to date. This patient was discharged on 11/26/12.
Patient #12 closed record had VO dated 11/10/12, 11/23/12 and 11/24/12 that have not signed to date. This patient was discharged on 11/25/12.
Nursing Policy for Physician Orders in Nursing Services dated 7/2008 indicated Verbal and telephone orders will be signed within 24 hours.
An interview was conducted with the Director of Medical Records on 3/6/13 at approximately 9:20 AM. The Director stated that physician verbal or telephone orders are required by written hospital policy to be counter-signed by the physician within 24 hours of being taken by the nurse. She also acknowledged they have had problems getting compliance with some of the physicians in this area.

Based on record and policy review and staff interview the facility did not ensure that 7 of 12 ( #9, #10, #11, #12, #13, #14, and #20) closed records reviewed from 11/12 to 2/13 had discharge summaries.
The findings are:
Patient #9 was admitted 12/12/12 and expired on 12/15/12; review of the closed record indicated there was no discharge summary.
Patient #10 was admitted on 12/14/12 and expired on 12/15/12; review of the closed record indicated there was no discharge summary.
Patient #11 was admitted on 11/23/12 and expired on 11/26/12; review of the closed record indicated there was no discharge summary.
Patient #12 was admitted on 11/5/12 and expired on 11/25/12; review of the closed record indicated there was no discharge summary.
Review of the "General Rules and Regulation" through Medical By-Laws indicated at (21) "A discharge clinical resume/summary will be written or dictated on all medical records of patients hospitalized over 48 hours. At (27) The attending practitioner is responsible for completing medical records on all patients with in fifteen (15) days of discharge."
Interview with Director of Nurses on 3/5/13 at 1:30 PM indicated Discharge summaries should be completed on all records of patients whose length of stay was greater than 48 hours, and is aware that there is an issue, as she was recently notified by Medical Records personnel that this was lacking in many records.



26001

A closed record review was conducted for sample patient #13. The record contained a deficiency sheet from the medical record department for the admission of 1/14/13 - 1/19/13 indicating the chart is incomplete due to there being no discharge summary in the chart. Further review of the clinical record reveals there is no discharge summary. An interview was conducted with the Director of Nursing on 3/6/13 at approximately 10:40 AM. The Director of Nursing was unable to find the discharge summary for the patient.

A closed record review was conducted for sample patient #14. The record contained a deficiency sheet from the medical record department for the admission of 1/24/13 - 1/28/13 indicating the chart is incomplete due to there being no discharge summary in the chart. An interview was conducted with the Director of Nursing on 3/6/13 at approximately 10:40 AM. The Director of Nursing was unable to find the discharge summary for the patient.


A closed record review was conducted for sample patient #20. The record was contained a deficiency sheet from the medical record department for the admission of 1/31/13 - 1/8/13 indicating the chart is incomplete due to there being no discharge summary in the chart. An interview was conducted with the Director of Nursing on 3/6/13 at approximately 10:40 AM. The Director of Nursing was unable to find the discharge summary for the patient.