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1. Based upon review of inpatient medical records and interview with hospital staff verbal orders the medical record entries reviewed were not complete, dated and or timed in written or electronic form by the person responsible for providing or evaluating the service provided. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) 9 out of the 20 medical records (MR) (45%) (MR#1, 2, 3,4,13,17,18,19 and MR#20) reviewed had verbal orders or telephone orders that were not timed or dated by physician and or practitioner within 48 hours. Out of the 20 medical records reviewed 6 out of the 20 medical records reviewed (MR# 9,10,11,13,15 and MR# 20) (30%) had informed consent sheets that were not dated and timed by the physician or the patient did not date and timed informed consent. Out of the 20 medical records reviewed 16 out of the 20 medical records (80%) had medical entries that were either not dated/timed and or authenticated. These medical entries included regular physician orders, progress notes, operative reports, discharge summaries, history and physicals and consults. There were 6 out of 20 (30%) medical record reviewed history and physicals that were not placed in record within 24hrs because of late transcriptions.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirements of this regulation and could not provide evidence that these requirements were met.

1. Based upon review of inpatient medical records and interview with hospital staff all verbal orders are not being dated, and timed by the ordering practitioner. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) 9 out of the 20 medical records (MR) (45%) (MR#1, 2, 3,4,13,17,18,19 and MR#20) reviewed had verbal orders or telephone orders that were not timed or dated by physician and or practitioner within 48 hours.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirements of this regulation and could not provide evidence that these requirements were met.

1. Based upon review of inpatient medical records and interview with hospital staff the medical record entries reviewed were not complete, dated and or timed in written or electronic form by the person responsible for providing or evaluating the service provided. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) 9 out of the 20 medical records (MR) (45%) (MR#1, 2, 3,4,13,17,18,19 and MR#20) reviewed had verbal orders or telephone orders that were not timed or dated by physician and or practitioner within 48 hours.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirements of this regulation and could not provide evidence that these requirements were met.

1. Based upon review of inpatient medical records and interview with hospital staff history and physical examinations are not being placed in the medical record within 24 hours. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) There were 7 out of 20 (MR# 10,14,15,16,17,19 and MR #20 (35%) medical record reviewed history and physicals that were not placed in record within 24hrs because of late transcriptions or the history and physicals dates were not known because the medical entry was not dated/timed or authenticated by the physician. Pt. #10, 89 year old male history and physical were not dated/timed and the physician did not sign the document. Patient (PT #15 78 year old (y/o) female had an history and physical that was not dated and timed by physician. PT# 16, 15 year old female was admitted on Oct. 12, 2009 and her history and physical was transcribed on10/20/09. PT # 17, 38y/o male was admitted on 11/7/09, history and physical was transcribed on 11/10/09., PT # 19, 47y/o male was admitted on 11/25/09 her history and physical was transcribed on 11/27/09. PT #20, 70 y/o female history and physical was not dated and timed.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirements of this regulation and could not provide evidence that these requirements were met.

1. Based upon review of inpatient medical records and interview with hospital staff history and physical examinations are not being placed in the medical record within 24 hours. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) There were 7 out of 20 (MR# 10,14,15,16,17,19 and MR #20 (35%) medical record reviewed history and physicals that were not placed in record within 24hrs because of late transcriptions or the history and physicals dates were not known because the medical entry was not dated/timed or authenticated by the physician. Pt. #10, 89 year old male history and physical were not dated/time and the physician did not sign the document. Patient (PT #15 78 year old (y/o) female had an history and physical that was not dated and timed by physician. PT# 16, 15 year old female was admitted on Oct. 12, 2009 and her history and physical was transcribed on10/20/09. PT # 17, 38y/o male was admitted on 11/7/09, history and physical was transcribed on 11/10/09., PT # 19, 47y/o male was admitted on 11/25/09 her history and physical was transcribed on 11/27/09. PT #20, 70 y/o female history and physical was not dated and timed.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirements of this regulation and could not provide evidence that these requirements were met.

1. Based upon review of inpatient medical records and interview with hospital staff the medical record entries reviewed had inform consents forms that were not complete. This requirement was not met as follows:

Findings:

a. In review of 20 patient medical records (MR#) (MR# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19 and MR#20) .Out of the 20 medical records reviewed 6 out of the 20 medical records reviewed (MR# 9,10,11,13,15 and MR# 20) (30%) had informed consent sheets that were not dated and timed by the physician or the patient did not date and timed informed consent.

b. Interviewed staff # 8 director of health information manager at 1:00pm on January 10, 2010 in an office in the facility near the administrative suite. Reviewed 6 records with the health information manager containing the medical record deficiency cited earlier. Staff # 8 agreed that the medical records did not meet the requirments of this regulation and could not provide evidence that these requirments were met.