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Based on record review and interview, the facility failed to ensure that patient medical records were completed, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided; and in accordance with the facility's policies and procedures for 2 of 20 patient records reviewed (Patient #4 and #8).

Findings included:

Record review of Patient #4's Anesthetic Record from 4/7/23 revealed the Post Operative Assessment was signed and dated by the CRNA, but the time was not documented.

Record review of Patient #8's Medical record from 11/29/23 revealed the following:

-Patient Consent and Acknowledgement of Receipt of Privacy Notice was signed by the patient but was not dated nor timed.

-The Patient Rights was signed by the patient but was not dated nor timed.

-Authorization for Release of Information/Health Care Information was signed by the patient but was not dated nor timed.

-Anesthetic Record, Post operative Assessment was signed and dated by the CRNA but no time was documented.

Interview on 7/11/23 at 2:45 PM with Facility Staff #4 confirmed the above records were incomplete, undated, untimed, and not authenticated in written or electronic form by the person responsible for providing or evaluating the services provided.

Record review of the facility policy, Analyzing Components of Medical Records for completeness, approved 4/4/12, states in part:
A. Required components of the medical record:
2. Each medical record must contain (and is analyzed for) the following components (all entries must be dated, signed, and timed when required, and written in ink.)

Record review of the facility policy, Analyzing Charts for Deficiencies, approved 8/23/12, states in part....A record shall remain incomplete until all identified deficiencies are corrected by the appropriate clinical providers.

Based on observations and interviews, the facility failed to provide a clean, sanitary, and safe environment to avoid sources and transmission of infections and communicable diseases.

Specifically, observations of the facility revealed the following:

1.) The Medical Surgical area was unsanitary and unsafe to avoid transmission of infection and communicable diseases.

2.) The Intensive Care Unit (ICU) area was unsanitary and unsafe to avoid transmission of infection and communicable diseases.

These deficient practices placed the patients' health and safety at risk for the transmission of infections and/or communicable diseases.

Findings included:

Observations on 7/10/23 at 11:50 AM of the facility with staff #20 revealed the following:

1.) Med/Surg

A) A room with a sign "Soiled Utility" had a laminate countertop at the sink that was "chipped" at the front of the sink, exposing particle/plywood.

B) Patient room 211 B. The recliner ' s metal frame and footwell were dusty.

2.) ICU

Medication prep area at the ICU nurses station, there were 5 holes in the wall where screws had been. No longer wipeable surfaces to sanitize or disinfect the surface. The drawer front had a sticky residue where tape had been. The sticky residue was discolored to a greyish/brownish color that could not be wiped down nor sanitized.

In the Medication room, the trash can was full. Trash was piled up past the brim. A piece of trash had fallen to the floor. The wall behind the medication pyxis machine, there were 6 little holes where screws had been; making the wall a non-wipeable surface that could not be disinfected nor sanitized. The cabinet frame had 4 holes that were bored into the wood.

Interview on 7/10/23 at the time of the observations with Staff #20 confirmed all the above findings.

Interview on 7/11/23 at 1:55 PM with the Infection Prevention Registered Nurse and Director of Quality confirmed that the countertop and walls needed to be wipeable surfaces in order to sanitize and disinfect, stating, "Has to be wipeable." The Director of Quality stated the facility would need to look at alternatives to address the wall concerns.