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Based on staff interview, the hospital failed to ensure the entire medical record was accessible. Findings include:

During an interview on 10/7/14 at 9:30 a.m., staff member J, ICU manager, was asked to access the electronic health record (EHR). Staff member J, stated she did not have access to the entire electronic health record. The electronic health record contained the paper work from the start of the admission process for all patients. This included the consent for treatment form.

During an interview on 10/7/14 at 10:15 a.m., staff member S, admission director, stated she was not aware of who all had access to the EHR. When a patient came through the emergency room, the EHR was started with the required paperwork.

During an interview on 10/7/14 at 4:30 p.m., staff member R, compliance manager, stated she was not aware that all staff could not access the needed patient information in their EHR.

Based on record review the hospital failed to ensure all entries in the medical record were complete, dated, and timed for 9 (#s 10, 12, 17, 18, 19, 24, 45, 46, and 48) of 48 records reviewed. Findings include:

1. Review of patient #10's medical record reflected the discharge summary, dated 3/27/14, was not authenticated with a signature, date, or time. The critical care progress note, dated 3/20/14, was not authenticated with a signature, date, or time.

2. Review of patient #12's medical record reflected a discharge summary, dated 5/6/14, was not authenticated with a signature, date, or time. The critical care progress note dated 5/1/14 was not authenticated with a signature, date, or time.

3. Review of patient #24's medical record reflected a history and physical, dated 9/13/14, was not authenticated with a signature, date, or time. The consultation report, dated 9/14/14, was not authenticated with a signature, date, or time.


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4. Review of patient #17's medical record lacked the presence of a history and physical, and discharge summary.

5. Review of patient #18's medical record reflected a notification of death/release of body form, dated 6/26/14. The form was incomplete with missing documentation under the notification section, regarding autopsy, organ/tissue donation, ventilated or non-ventilated patient, and candidate for donation.

6. Review of patient #19's medical record reflected a notification of death/release of body form, dated 3/12/14. The form was incomplete with missing documentation under the notification section regarding autopsy, and candidate for donation. The form lacked a signature, date, and time under the mortician's receipt section.

7. Review of patient #45's medical record reflected a notification of death/release of body form, dated 1/30/14. The form lacked a documented time for initial notification of referral. The form lacked a date and time for the release of the body.

8. Review of patient #46's medical record reflected a notification of death/release of body form, dated 1/18/14. The form lacked a date and time of physician notification.

9. Review of patient #48's medical record reflected a notification of death/release of body form, dated 1/6/14. The form lacked a signature, date, and time under the mortician's receipt section.

Based on record review and policy review, the facility failed to ensure that all orders were dated and/or timed by the ordering practitioner in 5 (#s 22, 23, 25, 27, and 33) of 48 sampled patients' records. Findings include:

1. Review of patient #22's medical record reflected the discharge summary, dated 9/24/14, did not include a time or discharge date when signed by the physician.

2. Review of patient #23's medical record reflected a verbal order, taken on 9/15/14 at 10:00 a.m., had not been signed, dated or timed by the physician; a form titled "Oxytocin Administration/Induction/Augmentation Orders" was not signed, dated or timed by the physician; and a read-back telephone order (RBTO) dated 9/16/14 at 2:15 a.m. was not signed, dated or timed by the physician.

3. Review of patient #25's medical record reflected a read-back verbal order (RBVO) taken on 7/9/14 at 4 p.m. was not dated or timed when signed by the physician; a RBTO taken on 7/10/14 at 10:50 a.m. was not dated or timed by the physician; a telephone order taken 7/10/14 at 2:00 p.m. was not dated or timed by the physician; and a RBTO taken on 7/14/14 at 11:00 a.m. was not dated or timed by the physician.

4. Review of patient #27's medical record reflected RBVOs taken on 4/12/14 at 8:45 a.m. and 9:00 a.m., were not dated or signed by a physician; and a RBTO taken on 4/12/14 at 6:15 p.m. was not dated or timed by the physician.

5. Review of patient #33's medical record reflected the newborn nursery admission orders were not dated or timed by the physician.

Review of the policy titled, "Medical Records Completion" dated 7/14, showed:
..."Definition: 'Completion' includes all final signatures: dictations, changes, corrections, orders, etc. (ie, if you come to the department to dictate, that final dictation must be signed.)"

Based on record review and staff interview, the hospital failed to have the informed consent form for treatment authenticated with a signature, date, and time for 9 (#s 3, 6, 7, 11, 29, 30, 32, 38, and 46) of 48 records reviewed. Findings include:

1. Review of patient #3's medical record reflected the informed consent for treatment, dated 10/6/14, was not authenticated with a signature, date, or time.

2. Review of patient #6's medical record reflected the informed consent for treatment, dated 10/1/14, was not authenticated with a date or time.

3. Review of patient #7's medical record reflected the informed consent for treatment, dated 10/7/14, was not authenticated with a signature, date, or time.

4. Review of patient #11's medical record reflected the informed consent for blood transfusion, dated 4/4/14, was not authenticated time.

5. Review of patient #38's medical record reflected the informed consent for treatment, dated 9/20/14, was not authenticated with a signature.


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6. Review of patient #30's medical record reflected the consent for treatment form of the newborn was in the medical record, was blank, and did not have a signature, date or time by the infant's parent or witness.

7. Review of patient #32's medical record reflected the consent for treatment of the newborn, dated 7/9/14, was not signed, dated or timed by a witness, and the consent for the newborn metabolic screen program, dated 7/9/14, was not signed and dated by the nurse.

8. Review of Patient #29's medical record reflected the informed consent for a cesarean section with a possible hysterectomy, dated 11/13/13 was not timed when signed by the witness on 11/13/13.

During an interview on 10/8/14 at 3:05 p.m., staff member H, medical records manager, stated patient #30 may have an electronic 'consent for treatment', in the electronic system, Image.

During an interview on 10/8/14 at 3:15 p.m., staff member R, compliance manager, stated staff member H checked, and there was not an electronic consent for treatment for patient #30.


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9. Review of patient #46's medical record lacked an informed consent for treatment for the admission dated 1/10/14.

Based on observation and staff interview the hospital failed to provide food service under sanitary conditions. Findings include:

During an observation on 10/6/14 at 10:45 a.m., with staff member Q, dietary manager, the kitchen staff members were preparing food and did not have their hair restrained. There was a male staff member with facial hair preparing food. His facial hair was not restrained. Staff member Q stated she was not aware the hair net had to cover the entire head and a facial net was required for facial hair.

During the same observation, a freezer had a large accumulation of ice from the condenser. The ice was thick and dripping on boxes of food. The ice had accumulated on the racks in the freezer and the floor. At this time, the dietary manager stated she was unaware the condenser was not working. The maintenance department was notified.