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Tag No.: C0307
13611
15508
Based on interview, policy and record review, the facility failed to ensure for each patient that received health care services, entries in the medical record were authenticated with dated, timed signatures for 5 of 6 (IP1, IP2, IP3, IP5, IP6) in-patient records reviewed. Findings include:
IP1 was admitted on 10/13/10, after being seen in the emergency room. There was no time on the emergency physician's order sheet. There was no times on the physician-A's progress notes and orders dated 10/14/10.
IP2 was admitted on 10/14/10, and the admission orders written by physician-B were not dated or timed when signed.
IP3 was admitted on 10/12/10. The orders written on 10/12/10, were not timed when signed by physician-C. On 10/13/10, midlevel-A did not time an order when signed.
IP5 was admitted on 10/12/10, for a total hip surgery. Physician-D did not date or time the inpatient pre-op order, or physician's orders of 10/12/10.
IP6 was admitted for knee arthroplasty on 10/11/10. Physician-E did not time the orders of 10/13/10.
On 10/14/10, at 3 p.m. an interview with the Quality Director verified the findings.