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Based upon review of medical records and interview with staff it was determined that 17 out of 27 (63%) (MR# 7,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25 and MR#26) of medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement is not met as follows.

Findings:

a. Reviewed 27 medical records (MR # 1-27) there were 17 out of 27 (63%) of the medical records reviewed ( MR# 7,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25 and MR#26) that had medical entries or authentications that were either not dated and/or timed and/or authenticated. These medical entries ranged from history and physicals and verbal/telephone orders that were not dated or timed, lack of discharge notices in medical records of swing bed patients. There were 14 out of the 27 (52%) medical records (MR# 7,11,12,13,14,18,19,20,21,22,23,24,25 and MR#26) reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours. There were 2 out of 26 medical records (7%) (MR# 7 and MR #10) that had history and physicals that were not dated and timed by physician.

b. Interviewed staff #12, Director of Health Information Management (HIM) at 10:00am on Sept. 13, 2010 in the administration conference room and explained and showed examples of medical entries that contained missing dates, times or authentications that were missing date and/or time and also showed swing bed medical records that were missing discharge notices. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that 17 out of 27 (63%) (MR# 7,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25 and MR#26) of medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement is not met as follows.

Findings:

a. Reviewed 27 medical records (MR # 1-27) there were 17 out of 27 (63%) of the medical records reviewed ( MR# 7,10,11,12,13,14,16,17,18,19,20,21,22,23,24,25 and MR#26) that had medical entries or authentications that were either not dated and/or timed and/or authenticated. These medical entries ranged from history and physicals and verbal/telephone orders that were not dated or timed, lack of discharge notices in medical records of swing bed patients. There were 14 out of the 27 (52%) medical records (MR# 7,11,12,13,14,18,19,20,21,22,23,24,25 and MR#26) reviewed that had verbal orders that were not timed and/or dated by the provider within 48 hours. There were 2 out of 26 medical records (7%) (MR# 7 and MR #10) that had history and physicals that were not dated and timed by physician.

b. Interviewed staff #12, Director of Health Information Management (HIM) at 10:00am on Sept. 13, 2010 in the administration conference room and explained and showed examples of medical entries that contained missing dates, times or authentications that were missing date and/or time and also showed swing bed medical records that were missing discharge notices. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Reviewed hospital policies and procedures and interviewed quality assurance coordinator and director of diatery department.

Findings:

1. Reviewed policies and procedures and did not find any inclusion of the dietary department in the quality assurance process improvement program.

2. Interviewed the director of quality assurance on September 09, 2010 at 11:30 am and she confirmed that the facility did not include the dietary department in the quality assurance program. Interviewed the director of dietary services and he confirmed that he was not performing any quality assurance activities for his department.