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The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to protect the patient's right for restraints and informed consent for 3 of 25 patients (#1, 7 and 12) and failed to assure the hospital properly maintained medical records for patients #2, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24 and 25.

Findings included:

- The hospital failed to protect and assure the patients had signed consents for treatments and for the use of restraints as evidenced at CFR 482.13 condition of participation for patient rights.

- The hospital failed to protect and assure the patients had signed consents for treatments and for the use of restraints as evidenced at CFR 482.13 condition of participation for patient rights.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure the medical staff followed their rules and regulations for medical record completion.

Findings included:

- Review of Hospital policy for "History and Physical for Inpatient or Outpatient Surgical or Procedures Requiring Anesthesia Services...", #140-250, stated that History and Physicals (H&P's) will be valid for 30 days. H&P's greater than 7 days old, but within 30 days, require an interim note to update the H&P for any changes in patient condition. This policy stated that "...An H&P completed greater than 30 days prior to an admission does not meet the requirement for a current H&P and cannot be updated. A new H&P is, therefore, required..."

- The Hospital's Pre-Procedure Surgical checklist contained an area to document the surgical patient's required H&P.

- Review of the medical record for patient #21, admitted for surgery on 1/7/10, documented the Hospital accepted a H&P completed by a physician on 8/24/09. The medical record failed to contain any update to the H&P of 8/24/09. The only H&P in patient #21's medical record was greater than four months old.

- Review of the medical record for patient #22, admitted for surgery on 2/1/10, documented a H&P completed on 12/7/09, 34 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P"section on 2/1/10 instead of completing a new H&P as the Hospital policy directed. This patient's record documented diagnoses that would require current assessment of the patient's status which included Hypertension and Type 2 Diabetes.

- Review of the medical record for patient #23, admitted for surgery on 12/29/09, documented a H&P completed on 11/9/09, 51 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 12/29/09 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #24, admitted for surgery on 3/8/10, documented a H&P completed on 2/2/10, 35 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 3/8/10 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #25, admitted for surgery on 2/15/10, documented a H&P completed on 1/5/10, 40 days prior to admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P section on 2/15/10, instead of completing a new H&P as the Hospital policy directed.

-Interview with staff member C, on 5/13/10 at 10:30am verified the Hospital Physicians did not follow the hospital policy for proper documentation and update of the History and Physicals for the five patients prior to surgery.

- The Governing Body failed to assure the Accountability of the Physician's for following the Hospital policy directing proper assessment and completion of the History and Physicals for surgical patients.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to monitor their contract dialysis services to assure the patients received dialysis treatments as ordered by the physician for 1 of 1 patients (#10).

Findings included:

- Review of patient #10's medical record revealed an admission date of 1/20/10 and required acute dialysis treatments.

Review of patient #10's treatment records revealed the contract dialysis staff failed to follow the physician's dialysis orders for their dialysis treatments between 1/20/10 and 1/25/10 as follows:

1. Review of their dialysis orders dated 1/20/10, lacked a time, directed the staff to provide three and a half hours of dialysis treatment, at a blood flow rate 400 and dialysate flow rate of 800. The order directed the staff to use normal saline flushes to prevent the blood from clotting and use a linear sodium profile with a profile II setting for management of hypotension.

Review of the treatment record for 1/20/10 revealed the dialysis staff provided 3 hours and 4 minutes, which shortened their treatment by 26 minutes and set the dialysate flow rate at 500 not the ordered 800.

The dialysis staff administered 2300 ml (milliliters) of normal saline during the treatment without an order. The patient has a fluid restriction due to their inability to excrete fluid.

The nurse noted they turned off the ultra filtration rate (UFR), (the process of fluid and toxin removal during treatment, which takes place of urination) at 10:45am to manage the patient's hypotension (low blood pressure) without physician orders.

2. Review of the dialysis treatment orders dated 1/22/10, lacked a time, directed the staff to provide three and a half hours of dialysis treatment with a dialysate flow rate of 500 and lacked directions to manage hypotension.

Review of the treatment record for 1/22/10 revealed the contract dialysis staff provided two hours and 12 minutes of dialysis, which shorten their treatment by one hour and 18 minutes and set the dialysate flow rate at 800.

The staff documented they turned off the UFR at 11:30 and administered 2300 ml of normal saline without physician orders to manage the patient's hypotension.

3. Review of the dialysis treatment orders dated 1/25/10, lacked a time, directed the staff to provide three and a half hours of treatment, administer 50 mg (milligrams) of albumin three times during treatment.

Review of the treatment record for 1/25/10 revealed the contracted dialysis staff provided three hours and eight minutes of treatment, which shortened the treatment by 22 minutes.

The treatment documentation revealed the contract staff administered two doses of 25 mg albumin, not the ordered three doses of 50 mg of the medication and administered 2100 ml of normal saline without a physician's order.

4. Review of the dialysis treatment orders dated 1/27/10, lacked a time, directed the staff to provide three and a half hours of treatment.

Review of the treatment documentation revealed the staff provided three hours and 25 minutes of dialysis treatment and turned off the UFR at 8:30am, but document the UFR continued to run during treatment and administered 1500 ml of normal saline without a physician's order.

Interview with administrative staff B on 5/13/10 at 8:00am reported the hospital did not include the contracted dialysis staff in their quality assurance reviews and lacked knowledge of their failure to follow physician orders.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure staff obtained signed informed consents for 2 of 25 patients (#7 and 12). Staff failed to follow their established policies for restraint use for patient #2.

Findings included:

- The hospital failed to assure the patients had signed consents for treatments as evidenced at CFR 482.13(b)(2), at A-131.

- The hospital failed to assure the staff established a plan of care for the use of restraints as evidenced at CFR 482.13(e)(4)(i), at A-166.

- The hospital failed to assure the staff obtained physician orders for the use of restraints as evidenced at CFR 482.13(e)(5), at A-168.

- The hospital failed to assure the physician's did not use PRN orders for the use of restraints as evidenced at CFR 482.13(e)(6), at A-169.

- The hospital failed to assure the staff documented when they discontinued the use of restraints as evidenced at CFR 482.13(e)(9), at A-174.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure staff obtained written consents for 2 of 25 patient medical records reviewed ( # 7 and #10).

Findings included:

- Review of the hospital's policy for consent for treatment #950.73, revised on 1/6/06 directs the hospital staff to obtain a consent from patients and from the parent when the child is under the age of 16 prior to invasive procedures.

- Review of newborn, patient #7's medical record revealed a birth date of 3/10/10 and required a MRI (Magnetic Residence Imaging), with contrast dye on 3/12/10. Review of the medical record lacked evidence of a signed consent for the MRI with contrast.

Interview with administrative staff B on 5/12/10 at 10:00am reported the record lacked evidence of a signed consent for the MRI.

- Review of patient #10's medical record revealed a admission date of 1/19/10. Patient # 10 had surgery for the removal of a dialysis catheter on 1/20/10 and required acute dialysis treatment.

Review of the surgical record revealed physician Y allowed resident Z in the operating room during the patient's catheter removal.

Review of the surgical consent lacked evidence of the patient consent to have the resident present during their surgery.

Review of the medical record revealed the patient had four dialysis treatments between 1/20/10 and 1/25/10. Review of the medical record lacked evidence of a consent for their dialysis treatments.

Interview with administrative staff B on 5/12/10 at 10:00am reported the record lacked evidence of a signed consent for the resident during surgery and the dialysis treatments.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure the staff established a plan of care for the use of restraints for 1 of 1 patients who required restraints (patient #2).

Findings included:

- Review of the hospital's policy for Plan of Care #NS-C-VI-05, revised 11/08 directed the staff to establish a plan of care that reflects the patient's needs, healthcare concerns and patient goals/outcomes within eight hours of admission and revised the plan of care as appropriate.

Review of patient #2's medical record revealed an admission date of 2/10/10 with diagnoses of anemia, syncope, aortic dissection and required use of restraints.

Review of the patient's restraint flow sheet revealed the patient had soft wrist restraints, bedrails and chemical restraint initiated on 2/16/10.

Review of the medical record lacked evidence of the use of plan of care for the use of restraints.

Interview with administrative staff B on 5/12/10 at 3:00pm reported the medical record lacked evidence of a restraint plan of care.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to obtain a written physician's order for restraints for patient # 2.

Findings included:

- Review of Restraint policy #NS-C-XVI-02 revised 3/07 states"A patient has the right to be free from restraints of any form that are not medically necessary; therefore restraints shall be used only if needed to improve patient's "well being" and when ordered by a physician, for a specific purpose when medically indicated. The physician/licensed independent practitioner (LIP) order must be written for a specific type, specific purpose, duration of time including when to discontinue and the use of standing orders/PRN orders are not acceptable.

Review of patient #2's medical record revealed an admission date of 2/10/10 with diagnoses of anemia, syncope, a aortic dissection and required use of restraints.

Review of the patient's medical record revealed a PRN order for restraints on the hospital's Post Cardiac Surgical Orders revised 11/09, that directed the staff "Standard ICU Nursing Care" Soft Wrist restraints PRN while patient intubated and Discontinue after extubation." The order lacked evidence of a physician's signature.

Review of the physician orders dated 2/16/10 revealed a written order for soft wrist restraints. Review of the order on 5/11/10 lacked evidence of a physician signature.

Interview with administrative staff B on 5/12/10 at 3:00pm reported the medical record lacked evidence of a signed order for the use of the restraints.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to prohibit the use of standing orders for the use of restraints for 1 of 1 patients that required restraints (patient # 2).

Findings included:

- Review of Restraint Policy #NS-C-XVI-02 revised 3/07 stated "A patient has the right to be free from restraints of any form that are not medically necessary; therefore restraints shall be used only if needed to improve patient's "well being" and when ordered by a physician, for a specific purpose when medically indicated. The physician/licensed independent practitioner (LIP) order must be written for a specific type, specific purpose and duration of time including when to discontinue. Standing orders and PRN orders are not acceptable.

Review of patient #2's medical record revealed an admission date of 2/10/10 with diagnoses of anemia, syncope, required surgery to correct a aortic dissection and required use of restraints.

Review of the patient #2's medical record revealed a Post Cardiac Surgical Orders revised 11/09, not signed by the physician, dated 2/15/10 that directed the staff "Standard ICU Nursing Care" to apply Soft Wrist restraints PRN while patient intubated and Discontinue after extubation."

Interview with administrative staff B on 5/12/10 at 3:00pm reported the hospital did not allow PRN restraints and verified the staff had placed the patient in restraints.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure the staff documented when they discontinued the use of restraints for 1 of 1 patients (patient #2).

Findings included:

- Review of the hospital's policy for Restraints policy #NS-C-XI-02 revised 3/07 states "A patient has the right to be free from restraints of any form that are not medically necessary; therefore restraints shall be used only if needed to improve patient's "well being" and when ordered by a physician, for a specific purpose when medically indicated. Restraints shall be used only when least restrictive measures have been found to be ineffective to protect the patient and others from harm, and removed at the earliest possible time.

Review of patient #2's medical record revealed an admission date of 2/10/10 with diagnoses of anemia, syncope, a aortic dissection and required use of restraints.

Review of restraint flow sheet revealed the staff initiated soft wrist restraints, bedrails and chemical restraints on 2/16/10 and lacked evidence of when the staff discontinued the restraint for this patient.

Interview with administrative staff B on 5/12/10 at 3:00pm reported the medical lacked evidence of when the staff discontinue the restraint.

The Hospital identified a census of 116 patients. Based on record review, document review and staff interview, the Medical Staff failed to ensure physicians properly completed a History and Physical prior to surgery for 5 of 7 surgical patients (#21, 22, 23, 24, 25).

Findings included:

- Review of Hospital policy for "History and Physical for Inpatient or Outpatient Surgical or Procedures Requiring Anesthesia Services...", #140-250, stated that History and Physicals (H&P's) will be valid for 30 days. H&P's greater than 7 days old, but within 30 days, require an interim note to update the H&P for any changes in patient condition. This policy stated that "...An H&P completed greater than 30 days prior to an admission does not meet the requirement for a current H&P and cannot be updated. A new H&P is, therefore, required..."

- The Hospital's Pre-Procedure Surgical checklist contained an area to document the surgical patient's required H&P.

- Review of the medical record for patient #21, admitted for surgery on 1/7/10, documented the Hospital accepted a H&P completed by a physician on 8/24/09. The medical record failed to contain an update to the H&P of 8/24/09. The only H&P in #21's medical record was greater than 4 months old.

- Review of the medical record for patient #22, admitted for surgery on 2/1/10, documented a H&P completed on 12/7/09, 34 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P"section on 2/1/10 instead of completing a new H&P as the Hospital policy directed. This patient's record documented diagnoses that would require current assessment of the patient's status which included Hypertension and Type 2 Diabetes.

- Review of the medical record for patient #23, admitted for surgery on 12/29/09, documented a H&P completed on 11/9/09, 51 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 12/29/09 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #24, admitted for surgery on 3/8/10, documented a H&P completed on 2/2/10, 35 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 3/8/10 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #25, admitted for surgery on 2/15/10, documented a H&P completed on 1/5/10, 40 days prior to admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P section on 2/15/10, instead of completing a new H&P as the Hospital policy directed.

-Interview with staff member C, on 5/13/10 at 10:30am verified the Hospital Physicians did not follow the facility policy for proper documentation and update of the History and Physicals for the five patients prior to surgery.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure the staff established a plan of care to meet the patients needs for 4 of 25 patients (#1, 2, 9 and 10).

Findings included:

- Review of patient #5's medical record revealed an admission date of 1/27/10 with the diagnosis of stomach cancer and required TPN (total parental nutrition) intravenously.

Review of patient #5's plan of care lacked documentation for their dietary needs.

- Review of patient #9's medical record revealed an admission date of 1/11/10 with diagnoses of appendicitis with abscess and possible appendix perforation. Review of the medical record revealed they had a urinary catheter and orders not to eat prior to their surgery on 1/11/10 and after the surgery had orders to advance their diet as tolerated.

Review of patient #9's plan of care lacked documentation for the use of a urinary catheter and diet requirements for this patient.

- Review of patient #10's medical record revealed an admission date of 1/19/10 with diagnosis of end stage renal disease and require dialysis.

Review of their plan of care lacked evidence of a their renal diet, fluid restrictions and dialysis treatments.

- Non compliance with plans of care also affected patients #1 and 2.

- Interview with administrative staff B on 5/13/10 at 10:00am reported the medical records lacked plans of care that reflected the patients needs.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure the medical staff properly signed medication orders for 1 of 25 patients (#2).

Findings included:

- Review of patient #2's medical record revealed an admission date of 2/10/10 with diagnoses of anemia, syncope and a aortic dissection and a discharge date of 3/4/10. Review of their medication orders on 5/12/10 revealed nine entries between 2/11/10 to 3/4/10 for medications that lacked a physician signature, an example of which follows:

2/11/10 Lortab (a pain medication) 5 mg (milligrams) one to two tablets PRN, phone ordered and not signed by physician V.

2/11/10 Sliding scale insulin, ordered and not signed by physician AA.

2/11/10 Fentanyl 50 mcg (microgram) intravenously one time, ordered and not signed by physician E.

2/15/10 ASA 81 mg and diazepam 5 mg, ordered and not signed by physician D.

2/15/10 lactated ringer 125 ml/hr (milliliter per hour), ordered and not signed by physician DD

3/3/10 Zofran 4 mg IV every 8 hours ordered and not signed by physician N.

Interview with administrative staff B reported the hospital required all medication orders to be signed in 48 hours and verified these orders lacked signatures.

The Hospital identified a census of 116 patients. Based on record review, document review and staff interview, the hospital failed to assure 14 of 20 sampled medical records had all entries timed by the practitioners (#2, 4, 5, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20), and failed to assure 3 Physicians (AA , X, and V) properly authenticated all medical records for patient #2, failed to assure physicians completed a History and Physical prior to surgery for 5 of 7 surgical patients (#21, 22, 23, 24, 25), failed to assure staff obtained signed informed consents for 2 of 25 patients (#7 and 12), failed to assure the timely completion of all medical records, and failed to enforce it's policy for Physician suspension for the 18 Physicians involved (D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U).

Findings included:

- The hospital failed to assure the entries in the patients records were complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures as evidenced at CFR 482.24(c)(1), A-450.

- The hospital failed to assure the physician completed histories and physicals in a timely manner as evidenced at CFR 482.24(c)(2), A-458.

- The hospital failed to assure the medical records had final diagnosis with completion of medical records within 30 days following discharge as evidenced at CFR 482.24(c)(2)(v), A-466.

- The hospital failed to assure the medical records had properly executed informed consent forms for procedures and treatments as evidenced at CFR 482.24(c)(2)(v)(iii), A-469.

The Hospital identified a census of 116 patients. Based on record review, document review and staff interview, the Hospital failed to assure 14 of 20 sampled medical records had all entries timed by the practitioners (#2, 4, 5, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20), and failed to assure 3 Physicians (AA , X, and V) properly authenticated all medical records for patient #2.

Findings included:

- Review of the Hospital policy titled :"Medical Record Content, Maintenance & Completion", number 768.09, last revised on 12/1/09, "...34. All medical record entries must be legible, dated, timed and authenticated in written or electronic form..."

- Review of the medical record for patient #11 revealed Physician's orders dated 10/23/09, 10/24/09, and two orders on 10/21/09, lacked the timing of the entry into the medical record. This medical record also contained Progress notes on 10/21/09 and 10/24/09 which lacked timing of the entry.

- Review of the medical record for patient #13 revealed Physician's orders on 5/5/10 and 5/7/10 which lacked documentation of the time the staff made the entry into the medical record.

- Review of the medical record for patient #14 revealed Physician's orders dated 5/6/10 (2 entries), 5/7/10, and 5/9/10 lacked documentation of the time the staff made the entry into the medical record.

- Interview with staff member C, on 5/13/10 at 10:30am verified the Hospital had difficulty getting some Physician's to time entries made in the medical record.

- Lack of compliance with this regulation also affected patients #2, 4, 5, 8, 9, 10, 18, 19, 20.


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- Review of patient #2's medical record revealed a consultation report by physician X and history and physical by physician V lacked evidence of a signature on the reports when reviewed on 5/13/10.

Interview with administrative staff C on 5/13/10 at 10:15am stated the physician failed to sign the report and the report lacked authentication.

- Review of patient #2's progress notes revealed six entries by physician AA that lacked notation of the year and time they made the entry.

- Review of patient #4's medical record revealed a admission date of 2/10/10. Review of their progress notes revealed physician R failed to write the year after the date on a progress note.

Review of patient #4's social work notes dated 2/24/10 revealed the addendum note lacked a signature of the social worker that completed the documentation.

-Interview with administrative staff C on 5/13/10 at 10:15am review the documents and reported the physician failed to properly date and time their entry.

The Hospital identified a census of 116 patients. Based on record review, document review and staff interview, the Hospital failed to assure physicians completed a History and Physical prior to surgery for 5 of 7 surgical patients (#21, 22, 23, 24, 25).

Findings included:

- Review of Hospital policy for "History and Physical for Inpatient or Outpatient Surgical or Procedures Requiring Anesthesia Services...", #140-250, stated that History and Physicals (H&P's) will be valid for 30 days. H&P's greater than 7 days old, but within 30 days, require an interim note to update the H&P for any changes in patient condition. This policy stated that "...An H&P completed greater than 30 days prior to an admission does not meet the requirement for a current H&P and cannot be updated. A new H&P is, therefore, required..."

- The Hospital's Pre-Procedure Surgical checklist contained an area to document the surgical patient's required H&P.

- Review of the medical record for patient #21, admitted for surgery on 1/7/10, documented the Hospital accepted a H&P completed by a physician on 8/24/09. The medical record failed to contain an update to the H&P of 8/24/09. The only H&P in patient #21's medical record was greater than four months old.

- Review of the medical record for patient #22, admitted for surgery on 2/1/10, documented a H&P completed on 12/7/09, 34 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P"section on 2/1/10 instead of completing a new H&P as the Hospital policy directed. This patient's record documented diagnoses that would require current assessment of the patient's status which included Hypertension and Type 2 Diabetes.

- Review of the medical record for patient #23, admitted for surgery on 12/29/09, documented a H&P completed on 11/9/09, 51 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 12/29/09 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #24, admitted for surgery on 3/8/10, documented a H&P completed on 2/2/10, 35 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 3/8/10 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #25, admitted for surgery on 2/15/10, documented a H&P completed on 1/5/10, 40 days prior to admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P section on 2/15/10, instead of completing a new H&P as the Hospital policy directed.

-Interview with staff member C, on 5/13/10 at 10:30am verified the Hospital Physicians did not follow the hospital policy for proper documentation and update of the History and Physicals for the five patients prior to surgery.

The hospital reported a census of 116 patients with 25 open and closed medical records reviewed. Based on document review and staff interview the hospital failed to assure staff obtained signed informed consents for 2 of 25 patients (#7 and 12).

Findings included:

- Review of the hospital's policy for consent for treatment #950.73, revised on 1/6/06 directs the hospital staff to obtain a consent from patients and from the parent when the child is under the age of 16 prior to invasive procedures.

- Review of newborn, patient #7's medical record revealed a birth date of 3/10/10 and required a MRI (Magnetic Residence Imaging), with contrast dye on 3/12/10. Review of the medical record lacked evidence of a signed consent for the MRI with contrast.

Interview with administrative staff B on 5/12/10 at 10:00am reported the record lacked evidence of a signed informed consent for the MRI.

- Review of patient #10's medical record revealed a admission date of 1/19/10. Patient # 10 had surgery for the removal of a dialysis catheter on 1/20/10 and required acute dialysis treatment.

Review of the surgical record revealed physician Y allowed resident Z in the operating room during the patient's catheter removal.

Review of the surgical consent lacked evidence of the patient consent to have the resident present during their surgery.

Review of the medical record revealed the patient had four dialysis treatments between 1/20/10 and 1/25/10. Review of the medical record lacked evidence of a consent for their dialysis treatments.

Interview with administrative staff B on 5/12/10 at 10:00am reported the record lacked evidence of a signed informed consent for the resident during surgery and the dialysis treatments.

The Hospital identified a census of 116 patients. Based on document review and staff interview, the Hospital failed to assure the timely completion of medical records, and failed to enforce it's policy for Physician suspension for the 18 Physicians involved (D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U).

Findings included:

- The Hospital Policy for "Delinquent Medical Records", 768.06, last revised on 3/1/09, documented "...2. SUSPENSION OF CLINICAL PRIVILEGES DUE TO DELINQUENT MEDICAL RECORDS: A medical record is delinquent when it remains incomplete 30 days post discharge as identified on the practitioners incomplete chart list..." "...2.2 Failure to complete the delinquent medical records will be cause for temporary suspension of a practitioner's clinical privileges until all such medical records are completed. A temporary suspension of clinical privileges will encompass all admissions to the hospital (inpatient, outpatient, emergency and ancillary service admissions), consultations and performance of any and all other hospital-based procedures..."

- Review of the Physician Record Delinquencies list, generated on 5/13/10 at 10:43am, revealed multiple delinquent patient records, without suspension of the Physician's by the hospital which included:

(1) Physician D failed to complete the medical record of patient #26 for 614 days.

(2) Physician E failed to complete the medical record of patient #27 for 114 days.

(3) Physician F failed to complete the medical record of patient #26 for 614 days.

(4) Physician G failed to complete the medical record of patient #28 for 238 days , patient #29 for 133 days and patient #30 for 132 days.

(5) Physician H failed to complete the medical record of patient #31 for 60 days.

(6)Physician I failed to complete the medical record of patient #32 for 602 days, and patient #33 for 162 days.

(7) Physician J failed to complete the medical record of patient #34 for 132 days.

(8) Physician K failed to complete the medical record of patient #29 for 114 days.

(9) Physician L failed to complete the medical record of patient #35 for 259 days.

(10) Physician M failed to complete the medical record of patient #36 for 106 days.

(11) Physician N failed to complete the medical record of patient #37 for 230 days.

(12) Physician O failed to complete the medical record of patient #38 for 216 days.

(13) Physician P failed to complete the medical record of patient #39 for 214 days.

(14) Physician Q failed to complete the medical record of patient #40 for 197 days.

(15) Physician R failed to complete the medical record of patient #41 for 152 days.

(16) Physician S failed to complete the medical record of patient #27 for 114 days.

(17) Physician T failed to complete the medical record of patients #42 and #43 for 84 days.

(18) Physician U failed to complete the medical record of patient #44 for 64 days, patient #45 for 57 days, patient #46 for 41 days, patient #47 for 40 days, patient #48 for 39 days, and patient #49 for 35 days.

- Interview with staff member C, on 5/13/10 at 12:05pm stated someone of unknown origin turned off the computer system which alerted medical records of delinquent records and therefore no physician's got suspended for the overdue records. This staff member verified the Hospital allowed the physician's to continue to admit and care for patients.

The Hospital identified a census of 116 patients. Based on record review, document review and staff interview, the Surgical Staff failed to assure the medical record contained a properly completed History and Physical prior to surgery for 5 of 7 non-emergent surgical patients (#21, 22, 23, 24, 25).

Findings included:

- Review of Hospital policy for "History and Physical for Inpatient or Outpatient Surgical or Procedures Requiring Anesthesia Services...", #140-250, stated that History and Physicals (H&P's) will be valid for 30 days. H&P's greater than 7 days old, but within 30 days, require an interim note to update the H&P for any changes in patient condition. This policy stated that "...An H&P completed greater than 30 days prior to an admission does not meet the requirement for a current H&P and cannot be updated. A new H&P is, therefore, required..."

- The Hospital's Pre-Procedure Surgical checklist contained an area to document the surgical patient's required H&P.

- Review of the medical record for patient #21, admitted for surgery on 1/7/10, documented the Hospital accepted a H&P completed by a physician on 8/24/09. The medical record failed to contain an update to the H&P of 8/24/09. The only H&P in patient #21's medical record was greater than four months old.

- Review of the medical record for patient #22, admitted for surgery on 2/1/10, documented a H&P completed on 12/7/09, 34 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P"section on 2/1/10 instead of completing a new H&P as the Hospital policy directed. This patient's record documented diagnoses that would require current assessment of the patient's status which included Hypertension and Type 2 Diabetes.

- Review of the medical record for patient #23, admitted for surgery on 12/29/09, documented a H&P completed on 11/9/09, 51 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 12/29/09 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #24, admitted for surgery on 3/8/10, documented a H&P completed on 2/2/10, 35 days prior to this admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P" section on 3/8/10 instead of completing a new H&P as the Hospital policy directed.

- Review of the medical record for patient #25, admitted for surgery on 2/15/10, documented a H&P completed on 1/5/10, 40 days prior to admission. The Physician signed the form adopted by the Hospital for completion of an updated H&P, if done within the previous 30 days, marked the "I concur with the H&P section on 2/15/10, instead of completing a new H&P as the Hospital policy directed.

-Interview with staff member C, on 5/13/10 at 10:30am verified the Hospital Physicians did not follow the hospital policy for proper documentation and update of the History and Physicals for the five patients prior to surgery.