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Based on interview and clinical record review, the facility failed to ensure each clinical record contained a complete report of physical examinations. This affected one of 10 sampled patients, Patient #3. The sample size was 10 patients, and the census was seven patients.

Findings include:

The clinical record review for Patient #3 was completed on 02/20/13. The clinical record review revealed the 74 year old patient presented to the emergency department on 11/26/11 at 3:58 P.M. with a chief complaint of unsteadiness on feet and a fall. The clinical record review revealed a nursing assessment dated 11/26/11 at 4:08 P.M. that stated the patient had a normal gait and was alert and oriented to person place and time. The assessment stated the patient had strong and equal bilateral hand grasps, and the patients smile was symmetrical and speech clear and coherent.

The clinical record review revealed a physician's report dated 11/26/11 that stated the patient's chief complaint was an unsteady gait, diaphoresis and ... confusion. The report did not reveal where the physician included a neurological exam.

The clinical record review revealed a computed tomography scan was performed and the results were negative for an "acute intracranial process", i.e., cerebrovascular accident.

Review of the medical staff rules and regulation, as amended on 06/11, revealed history and physical exams have to have minimum content. Among the minimum content required included a report of relevant examinations. Patient #3's record lacked evidence of a neurological exam.

The clinical record review revealed Patient #3 returned to the emergency department on 11/28/11 at 12:48 P.M. with a chief complaint of left sided weakness. A nursing assessment timed at 12:47 A.M. stated the patient had left sided weakness.

The physician's report dated 11/28/11 did include a neurological exam that included an assessment of cranial nerves and an examination of the left upper extremity, found to be demonstrate weakness.

The clinical record review revealed a computed tomography report dated 11/28/11 at 2:10 P.M. that stated the patient had a right sided infarct, i.e. stroke.

The clinical record review revealed a physician's report dated 11/28/11 at 4:00 P.M. that affirmed the computed tomography report of a right sided infarct, i.e., stroke, and would be transferred to another facility "where Neurology is available."

The record review revealed a transfer form to an acute care facility. The form did not include the name of the receiving physician who agreed to accept the patient on transfer.

Review of a peer review document dated 02/21/12 for Physician #1 revealed care was appropriate but the "case" would have been strengthened by better documentation. The document stated no action was taken against Physican #1.

On 02/20/12 at 11:15 A.M. in an interview, Executive #1 and #2 confirmed no action had been taken against Physician #1, but noted he/she had resigned from the medical staff on 08/01/12.

This substantiates complaint OH00068622.

Based on interview and clinical record review, the facility failed to ensure all entries in the medical record of Patient #1, #2, and #9 were timed and dated. The sample size was 10 patients, the census was seven patients.

Findings include:

The clinical record review for Patient #9 was completed on 02/20/13. The clinical record review revealed the 72 year old patient presented to the emergency department on 02/19/12 at 10:58 A.M. with a chief complaint of a sinus headache.

The clinical record review revealed a physician order for Dilaudid one milligram and 25 milligrams phenergan to be given intramuscularly. Review of the order did not reveal a date or time of when the medications were ordered. The clinical record review revealed the medicines were given on 02/19/12 at 12:40 P.M.

The clinical record review for Patient #2 was completed on 02/20/13. The record review revealed the 57 year old patient presented to the emergency department via emergency medical services on 12/10/11 at 2:00 A.M. for a chief complaint of having parasites.

The record review revealed a physicians order for Haldol five milligrams intramuscularly. The review of the order did not reveal a date or time of when the medications were ordered.

The clinical record review for Patient #1 was completed on 02/20/13. The clinical record review revealed the 65 year old patient presented to the emergency department on 09/03/12 at 11:23 A.M. for a chief complaint of a head ache for the past two days.

The record review revealed a physician's order for Dilaudid, two milligrams, Soludmedrol 125 milligrams, Zofran four milligrams, and Rocephin one gram-all to be given intravenously and a 10 milligrams pill of zyrtec. None of these orders contained a date and/or time when the medications were ordered.

Review of policy A-143, Content of Hospital Medical Records, effective 06/02, was completed on 02/20/13. The review revealed all " entries, tests, and results " be " dated, timed, and authenticated by the physician ... making the entry. "

On 02/20/13 at 11:15 A.M. in an interview, the Director of Nursing reviewed the physician orders for Patient #1, #2, and #9, and confirmed the physician medication orders were not timed and dated.