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Based on record review and interview the hospital lacked evidence patients or the patient's representative received notification of their rights for three of twenty medical records reviewed (#'s 3, 4, and 5).

Findings included:

- Medical record review of 20 inpatient medical records revealed the following:

- Medical record review on 8/10/10 for patient #3 revealed an admission date of 7/26/10 with a diagnosis of Anemia and fever. Review of the hospital's "Treatment Authorization and Acknowledgement Form" documentation acknowledged "patient unable to sign" . Fourteen days after admission the record lacked evidence the hospital provided the patient or the patient's representative with their Patient Rights.

- Medical record review on 8/10/10 for patient #4 revealed an admission date of 8/3/10 with a diagnosis of Congestive Heart Failure. Review of the hospital's "Treatment Authorization and Acknowledgement Form" documentation acknowledged "patient unable to sign".. Seven days after admission the record lacked evidence the hospital provided the patient or the patient's representative with their Patient Rights.

- Medical record review on 8/10/10 for patient #5 revealed an admission date of 7/26/10 with a diagnosis of Myocardial Infarction (heart attack). Review of the hospital's "Treatment Authorization and Acknowledgement Form" documentation acknowledged "patient unable to sign". Fourteen days after admission the record lacked evidence the hospital provided the patient or the patient's representative with their Patient Rights.

Administrative staff A on 8/10/10 at 11:15am, 12:00pm, and 1:30pm acknowledged the hospital lacked evidence patients or the patient's representative received notification of their rights for patients #3, 4, and 5.
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Based on document review and staff interview the Hospital failed to renew orders for restraints according to the Hospital's policy for two of two patients restrained (#19 and 20).

Findings included:

- On 8/11/10 review of the "RESTRAINT/SECLUSION" policy directed staff, "The Algorithm for Restraint Use is used to document restraint orders. The nurse will complete the information on the form and have the physician sign the order." The policy also directed staff, "The original order must be renewed with in 24 hour period/calendar day." The hospital failed to renew the restraint orders as directed by their policy.

- Patient #19's closed medical record revealed an admission to the Intensive Care Unit (ICU) with a diagnosis of acute and chronic respiratory status and failure on 5/19/10 and discharged on 6/2/10. On 5/22/10 the patient required the use of a mechanical ventilator to assist with their breathing. The record revealed an order for soft wrist restraints on 5/22/10. The order lacked a physician's signature, date and time. Review of the restraint flow sheet for 5/23/10 revealed the patient remained in restraints. The record lacked an order for the use of restraints on 5/23/10. The record revealed an order for restraints on 5/24/10 at 7:00am, the order lacked a physician's signature. The physician on 6/23/10 at 7:49am electronically signed the restraint order for 5/24/10, twenty-nine days after the restraint of the patient.

- Patient #20's closed medical record revealed an admission to the ICU after open-heart surgery on 6/16/10 and discharged on 7/2/10. On 6/21/10 the patient required the use of a mechanical ventilator to assist with their breathing. The record revealed, on 6/21/10 an order for soft wrist restraints for patient safety. On 6/23/10, 6/24/10, 6/25/10, and 6/26/10 the orders for restraints lacked a physician's signature, date and time. The physician on 7/26/10 at 9:30am electronically signed the restraint orders for 6/25/10, twenty-nine days after the restraint of the patient. The physician on 7/28/10 at 7:13am electronically signed the restraint order for 6/26/10, thirty-two days after the restraint of the patient. The record lacked an order for the use of restraints on 6/27/10.

Staff A on 8/11/10 at 11:30am and 4:30pm acknowledged the medical records lacked the physician's signature on the restraint orders and orders for the use of the restraints as required according to their policy.

Based on document review and staff interview the Hospital failed to assure staff followed the Hospital policy to assess and monitor the use of physical restraints for one of two patients restrained (#20).

Findings included:

- Review of the Hospital's policy, "Restraint/Seclusion", last revised on March 2010, instructed staff, "Patients in restraints will be regularly monitored and assessed. The Restraint Care Flowsheet-Medical Condition will be used to document assessment information. Assessment will occur: Every hour for: skin integrity/circulation, mental status/response to restraints, effectiveness of restraints, privacy/comfort/warmth, readiness for release from restraint, and Every two hours(in addition to the above) for: vital signs, intake and output, fluid/food/ toilet offered, call light and activities of daily living, and range of motion."

- Patient #20's medical record revealed an admission to the Intensive Care Unit (ICU) on 6/16/10 after open-heart surgery and discharged on 7/2/10. Review of the medical record revealed the patient required the use of a mechanical ventilator to assist with their breathing. The record revealed orders for the use of soft wrist restraints from 6/21/10 to 6/26/10. Review of the "restraint log" indicated the use of restraints from 6/21/10 to7/2/10. The medical record lacked documentation of ongoing assessment and monitoring of the patient in restraints from 6/21/10 to 6/24/10 at 3:00pm. The staff failed to assess and monitor the patient according to their policy.

Staff A on 8/12/10 at 8:50am per telephone call acknowledged the staff failed to assess and monitor the patient from 6/21/10 to 6/24/10 at 3:00pm according to their policy.

Based on record review and staff interview the hospital failed to ensure medical staff dated and/or timed all entries in the medical record for 12 of 20 sampled medical records (#'s 2, 3, 5, 8, 11, 13, 15, 16, 17, 18, 19, and 20).

Findings included:

- Document review on 8/9/10 of the hospital's "Medical Staff Rules and Regulations" directed "...All clinical entries, including progress notes, in the patient's medical record shall be accurately dated, timed and authenticated..."

- Patient #2's medical record revealed an admission date of 7/30/10 with a diagnosis of Major Depression. The medical record revealed seven progress notes and one physician order between 7/30/10 and 8/9/10 lacked a time when authenticated (signed).

- Patient #3's medical record revealed an admission date of 7/26/10 with diagnoses of Anemia and fever. The medical record revealed 18 progress notes and eight physician orders between 7/26/10 and 8/10/10 lacked a time when authenticated (signed).

- Patient #5's medical record revealed an admission date of 7/26/10 with a diagnosis of Myocardial Infarction (a heart attack). The medical record revealed 15 progress notes and three pre-printed physician orders between 7/26/10 and 8/10/10 lacked a date and/or time when authenticated (signed).

- Patient #8's medical record revealed an admission date of 7/21/10 with a diagnosis of Abdominal Pain. The medical record revealed seven progress notes and eleven physician orders between 7/21/10 and 8/10/10 lacked a time when authenticated (signed).

- Patient #11's medical record revealed an admission date of 8/10/10 with a diagnosis of Congestive Heart Failure. The medical record revealed one progress note and one physician order between 8/10/10 and 8/11/10 lacked a time when authenticated (signed).

- Patient #13's medical record revealed an admission date of 4/27/10 with a diagnosis of Aortic Valve Disorder. The medical record revealed three progress notes and three physician orders between 4/27/10 and 5/2/10 lacked a time when authenticated (signed).

- Patient #15's medical record revealed an admission date of 4/29/10 with a diagnosis of a fractured femur (thigh bone). The medical record revealed nine progress notes and three physician orders between 4/29/10 and 5/3/10 lacked a time when authenticated (signed).

- Patient #16's medical record revealed an admission date of 3/4/10 with a diagnosis of Abdominal Aortic Aneurysm (a bulging of the main artery). The medical record revealed three physician orders between 3/4/10 and 3/5/10 lacked a date and/or time when authenticated (signed).

- Patient #17's medical record revealed an admission date of 5/20/10 with a diagnosis of Post Traumatic Pulmonary insufficiency (a lung condition). The medical record revealed three progress notes and 13 physician telephone/voice orders between 5/20/10 and 6/2/10 lacked a date and/or time when authenticated (signed).

- Patient #18's medical record revealed an admission date of 3/14/10 with a diagnosis of an overdose. The medical record revealed seven progress notes, three physician orders, and nine telephone/verbal physician orders between 3/14/10 and 3/23/10 lacked a date and/or time when authenticated (signed).






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- Patient #19's closed medical record revealed an admission to the Intensive Care Unit (ICU) on 5/19/10 with a diagnosis of Acute and Chronic Respiratory Status and Failure and discharged on 6/2/10. The medical record revealed nine progress notes, thirteen physician telephone/voice orders, and two telephone orders received by a nurse from the physician between 5/19/10 and 6/2/10 lacked a date and/or time when authenticated (signed).

- Patient #20's closed medical record revealed an admission to the ICU on 6/16/10 after open-heart surgery and discharged on 7/2/10. The medical record revealed nine progress notes, 21 physician telephone/voice orders between 6/16/10 and 7/2/10 lacked a date and/or time when authenticated (signed).

During record review through out the survey on 8/9/10-8/11/10 staff A, acknowledged all entries into the medical record lacked a date and/or time when authenticated.