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Based on staff interview and record review the facility revealed that for 8, (#s 21,22,24,25,27,28,29, and #30), of 10 ER records reviewed, the facility failed ensure that all entries on the Emergency Room Physician Treatment Sheet were dated and timed by the physician/practitioner.

Findings:

Review of the emergency room medical record for patient #21 revealed that the patient was seen in the emergency room on 12/31/2016. The Physician Treatment Sheet revealed that both the sections titled Progress and Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #22 revealed that the patient was seen in the emergency room on 12/30/2016. The Physician Treatment Sheet revealed that both the sections titled Progress and Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #24 revealed that the patient was seen in the emergency room on 12/19/2016. The Physician Treatment Sheet revealed that both the sections titled Progress and Clinical Impressions did not reveal the time the entry was made by the physician/practitioner

Review of the emergency room medical record for patient #25 revealed that the patient was seen in the emergency room on 11/30/2016. The Physician Treatment Sheet revealed that the section titled Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #27 revealed that the patient was seen in the emergency room on 11/25/2016. The Physician Treatment Sheet revealed that the section titled Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #28 revealed that the patient was seen in the emergency room on 10/28/2016. The Physician Treatment Sheet revealed that the section titled Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #29 revealed that the patient was seen in the emergency room on 10/27/2016. The Physician Treatment Sheet revealed that both the sections titled Progress and Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

Review of the emergency room medical record for patient #30 revealed that the patient was seen in the emergency room on 10/26/2016. The Physician Treatment Sheet revealed that both the sections titled Progress and Clinical Impressions did not reveal the time the entry was made by the physician/practitioner.

During an interview on 01/04/2017 at 1:30 PM, the Director of Nursing states that she was aware that the physicians dating and timing of emergency room medical records was problematic.

Review of the the facilty's policy and procedure "Medical Records " no date, shows under Recorded Entries in the Medical Record Line B "All entries in the medical record shall clearly identify the date and time of the entry. The date and time shall identify when the entry is made, regardless of whether it relates to prior events.

Based on staff interview, of the medial facility document review and medical record review the facility failed for 1, (#1), of 30 records reviewed to ensure that a History and Physical was completed within 24 hours after admission.

Findings:

Review of the Medical Record for patient #1 revealed that he was admitted to the facility on 12/31/2016. Review of the medial record on 01/03/2016 at 11:09 AM did not reveal that a History and Physical was completed.

During an interview on 01/05/2017 at 1:17 PM, the Director of Medical Records and review of the medical record for patient #1 on 01/05/2017 at 1:17 PM did not reveal that a History and Physical was completed by the physician. The Director of Medical Records revealed History and Physical. (H&P) are to be completed within 24 hours of admission.

Review of the the facility's policy titled "Medical Records Policy and Procedure History and Physical( H and P) : shows " The H&P shall be dictated no later that 24 hours after the patient's admission..."

Based on medical record review, interview, and review of the facility's Policy and Procedures revealed that the physician failed to read, interpret, and dictate findings of Echocardiograms of 2 (patient #7 & #14) of 17 of discharged patients reviewed.

Finding:

Medical record review for patient #7 that she presented to the Emergency Room (ER) on 07/16/16 with a complaint of Chest Pain, and the ER physician ordered an Echocardiogram (Echo), and to be interpreted and read by the Cardiologist. The content of the medical record failed to have documentation of dictation of the findings of the Echo by the Cardiologist.

Medical record review for patient #14 that he presented to the ER on 10/02/16 with a complaint of Chest Pain, and the ER physician ordered an Echo, and to be interpreted and read by the Cardiologist. The content of the medical record failed to have documentation of dictation of the findings of the Echo by the Cardiologist.

During an interview on 01/04/17 at 10:00 AM,the Director of Radiology stated, we had difficulty with that physician having documentation of dictation of his findings, and we used to ask him before he left the building each day if he had read and dictated the Echo's that we had presented to him, and he always said yes, and we had discovered that he had not.

Review of the facility's Policy and Procedures titled "Medical Records" no date shows the following: Consultative Records: All patient records, both inpatient and outpatient, must contain the results of consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. The information must be promptly filed in the medical record.