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Based on medical record and facility policy review the the facility failed for 3 of 44 patients, (WM#13, WM#14 and WM#15), to ensure that all medical entries were timed as required by the Medical Staff Rules and Regulations.

Findings:

1. Review of the medical record for patient #WM#13 revealed physician orders dated 11/21/2011, 11/18/2011, 11/17/2011,(2 entries), 11/15/2011,(2 entries), 11/13/2011,(2 entries), and 11/12/2011 that did not include a time the orders were written.

2. Review of the medical record for patient #WM#14 revealed physician orders dated 11/21/2011,(3 entries), that did not include a time the orders were written.

Review of the medical record for patient #WM#14 revealed physician progress notes dated 11/22/2011, 11/21/2011, 11/21/2011,(Infectious Disease), 11/20/2011, and 11/19/2011 that did not include a time the progress notes were written.

3. Review of the medical record for patient #WM#15 revealed physician orders dated 11/16/2011, 11/15/2011,111/14/2011,(2 entries), that did not include a time the orders were written. Further review revealed a Total Parenteral Nutrition Monitoring Order form signed by the physician and a pharmacist without either the date or time documented on order form.

4. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under #1 "A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence. Verbal orders must be dated and timed at the time they are taken. They must be authenticated in written or electronic form by the person (identified by name and discipline) who is responsible for ordering, providing or evaluation the service provided within 48 hours and may be authenticated by another practitioner responsible for the care of the patient. (10/24/07)."

5. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under C, "All clinical entries in the patient's medical record shall be legible, dated timed and authenticated in written or electronic form by whomever is responsible for ordering or providing services. (7/28/2011)".

Based on medical record and facility policy review the the facility failed for 3 of 44, ( #WM 13, WM#14 and WM#15), to ensure that all physician orders are timed as required by the Medical Staff Rules and Regulations.

Findings:

1. Review of the medical record for patient #WM#13 revealed physician orders dated 11/21/2011, 11/18/2011, 11/17/2011,(2 entries), 11/15/2011,(2 entries), 11/13/2011,(2 entries), and 11/12/2011 that did not include a time the orders were written.

2. Review of the medical record for patient #WM#14 revealed physician orders dated 11/21/2011,(3 entries), that did not include a time the orders were written.

Review of the medical record for patient #WM#14 revealed physician progress notes dated 11/22/2011, 11/21/2011, 11/21/2011,(Infectious Disease), 11/20/2011, and 11/19/2011 that did not include a time the progress notes were written.

3. Review of the medical record for patient #WM#15 revealed physician orders dated 11/16/2011, 11/15/2011,111/14/2011,(2 entries), that did not include a time the orders were written. Further review revealed a Total Parenteral Nutrition Monitoring Order form signed by the physician and a pharmacist without either the date or time documented on order form.

4. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under #1 "A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his/her sphere of competence. Verbal orders must be dated and timed at the time they are taken. They must be authenticated in written or electronic form by the person (identified by name and discipline) who is responsible for ordering, providing or evaluation the service provided within 48 hours and may be authenticated by another practitioner responsible for the care of the patient. (10/24/07)."

5. Review of the Medical Staff Rules and Regulations page 11 of 33, Section 2 : Orders revealed under C, "All clinical entries in the patient's medical record shall be legible, dated timed and authenticated in written or electronic form by whomever is responsible for ordering or providing services. (7/28/2011)".