HospitalInspections.org

Based on record review, the facility failed to ensure the medical records of 5 (#s 1, 6, 9, 12, and 14) of 20 patients reviewed were complete. Findings include:

1. Patient #6 was admitted to the hospital on 1/29/10, transferred to swing bed status on 2/1/10, and then discharged on 2/16/10.

During record review on 7/20/10 at 12:45 p.m., a verbal order dated 2/11/10 was noted for "INR [International Ratio] stat [immediately]." The time of the order was not documented as to when it was completed.

Review of the Physical Therapy Progress Record showed entries dated 2/1/10, 2/2/10, 2/3/10, 2/4/10, 2/5/10, 2/8/10, 2/9/10, 2/10/10, 2/11/10, 2/12/10, 2/15/10, and 2/16/10, that lacked documentation of the time when they were written.

Review of the Occupational Therapy notes showed entries on 2/11/10 and 2/12/10 that they lacked documentation of the time when they were written.

2. Patient #9 was admitted on 6/11/10 and discharged on 6/12/10.

During record review on 7/20/10 at 1:30 p.m., the forms Pneumococcal & Influenza Vaccination Standing Orders and Discharge Planning Assessment were blank. The Physician's Orders form for discharge to home did not contain a time when it was written by the physician.

3. Patient #1 was admitted to the facility on 7/18/10.

The patient's medical record was reviewed on 7/20/10 at 9:00 a.m. It was noted the patient's vital signs sheets were not dated.

4. Patient #12 was admitted to the facility on 12/28/09, and discharged on 12/30/09.

The patient's medical record was reviewed on 7/20/10 at 2:00 p.m. It was noted that the patient's vital signs sheets were not dated. In addition, the Organ Donor Inquiry form, dated 12/30/09, was not signed by hospital staff.

5. Patient #14 was admitted to the facility on 3/26/10, and discharged on 3/28/10.

The patient's medical record was reviewed on 7/20/10 at 2:30 p.m. It was noted that the patient's Organ Donor Inquiry form, dated 3/28/10, was not signed by hospital staff.

Based on record review, the facility failed to ensure that medical entries for 3 (#s 8, 9, and 16) of 20 patient records reviewed were authenticated, which includes date and time of entry. Findings include:

1. Patient #8 was admitted as an inpatient on 2/9/10.

During record review on 7/20/10 at 1:00 p.m., a verbal order dated 2/11/10 was noted for "Nitropaste 3/4 inch [every] 6 ? [hours] x [times] 3 then off; Toprol 25 mg po [by mouth] BID [twice daily]; [symbol for decrease] IV [intravenous] to 77 cc/? [cubic centimeters per hour]; Continue both Cilostrozol et [and] ASA [aspirin]." The time of the verbal order was not written.

On 2/9/10, the physician wrote orders to "1. D/C [discontinue] private vehicle to St. Vincent's in c/o [care of] [Name of Physician] 2. Meds - Cipro 500 mg [milligrams] po BID - Flagyl 500 mg po [every] 8 ? - ASA 325 mg daily - Cilostozol 100 mg BID." The time of the order was not written.

On 2/13/10, the physician wrote an order for "Zofran 8 mg IV x 1 now." The time of the order was not written.

2. Patient #16 was admitted to the emergency room on 7/10/10 at 5:54 a.m., and was transferred to Billings on 7/10/10 at 10:55 a.m.

During record review on 7/20/10 at 3:00 p.m., the time the history and physical was written by the physician was not documented. There were three physician orders that were not dated as to when they were written.

3. Patient #9 was admitted on 6/11/10 and was discharged on 6/12/10.

During record review on 7/20/10 at 1:30 p.m., the time the discharge order was written was not documented.