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Based on review of credential files, review of physician orientation information and staff interview, the facility failed to ensure that 9 of 10 sampled medical staff reviewed (Physicians B, C, D, E, F, G, H, I and J) had a working knowledge of the hospital's restraint policies and procedures. The Medical Staff roster provided by the hospital listed 223 physician members with 101 in the Active category. Census on the first day of survey was 16. Findings are:

A. Interview with the Manager of Quality and Accreditation on 10/18/12 at 9:50 AM confirmed the hospital had no policy or procedure regarding physician and mid-level practitioner on the hospital's policy regarding the use of restraints or seclusions. education on restraint and seclusion.

B. Interview with the Medical Staff Coordinator on 10/18/12 from 9:00 AM - 9:45AM revealed the following:
- Physicians who are newly appointed to the medical staff must complete orientation;
- Part of the orientation is computer based with one screen concerning restraint use.
- Confirmed there was no documentation that the physicians had to sign acknowledging that they had read the restraint policy and procedure and had a working knowledge of the information.

C. Interview with the Medical Staff Coordinator on 10/18/12 at 11:00 AM revealed only those physicians with admitting privileges (Physicians in the Active category) would be able to order restraints.

D. Credential files for Physicians B, C, D, E, F, G, H, I and J were reviewed and these files included no documentation concerning training/education on restraint use.

Based on staff interviews, medical record reviews and review of the policies and procedures, the Acute Care Hospital (ACH) failed to maintain a medical record system in accordance with written policies and procedures to ensure completion of the medical record within 30 days for 7 closed patients' medical records (Patients 2, A, B, C, D, E, F and G). This pertained to completion of post operative reports for 1 of 1 closed inpatient (2-G); ensuring electronic signature for physician orders; and ensuring the record contained radiology reports for 2 closed patients' medical records (Patients H and I), ensuring the completion of radiology reports. Facility inpatient census was 16 upon entrance. Findings include:

A. Review on 10/16/12 at 3:00 PM of policies and procedures for delinquent medical records (effective date 4/23/12), revealed:
1) on page 1/3 - "Operative Reports - Handwritten operative reports shall be completed immediately after surgery. The surgeon shall also provide a dictated or ProVation operative report within 7 days of discharge";
2) on page 2/3 - "Any medical record with missing operative reports will be declared delinquent if not dictated or completed in ProVation system within 7 calendar days post discharge; All delinquent records of discharged inpatients, observation patients and ambulatory surgery patients will be declared delinquent if not completed within 30 calendar days following discharge";
3) on page 2/3 - "Each Thursday the Medical Records Department will notify physicians of their chart deficiencies. The notice will indicate which records are delinquent based on the definitions listed in section D of this policy. The notice will be faxed to the responsible physician's office. Furthermore, physicians will be informed that delinquent records are to be completed within two business days (or five calendar days of notification). If on the following Tuesday the delinquent medical record remains incomplete, the physician will be automatically suspended. A formal suspension letter will be sent to the physician.

Examples incude:
1) Review of Patient 2A's medical record dated 10/09/12, lacked a dicatated operative report, and was over 7 days post patient discharge;
2) Review of Patient 2-B's medical record dated 10/09/12, lacks a dictated operative report and was over 7 days post patient discharge;
3) Review of Patient 2-G's medical record dated 9/12/12, lacked an electronic physician's signature and the operative report and was 33 days post patient discharge; and
4) Review of Patient 2-H's medical record dated 9/12/12, lacked a radiology report and was over 33 days post patient discharge.

B. Interview with the Health Information Manager (HIM) on 10/17/12 at approximately 9:30 AM, revealed that the ACH had a total of 497 delinquent medical records from October 2011 through September 2012. This report did not indicate the reason the medical records fell into a delinquent status. Interview with the HIM further revealed at the time of survey if a physician's medical records were in a delinquent status the physician could continue to care for the current patients in the hospital, but would lose any further privileges to admit new patients. At the time of survey, there were no physicians that had lost their admission privileges. The HIM reported any authorized ACH personnel (including physicians) can access the electronic medical record system from offsite to make entries and complete any patient medical records.

Based on observation, staff interview and review of dietary documents, the facility failed to ensure that equipment and floors in the kitchen were kept clean. Patient census on the first day of the survey was 16. Findings are:

A. Tour of kitchen on 10/17/12 from 9:50 AM - 10:30 AM with the Dietary Manager revealed the following equipment and floors were in need of cleaning:

1. A moveable cart located by the cash register was soiled with food crumbs and other unidentified debris and was in need of cleaning. This cart held individual packets of salt and pepper and plastic disposable lids for beverages.

2. The top of the dishmachine had 2 large gloves that were stuck to the top of the dishmachine with a aqua-blue residue and was in need of cleaning.

3. The shelf under the clean side of the dishmachine had a white powder spilled onto the surface and was in need of cleaning.

4. The floor under the dishmachine was soiled with food, dirt, and other unidentified debris and was in need of cleaning.

5. A square floor fan that was running while food preparation was in progress was soiled with lint and fuzz clinging to the fan blades and the guards covering the fan blades.

6. The range/grill located next to the deep fat fryer was soiled with a greasy sticky residue on the left side of the range/grill, on the framework around the opening to the oven and on the bottom of the oven.

B. Interview with the Dietary Manager during the tour on 10/17/12 from 9:50 AM to 10:30 AM revealed that the dishroom should be cleaned every evening and confirmed that the dishroom had not been cleaned the evening of 10/16/12. Interview also revealed there were no cleaning check off sheets that were currently being used. The Dietary Manager provided copies of a Sanitation Self-Inspection Guide from the contract company that provided dietary services and indicated it had not been used.

C. Review of the contract for Nutrition Services dated 8/1/09 revealed the following concerning Sanitation "Nutrition Services employees shall be responsible for cleaning areas in accordance with mutually agreed upon policies and procedures. Client shall provide daily janitorial services for areas of the Premises in accordance with Client's policy."