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PEMISCOT COUNTY MEMORIAL HOSPITAL
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on interview and record review facility staff failed to ensure all orders were dated, timed and authenticated for three patients (Patients #1, #3 and #4) of five sampled patients. The facility census was 30.
Findings included:
1. Medical record review revealed Patient #1 entered the facility on 2/15/10. Review of Physician orders revealed the admit orders dated 2/15/10 were not timed.
2. Medical record review revealed Patient #3 entered the facility on 2/15/10. Review of the Physician orders revealed the admit orders dated 2/15/10 were not timed.
3. Medical record review revealed Patient #4 entered the facility on 2/11/10. Review of the Physician orders revealed the admit orders dated 2/11/10 were not timed.
In an interview on 2/17/10 Staff B, Quality Assurance Nurse confirmed the orders did not include the date. Staff B said the Physicians are to date and time their signatures.