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Based on clinical record review, interview and review of Medical Staff Rules and Regulations, it was determined the facility failed to ensure physician's orders were dated and timed for 10 (#2, #6, #9, #11, #12 -17, #19-22) of 30 patients (#1-#30). Failure to ensure physician's orders were dated and timed did not ensure orders would be followed and carried out in the time frame intended by the physician. Findings follow:

A. Review of Patient #2's Emergency Department Physician's Orders dated 04/12/13 revealed the physician did not time their signature. Findings were verified by the Chief Nursing Officer (CNO) at 1305 on 04/18/13.
B. Review of Patient #6's Emergency Department Physician's Orders revealed it was undated and the physician did not date or time their signature for one of one order. Findings were verified by the CNO at 1305 on 04/18/13.
C. Review of Patient #9's verbal admission orders dated 04/09/13 revealed the physician did not date and time their signature. Findings were verified by the CNO at 1305 on 04/18/13.
D. Review of Patient #11's clinical record revealed three of three (04/14, 15 and 16/13) restraint orders were without a date and/or time of the physician's signature. Findings verified by the CNO at 1305 on 04/18/13.
E. Review of Patient #12's clinical record revealed two of two (04/13 and 14/13) restraint orders were without the date and time of the physician's signature. Findings verified by the CNO at 1230 on 04/18/13.
F. Review of Patient #13's Emergency Department Physician's Orders revealed it was undated and the physician's signature was not dated and timed. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
G. Review of Patient #14's Emergency Department Physician's Orders revealed it was undated and the physician's signature was not dated and timed. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
H. Review of Patient #15's Emergency Department Physician's Orders revealed the physician did not date and time their signature for two of two orders. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
I. Review of Patient #16's Emergency Department Physician's Orders revealed the physician did not time their signature for one of one order. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
J. Review of Patient #17's Emergency Department Physician's Orders revealed it was undated and the physician did not date and time their signature for one of one order. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
K. Review of Patient #19's Emergency Department Physician's Orders revealed it was undated and the physician did not date and time their signature for two of two orders. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
L. Review of Patient #20's Emergency Department Physician's Orders revealed it was undated and the physician did not date or time their signature for one of one order. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
M. Review of Patient #21's Emergency Department Physician's Orders revealed the physician did not date and time their signature for one of one order. Findings verified by the Emergency Department Manager at 1410 on 04/17/13.
N. Review of Patient #22's Emergency Department Physician's Orders revealed it was undated and the physician did not date or time their signature for two of two orders. Findings were verified by the Emergency Department Manager at 1410 on 04/17/13.
O. Review of Medical Staff Rules and Regulations provided by the CNO at 1500 on 04/17/13 revealed under 12.1.5 "Except as specified herein, all orders for treatment shall be in writing, authenticated, signed, dated, and timed as required, before being carried out. Under 12.2.7 "The ordering Practitioner shall authenticate all telephonic orders within a reasonable time."

Based on observation and interview, it was determined soap holders located in 11 (Patient Rooms 534, 429, 439, 416, 421, 310, 313, 319, 244, 238, and 218) of 16 patient room showers were not maintained in a clean and good state of repair due to pitting and an accumulation of soap residue on the soap holders. The failed practice had the potential to affect all patients due to the unsanitary and damaged condition of the soap holders. The facility had a census of 97 patients on 04/15/13. The findings follow:

A. On a tour of the facility on 04/17/13 at 0845 with the Plant Operations Maintenance Supervisor, the soap holders located in Patient Rooms 534, 429, 439, 416, 421, 310, 313, 319, 244, 238, and 218 were pitted and had an accumulation of soap residue in the crevices and grooves of the holder
B. The Plant Operations Maintenance Supervisor verified the condition of the soap holders as they were observed on the tour.

Based on observation and interview, it was determined humidity levels in three of three (G.I. (Gastrointestinal) Lab A, G.I. Lab B, and G.I. Lab C) endoscopic procedure rooms were not monitored to ensure the humidity was maintained between 30% and 60% as required by the Rules and Regulations for Hospitals and Related Institutions in Arkansas, 2007 edition. The failed practice had the potential to affect all patients receiving endoscopic procedures due to the potential of static electricity associated with low humidity (below 30%) and creation of mold associated with high humidity (above 60%). The facility had four patients scheduled for procedures on 04/15/13. The findings follow:

A. On a tour of the facility on 04/15/13 at 1300 with the Chief Nursing Officer, Endoscopic Procedure Rooms, G.I. Lab A, G.I. Lab B, and G.I. Lab C, were observed to be operational.
B. In an interview conducted on 04/16/13 at 1545 the Plant Operations Maintenance Supervisor stated the humidity in the three endoscopic procedure rooms was not monitored by the building air-conditioning control system and verified there was no further documentation of monitoring available for review.

Based on clinical record review, Medical Staff Rules and Regulations review, and interview, it was determined the facility failed to ensure time of surgery was documented on the operative report for 12 of 12 (#4, #5, #7, #12, and #23-#30) surgical patients; and failed to ensure the operative report was signed by the physician immediately following surgery for nine (#4, #5, #12, #23, #24, and #27-#30) of 12 (#4, #5, #7, #12, and #23-#30) patients. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day, and failure to obtain the physician's signature did not indicate the physician had reviewed the report. Findings follow.

A. Review of operative reports revealed the following:
1) The time of surgery was not documented for 12 of 12 surgical patients (#4, #5, #7, #12, and #23-#30).
2) Patient #4 had surgery on 04/14/13; the operative report was not signed as of 04/18/13.
3) Patient #5 had surgery on 04/10/13; the operative report was not signed as of 04/18/13.
4) Patient #12 had surgery on 04/10/13; the operative report was not signed as of 04/18/13.
5) Patient #23 had surgery on 02/12/13; the operative report was not signed until 03/22/13.
6) Patient #24 had surgery on 02/14/13; the operative report was not signed until 04/03/13.
7) Patient #27 had surgery on 02/14/13; the operative report was not signed until 03/22/13.
8) Patient #28 had surgery on 02/14/13; the operative report was not signed until 03/25/13.
9) Patient #29 had surgery on 02/14/13; the operative report was not signed until 03/28/13.
10) Patient #30 had surgery on 03/14/13; the operative report was not signed until 04/01/13.
B. Review of Medical Staff Rules and Regulations revealed a statement stating the operative report shall be "promptly signed by the surgeon."
C. Findings were confirmed by the Quality/Risk Manager on 04/18/13 at 1405.

Based on policy and procedure review and interview, it was determined the facility failed to develop and implement cardiopulmonary policies and procedures for medication storage, access, control, administration and how to recognize and handle medication errors. Failure to develop a cardiopulmonary policies and procedures did not allow the staff to have access to written guidance on medications and did not allow the staff to be knowledgeable and proactive in their practice. The failed practice affected all patients receiving Respiratory Therapy services on 04/15/13. Findings follow:

A. Review of the Cardiopulmonary Policy and Procedure Manual revealed it did not contain a policy and procedure for the storage, access, control, administration of medications and medication errors.
B. During an interview with the Cardiopulmonary Manager at 0900 on 04/18/13, he stated the Cardiopulmonary Department did not have a policy and procedure for the storage, access, control, administration of medications and medication errors.