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Based on interview and record review it was determined the facility failed to furnish services to 1 of 10 sampled patients (Patient 10) in accordance with appropriate written patient care policies. Findings include:

During the re-visit survey it was determined that specific written patient care policies had been developed for the hospital's urgent care center. Those policies included a specific policy "Head Injuries-Urgent Care" to guide services provided to urgent care patients being treated for head injuries that included a loss of consciousness (LOC).

The policy "Head Injuries-Urgent Care" described specific procedures that were to be followed in furnishing services to patients with such symptoms. Those procedures included the completion of vital sign and neurological checks every 15 minutes for one hour, and every 30 minutes for one hour. In addition staff were to complete and document a full neurological assessment. Record review determined that the facility failed to implement that policy in the provision of care to Patient 10.

Facility records indicate that Patient 10 was admitted to the urgent care center on 5/24/11 with lacerations of the head, face and arm. The patient reported that he had "fallen down and hit his head." According to the physician record, clinical impressions included concussion, loss of consciousness and contusion/laceration.

Record review determined that facility staff had failed to complete vital signs and neurological checks every 15 minutes for one hour, and every 30 minutes for one hour as planned. Only two sets of vitals signs had been recorded during the Patients 3 hour stay. In addition, staff failed to complete and document a full neurological assessment as required by policy.

In interview on 6/1/11 at approximately 3:30 pm Witnesses 4, 5 and 6 acknowledged that urgent care staff had failed to provide services to Patient 10 in accordance with the appropriate written policy.

Based on interview and record review it was determined the facility failed to maintain a clinical record that included dated signatures of the doctor and/or health care professional providing health care services for 10 of 10 sampled patients (Patients 1 through 10). Findings include:

During the re-visit survey a sample of patient medical records was selected for review. That review determined that the clinical records for Patient 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 did not include a dated signature of the doctor or other health care professional who had provided services.

Although the clinical record included a variety of forms and documents signed by various staff, no dated signature from the treating physician was included in any of those clinical records. In interview on 6/1/11 at approximately 3:00 pm Witnesses 4, 5 and 6 agreed that the required dated signatures were not included in the charts.