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Based on record review, the medical staff bylaws, and interview the facility failed to ensure all physician ' s orders are dated, timed and authenticated for 5 (SP#2, SP#4, SP#5, SP#28, SP#30) of 30 Sampled Patients.

The findings:

1. Record review of SP#2 medical record showed the physician order set for Insulin (subcutaneous) Physician Order Set) dated 03/02/16, the Rapid Response Team protocols orders dated 03/18/16 were not signed by the physician, dated and timed . Review of the telephone orders dated 03/18/16 and 03/20/16 were not signed by the physician, dated and timed.

2. Record review of SP#4 medical record showed the Restraint orders dated 03/05/16, 03/08/16 and 03/09/16 were signed by the physician without the dates and times of the signatures.

3. Record review of SP#5 showed the Wound Treatment Algorithm order dated 03/09/16 was signed by the physician without the date and time. The Telephone orders dated 03/8/16-03/09/16 showed that the orders were signed by the physician without the dates and times.

4. Record review of SP#28 showed Restraint orders dated 03/10/16, 03/11/16, 03/15/16, and 03/19/16- 03/23/16 were signed by the physician without the dates and times of the signatures.

5. Record review of SP#30 showed the Restraint orders dated 3/19/16- 03/21/16 were signed by the physician without indicating the dates and times.

Interview with the Director of Quality and Risk Management on 03/23/2016 around 2 PM confirmed the findings that physician orders were not always fully authenticated with signature including the dates and times. The Director of Quality and Risk Management also stated that opportunities for improvement have already been identified and are currently working on the risk reduction strategies. The Unit Clerks on the floor are constantly reminding the physicians of orders requiring signature and have placed reminder stickers on the patient charts. The missing dates and times will be completely resolved as soon as the hospital converts to full electronic record. The nursing staff will be reinforced to be more aggressive in reminding the ordering practitioners to ensure full authentication of all orders promptly.

Observation conducted on the patient care area "8th Floor" on 3/24/16 around 2:30 PM showed that the charts for current patients have stickers to remind the practitioners to sign, date, and time their orders

The facility's "medical staff bylaws" state that all orders, including verbal orders must be dated, timed and authenticated by the prescribing physician, a licensed independent practitioner within the prescribing physician's group practice or specialty who is responsible for the patient's care or another physician responsible for the care of the patient, even if the order did not originate with him/her. The physician's order must be written clearly, legibly and completely.

Based on record review, medical staff bylaws, and interview the facility failed to ensure all physician ' s orders are dated, timed and authenticated for 5 (SP#2, SP#4, SP#5, SP#28 and SP#30) of 30 Sampled Patients.

The findings:

1. Record review of SP#2 medical record showed the physician order set for Insulin (subcutaneous) Physician Order Set) dated 03/02/16, the Rapid Response Team protocols orders dated 03/18/16 were not signed by the physician, dated and timed . Review of the telephone orders dated 03/18/16 and 03/20/16 were not signed by the physician, dated and timed.

2. Record review of SP#4 medical record showed the Restraint orders dated 03/05/16, 03/08/16 and 03/09/16 were signed by the physician without the dates and times of the signatures.

3. Record review of SP#5 showed the Wound Treatment Algorithm order dated 03/09/16 was signed by the physician without the date and time. The Telephone orders dated 03/8/16-03/09/16 showed that the orders were signed by the physician without the dates and times.

4. Record review of SP#28 showed Restraint orders dated 03/10/16, 03/11/16, 03/15/16, and 03/19/16- 03/23/16 were signed by the physician without the dates and times of the signatures.

5. Record review of SP#30 showed the Restraint orders dated 3/19/16- 03/21/16 were signed by the physician without indicating the dates and times.

Interview with the Director of Quality and Risk Management on 03/23/2016 around 2 PM confirmed the findings that physician orders were not always fully authenticated with signature including the dates and times. The Director of Quality and Risk Management also stated that opportunities for improvement have already been identified and are currently working on the risk reduction strategies. The Unit Clerks on the floor are constantly reminding the physicians of orders requiring signature and have placed reminder stickers on the patient charts. The missing dates and times will be completely resolved as soon as the hospital converts to full electronic record. The nursing staff will be reinforced to be more aggressive in reminding the ordering practitioners to ensure full authentication of all orders promptly.

Observation conducted on the patient care area "8th Floor" on 3/24/16 around 2:30 PM showed that the charts for current patients have stickers to remind the practitioners to sign, date, and time their orders

The facility's " medical staff bylaws" state that all orders, including verbal orders must be dated, timed and authenticated by the prescribing physician, a licensed independent practitioner within the prescribing physician's group practice or specialty who is responsible for the patient's care or another physician responsible for the care of the patient, even if the order did not originate with him/her. The physician's order must be written clearly, legibly and completely.