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Based upon review of medical records and interview with staff it was determined that nursing care plans were developed and kept current for only the chief complaint upon admission and not the secondary medical problems. This requirement was not met as follows.

Findings:

a. Based upon review 26 medical records (MR # 1-26) There were 12 out of 26 medical records (46%) reviewed (MR#1,2,3,4,5,6,13,14,15,16,17, and MR #18) that had developed and kept current nursing care plans that addressed only the chief complaint during admission and not the secondary problems of the patient.

b. Interviewed staff #2, Director of Risk Management at 1:20pm on January 13, 2010 in the administration conference room and staff #17, Director of Health Information at 2:30pm on January 14, 2010 and reviewed with them examples of discrepancies found. Staff interviewed could not provide evidence that these medical records reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that 19 out 26 (73%) (MR# 1,2,3,4,5,6,13,14,15,16,17,18,19,20,21,22,23,24 and MR#26) of medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement is not met as follows.

Findings:

a. Based upon review 26 medical records (MR # 1-26) there were 12 out of 26 (46%) of the medical records reviewed (MR# 1,2,3,4,5,6,13,14,15,16,17, MR#18) that had progress notes and or physician orders that were not dated or timed. There were 7 out of the 26 (27%) medical records (MR# 1,3,5,6,13,15 and MR# 16)reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours. There were 6 out of 6 swing bed patient medical records (MR#1-6) (100%) that did not have evidence that a planned multi or interdisciplinary meeting was held with all the primary disciplines responsible for care for that swing bed patient. In the swing bed medical record 5 out of 6 (MR#1-5) (83%) swing bed patient medical records reviewed the required notice before transfer notices were not signed dated and timed by the patient's representative. There were 7 out of 13 (54%)medical/surgical inpatient medical records reviewed(MR # 16,19,20,21,22,23 and MR# 24) of surgical patients informed consent forms that were not properly executed and were either not signed by the physician or any indication given that the physician properly informed patient. There were 12 out of 26 medical records (46%) reviewed (MR#1,2,3,4,5,6,13,14,15,16,17, and MR #18) that had nursing care plans that addressed only the chief complaint during admission and not the secondary problems of the patient.

b. Interviewed staff #2, Director of Risk Management at 1:20pm on January 13, 2010 in the administration conference room and staff #17, Director of Health Information at 2:30pm on January 14, 2010 and reviewed with them examples of discrepancies found. Staff interviewed could not provide evidence that these medical records reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that 19 out 26 (73%) (MR# 1,2,3,4,5,6,13,14,15,16,17,18,19,20,21,22,23,24 and MR#26) of medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement is not met as follows.

Findings:

a. Based upon review 26 medical records (MR # 1-26) there were 12 out of 26 (46%) of the medical records reviewed (MR# 1,2,3,4,5,6,13,14,15,16,17, MR#18) that had progress notes and or physician orders that were not dated or timed. There were 7 out of the 26 (27%) medical records (MR# 1,3,5,6,13,15 and MR# 16)reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours. There were 6 out of 6 swing bed patient medical records (MR#1-6) (100%) that did not have evidence that a planned multi or interdisciplinary meeting was held with all the primary disciplines responsible for care for that swing bed patient. In the swing bed medical record 5 out of 6 (MR#1-5) (83%) swing bed patient medical records reviewed the required notice before transfer notices were not signed dated and timed by the patient's representative. There were 7 out of 13 (54%)medical/surgical inpatient medical records reviewed(MR # 16,19,20,21,22,23 and MR# 24) of surgical patients informed consent forms that were not properly executed and were either not signed by the physician or any indication given that the physician properly informed patient. There were 12 out of 26 medical records (46%) reviewed (MR#1,2,3,4,5,6,13,14,15,16,17, and MR #18) that had nursing care plans that addressed only the chief complaint during admission and not the secondary problems of the patient.

b. Interviewed staff #2, Director of Risk Management at 1:20pm on January 13, 2010 in the administration conference room and staff #17, Director of Health Information at 2:30pm on January 14, 2010 and reviewed with them examples of discrepancies found. Staff interviewed could not provide evidence that these medical records reviewed met the requirements of this regulation.