HospitalInspections.org

The hospital reported a census of 52 patients. Based on record review and staff interview the hospital failed to ensure medical staff dated and/or timed all entries in the medical record for 7 of 16 current hospitalized sampled medical records (#'s 11, 12, 14, 22, 26, 28, and 29).

Findings included:

- Review on 6/16/10 of Medical Staff Rules and Regulations revealed under Section IV, 4.1-1 "...By the writing and signature of a member of the medical and dental staff. All orders will include date and time..."

- Review on 6/16/10 of the Medical Executive Committee meeting minutes of 5/14/10 revealed hospital administrative staff reviewed the requirement for dating and timing of orders.

- Patient #22's medical record revealed five physician orders lacked a time when written, three telephone order lacked a date and/or time when authenticated (signed), and four physician progress notes lacked a time when written between 6/9/10-6/14/10.








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- Patient #11's medical record revealed two physician verbal orders, one standing order for patient care and one medication order between 6/12/10 to 6/15/10 lacked the date and time when authenticated.

- Patient #12's medical record revealed three physician verbal orders on 6/15/10 lacked the date and time when authenticated.

- Patient #14's medical record revealed one physician verbal order, two routine orders for before and after surgery and one medication order on 6/15/10 lacked date or time when authenticated.


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- Patient #26's medical record revealed four verbal and/or telephone orders, dated 6/11/10-6/13/10, lacked a date and/or time when authenticated.

- Patient #28's medical record revealed ten verbal and/or telephone orders, dated 6/10/10-6/12/10, lacked a date and/or time when authenticated.

- Patient #29's medical record revealed four verbal and/or telephone orders, dated 6/8/10-6/13/10, lacked a date and/or time when authenticated.

- On 6/14/10 at 4:30pm, Administrative Staff A acknowledged the hospital required medical staff to date and time all entries in the medical record.