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Based on document review, policy and procedure review, medical record review and staff interview, the hospital failed to ensure all medical records are promptly completed following discharge.


Findings include:


Review of the facility document "Physician's Incomplete Chart List" revealed the facility had a total of 423 incomplete medical records over 30 days. These records included acute and swing bed records that ranged from April 2011 to January 2013. This document was confirmed by the Medical Records Director (MRD) on 03/05/2013 at 2:20 p.m.


Review of facility policy "Medical Staff Rules and Regulations" revealed, "Article 3 - Medical Records 3.1 The attending physician Practitioner shall be held responsible for the preparation of a complete and legible medical record for each patient ... ".


Review of facility policy "Bylaws of the Medical Staff of...Hospital " revealed, "7.3 Automatic suspension 7.3-1 Failure to complete medical records: A temporary suspension in the form of withdrawal of a Practitioner's admitting privileges, effective until the medical records are completed, shall be imposed automatically after warning of deficiency for failure to complete medical records within the time prescribed in the Rules of the Staff ... ".


During an interview on 03/06/12 at 12:45 p.m. the MRD was asked how many physicians were off staff (suspended). She stated, "Due to the size of our facility, no one (no physician) is off staff." The MRD also stated, "Medical records are considered delinquent after 30 days."

Based on document review, medical record review, policy and procedure review and staff interview, the hospital failed to ensure all medical records are promptly completed following discharge.


Findings include:


Cross Refer to A431 for the facility's failure to ensure all medical records are promptly completed following discharge.

Based on record review, policy and procedure review and staff interview, the hospital failed to ensure entries in five (5) of 14 medical records reviewed contained a documented entry time. (Medical Records #1, #3, #6, #8 and #9).


Findings include:

Medical Record (MR) review revealed:

MR#1 had no documented entry time on the 11/09/12 progress notes.

MR#3 had no documented entry time on the 11/26/12 and 11/27/12 physician's orders.

MR#6 had no documented entry time on the 12/20/12, 12/21/12 and 12/28/12 progress notes.

MR#8 had no documented entry time on the 03/05/13 and 03/06/13 progress notes; and on the 03/04/13 and 03/05/13 physician's orders.

MR#9 had no documented entry time on the 02/16/13, 02/20/13, 02/26/13, 02/27/13 and 03/05/13 progress notes.

During an interview on 03/06/13 at 12:45 p.m. the Medical Records Director stated, "All medical record entries were supposed to be timed."

Review of the facility's "Medical Staff Rules and Regulations" policy revealed, "...Article 3 - Medical Records ...3.8 All clinical entries in the patient's medical record shall be dated an authenticated."

Based on record review, policy and procedure review and staff interview, the hospital failed to document a properly executed informed consent for 14 of 14 medical records reviewed. (Medical Records #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14)


Findings include:


Review of Medical Records #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 revealed no documented witness signature and no documented date or time on the "...Hospital Conditions Of Admission" general consent form.


During an interview on 03/06/13 at 12:45 p.m. the Medical Records Director confirmed that the informed consents were not complete for the records reviewed. "There is no documented date (except for the patient sticker), time, or witness signature on the general consent for medical treatment at the facility."

Review of facility's "...Policy and Procedure Informed Consent" policy revealed, "Policy: It is the policy ...that the patient must be given the opportunity to give an " informed consent " prior to ...or situations when it is deemed advisable to have formal documentation of the patient's consent for treatment ...the date and time of witnessing the signature is completed."

Based documentation review, policy and procedure review and staff interview, the hospital failed to ensure all medical records are promptly completed within 30 days following discharge.


Findings include:


Cross Refer to A431 for the hospitals failure to ensure all medical records are promptly completed within 30 days following discharge.

Based on observation, staff interview, and policy and procedure review, the hospital failed to meet the condition that the hospital had pharmaceutical services that meet the needs of the patients.


Findings include:


Cross Refer to A491 for the hospitals failure to ensure that their drug storage area was administered in accordance with accepted professional principles.


Cross Refer to A500 for the hospitals failure to ensure that in order to provide patient safety, drugs and biological must be controlled and distributed in accordance with applicable standards of practice.

Based on observation, staff interview and policy review, the hospital failed to ensure that they followed their own policy for storing medications.


Findings include:


Review of the hospital's "Storage of Medications" policy revealed, "1. All medications are stored in locked compartments under proper temperature controls."

During a tour of the hospital with the Director of Nurses (DON) on 03/05/13 at approximately 1:45 p.m. the Certified Registered Nurse Anesthetist's (CRNA) office in the surgery area was entered. Observation revealed that the door was propped open and the room contained storage bins with multiple medications in them. When asked how she obtained medications from the pharmacy and how these medications were secured the CRNA stated, "I usually keep this door locked." Entrance into the central sterile area revealed multiple vials of medications on a shelf. The door to this sterile area was found open. When asked how these medications are secured the DON stated that the door was locked.

Based on observation and staff interview, the hospital failed to ensure that in order to provide patient safety, drugs and biological are controlled and distributed in accordance with applicable standards of practice.


Findings include:


During tour of the Emergency Room on 03/05/13 at approximately 2:00 p.m. observation in the medication room revealed a pill crusher with a moderate amount of white powdery substance inside. There were also two (2) pill cutters with a white powdery substance on them.

During the observation the Director of Nurses (DON) was asked if there was a policy for cleaning the pill crusher and pill cutters. She stated that there was not.

Based on staff interview, policy review and crash cart log review, the hospital failed to ensure that the defibrillator was discharged, plugged and unplugged and recorded in the log book daily.


Findings include:


Review of the hospital's "Crash Cart Maintenance" policy (Revised 09/26/08) revealed, "Policy: To ensure equipment is maintained and ready for use, the defibrillators are to be checked at least once a day and recorded in the log book. Procedure: In order to accomplish the crash cart maintenance policy the following must be done by a licensed nurse (RN/LPN): The items listed on the daily crash cart checklist must be checked once a day and documentation made on a daily log sheet to reflect this procedure. This provides documentation that the cart is locked, the defibrillator was discharged at 200j unplugged and plugged, monitor strip available...The monitor strip obtained during discharging the defibrillator at 200j unplugged and plugged will be placed in the daily log book."


A tour of the hospital facility was done on 03/05/13 at approximately 2:00 p.m. with the Director of Nursing (DON). While in the Labor and Delivery area the log for the crash cart was reviewed. There was no documented evidence that the defibrillator had been checked every day as per their policy. When asked what the protocol was for checking the defibrillator the Registered Nurse (RN) stated, "We check it every day."