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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on June 4, 2019, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on document review, observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure a safe and secure environment. This has the potential to affect all staff members, inpatients, and outpatients who received care by the Hospital.

Findings include:

1. During a tour of the Emergency Room (ER) on 5/28/19 at approximately 10:45 AM, the ER entrance doors were accessible to a public hallway, which contained an unsecured food storage room, the registration area, and the elevator to the inpatient care area. Across the hallway directly in front of the ER entrance doors was a window where an ER registration employee would be stationed and the ER entrance door was monitored on a screen mounted flush on the wall in the hallway of the ER department. The screen was unable to be viewed from the nurses station, patient care areas or either side of the same hallway where staff would be located.

2. The policy titled "Security" (last revised 9/2018) was reviewed on 5/30/19. The policy noted "Only authorized visitors are allowed in the workplace. Restricting unauthorized visitors helps maintain safety standards... safeguards employee welfare... 4. Emergency Room (ER) (inner vestibule) doors will be locked at 10:00 p.m.... a buzzer is located outside these doors that may be used by patients and employees to notify ER staff if access is needed..."

3. The policy titled "Scope of Service" (last revised 1/2019) was reviewed on 5/30/19. The policy noted "The Emergency Department is staffed with one (1) physician... two (2) RNs (Registered Nurses)... one (1) RN and one ER Tech (Technician)... An intake Tech, Registration Secretary, or Triage RN is commonly provided between the hours of 0600 (6:00 AM) and 2300 (11:00 PM) daily."

4. During an interview on 5/28/19 at approximately 10:45 AM, the Emergency Department Technician (E#6) stated "The registration window is staffed until 5:30 PM, but after that, if staff are needed in the back (ER patient care area), there is no one at the window. The door (ER entrance doors) doesn't lock until 10:00 PM so anyone could come in."

5. During an interview on 5/30/19 at approximately 11:30 AM, the Chief Nursing Officer (E#5) verbally agreed between 5:30 PM and 10:00 PM, the entrance was not secured and visitors had access to the food storage room, registration, and patient care areas. E#5 verbally agreed the security monitor was not able to be visualized from all areas to ensure unauthorized visitors had not entered the Hospital and should have been.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on June 4, 2019, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated June 4, 2019.

Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to provide safe care and services. Therefore the Condition of Participation 42 CFR 485.635, Provision of Services, was not met. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. The CAH failed to ensure the complaint and grievance process was implemented per policy. See C-271.

2. The CAH failed to ensure unusable drugs were not available for patient use. See C-276 A.

3. The CAH failed to ensure medications were managed in a manner that is safe and appropriate. See C-276 B.

4. The CAH failed to ensure equipment was appropriately maintained to aid in controlling infections and communicable diseases. See C-278.

5. the CAH failed to ensure hot and cold food holding temperatures were monitored, and maintained. See C-279 A.

6. The CAH failed to ensure its food storage policy was followed, to prevent the available use of outdated or unlabeled food products. See C-279 B.

7. The CAH failed to ensure dishwasher temperatures were monitored, maintained, and corrective actions were taken when temperature were out of of range. See C-279 C.

8. The CAH failed to ensure dietary food storage was not accessible to unauthorized persons to prevent the potential for cross contamination. See C-279 D.

9. The CAH failed to ensure dietary personnel hair was contained to prevent the potential for cross contamination. See C-279 E.

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Based on document review and interview, it was determined in 11 of 12 ( G #1, G#2, G#3, G #4, G #5, G #7, G #8 G #9, G #10, G #11, G #12 ) grievances reviewed in the complaint/grievance log, the Critical Access Hospital (CAH) failed to ensure the complaint and grievance process was implemented per policy. This has the potential to affect all patient's who receive care at the CAH with an average daily census of 2 patients per day.

Findings include:

1. The complaint and grievance log dated 1/1/19 through 5/29/19 was reviewed on 5/29/19 at approximately 2:00 PM. The log noted 10 of 12 grievances reported from 3/29/19 to 5/8/19 were not processed per policy. Grievance log stated that G#2, G#3, G #4, G #5, G #9, G #11 and G #12 were listed as status "in progress". Grievance log stated G#1, G #7, G #8 and G #10 were listed as status "closed". The previously mentioned complaint/ grievances lacked documentation that: an investigation was conducted, a resolution to the complaint was completed, a determination letter was sent, and/or a designee contacted the patient and acknowledged a delay in the resolution.

2. The policy titled "Patient Complaints and Grievances" (last revised by the Hospital: 08/2018) was reviewed on 5/30/19 at 8:15 AM. The policy required "...Procedure: d. The person responsible for addressing the issue will resolve the complaint/grievance as soon as possible and provide resolution to the Patient Advocate/ Risk manager. The resolution will address what steps were taken to resolve the situation...the date and manner that the patient was contacted and what resolution was provided to the guest...g. All grievances must be completely resolved...and final resolution letter written to the patient as soon as possible. If manager is not able to resolve the grievance within the first seven days, the responsible manager or designee must contact the patient and acknowledging the delay and stating when to expect resolution the grievance is resolved a "final resolution letter" must be written...the letter must include the steps taken on behalf of the patient to investigate the grievance and results of the grievance investigation and resolution."

3. During an interview with Risk Manager/Compliance and Quality Manager (E#1) on 5/29/19 at approximately 2:30 PM, E#1 verbally confirmed the above findings. E #1 stated that the investigations into the complaint/grievances were incomplete and the Hospital didn't inform the patients about the investigations.

4. On 5/30/19 at 8:15 AM, E#1 presented the policy titled "Patient Complaints and Grievances." E#1 stated "Was unaware of the policy and none of the patients had been sent a letter regarding the grievances."

A. Based on observation, interview, and document review, it was determined the Critical Access Hospital (CAH)failed to ensure unusable drugs were not available for patient use. This has the potential to affect all patients who receive care in the Radiology Department.

Findings include:

1. During an observational tour with the Chief Nursing Officer (E#5) of the Radiology Department on 5/28/19 at approximately 12:00 PM, a 250 milliliter (ml) bag of 0.9% Sodium Chloride (IV solution) was observed hanging from an IV pole in the CT (Computed Tomograph) room. The bag was observed to be labeled "5/28/19 1:00" (AM), spiked with uncapped tubing and the fluid level was at 150 ml.

2. During an interview on 5/28/19 at approximately 12:05 PM, the Radiology Technician (E#9) stated the IV solution was used to prime the Medrad contract injection system (medication injected into a patient prior to a CT scan). E#9 verbally agreed the IV solution had been opened and utilized for another patient's CT scan on 5/28/19 at 1:00 AM. E#9 verbally agreed the CT room and the IV solution had been left unattended and the IV solution was intended to be used to inject contrast into the next scheduled patient later in the day.

3. During an interview on 5/28/19 at approximately 12:10 PM, E#5 verbally agreed the IV solution should not have been left unattended, the tubing uncapped, and available for patient care.

4. During an interview on 5/30/19 at approximately 12:00 PM, E#5 stated "I talked with E#9... E#9 said the IV solution is not injected into the patient, it's only used to prime. I don't really understand that but still that bag should not have been left unattended. It's still medication... and the tubing should not have been left uncapped."

5. The policy titled "Storage of Medications in Patient Care Areas" (last revised by the Hospital: 12/2018) was reviewed on 5/30/19. The policy noted "Medications are removed from medication storage areas just prior to administration. Protective outer wrappers on medications and IV (Intravenous) solutions are not removed until immediately prior to administration... The medication must remain within the control of the healthcare professional until administered, wasted or returned to a second storage area."


B. Based on observation, document review, and interview, it was determined the Critical Access Hospital failed to ensure medications were managed in a manner that is safe and appropriate. This has the potential to affect all patients who receive care in the Radiology Department.

Findings include:

1. During a tour of the ED on 5/28/19 at approximately 10:45 AM, the "EMS-Narcotic Box Sign In/Out Log" dated 3/12/19 through 5/29/19 was reviewed. The log noted 25 entries in which 3 of the Paramedics signatures were legible; 2 were not dated; 1 lacked which box number was returned; and box 4 was noted to be signed out on 4/22/19, 37 days later.

2. During a tour of the Pharmacy on 5/29/19 at approximately 2:25 PM, the Pharmacist (E#11) stated the EMS Narcotic Box Sign In/Out Log only monitors which narcotic boxes are given to or received by a Paramedic in the ED. The Pharmacy tracking sheet provided by E#11 tracked the date, box number, lock number, and the pharmacist/technician who restocked the ED narcotic box. E#11 was unable to provide documentation of the number of narcotics signed out and who had the narcotics. E#11 was unable to verbalize a process or demonstrate in the policy how long a narcotic box can be unaccounted for and what actions are taken to account for the missing narcotics. E#11 stated the log should be accurately completed and each entry should be dated, timed, have a legible Paramedic and RN's signature, as well as, accurately note the correct box number received or given.

3. The policy titled "Emergency Medical Service (EMS) Replacement Policy" (last revised 1/2017) was reviewed on 5/29/19. The policy noted "... the pharmacy department to provide medication replacement services to Emergency Medical Services (EMS) including First Responders (i.e. qualified employees of the police and fire department)... If the pharmacist is not available, the drug can be obtained from the Emergency Department (ED) inventory with the assistance from a Registered ED Nurse... Pharmacy will check the EMS narcotic cabinet daily... reconcile all documentation accordingly."

4. During an interview on 5/30/19 at approximately 12:00 PM, the Chief Nursing Officer (E#5) stated "I spoke with E#11. He/She feels confident the Pharmacy has control of the distribution of the medications but I wasn't able to understand the process either. We need to sit down and review the policy (EMS Replacement Policy) and analyze this process."

Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure equipment was appropriately maintained to aid in controlling infections and communicable diseases. This has the potential to affect all Radiology staff and patients who receive Radiology services.

Findings include:

1. During a tour of the Radiology Department on 5/28/19 at approximately 11:45 AM, a secured biohazard puncture resistant container mounted on the wall in the x-ray room had used syringes and needles protruding through the top of the container and the key was in the security lock.

2. The policy titled "Safety SOP (Standard of Practice) for Radiology" (last revised 10/2016) was reviewed on 5/30/19. The policy noted "To prevent the possibility of acquiring infections, the following procedures must be followed:... 6. Needles: A. Used disposable needles must be placed in a rigid puncture resistant disposable container with a lid. B. Containers are present in every x-ray room."

3. During an interview on 5/28/19 at approximately 11:45 AM, the Laboratory/Radiology Manager (E#8) stated "Housekeeping must have accidentally left the key in when they were going to replace the box." E#8 verbally agreed the needle box was over filled and unsecured in a patient care area and should not have been.

A. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure hot and cold food holding temperatures were monitored, and maintained, to prevent the potential for food spoilage and/or contamination. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. An observational tour, with concurrent interview, of the Dietary Department was conducted on 5/29/19, between approximately 11:10 AM and 12:30 PM, with the Dietary Supervisor (E#3) and the Chief Nursing Officer (E#5).

a. The Dietary department contained a hot food holding cart. The hot food holding cart temperature logs dated 5/24/19 through 5/29/19 were reviewed during the tour. The logs lacked the time the temperatures were taken. E#3 was unable to state how long hot foods would sit in the hot food holding cart prior to being put onto the steam table. E#3 stated the temperatures of the hot food items (for the cafeteria serving line) were taken by the cook at the time the hot food items are placed into the hot food holding cart. "No, we don't check it (hot food temperatures) after that (when placed on the steam table, during steam table time, and/or at the end of steam table time). E#3 stated, "I'm not sure we have one (policies on holding temperature monitoring of hot and cold foods), but we go by what we learned in our sanitation class (IDPH). That's 135 (degrees F) for hot foods." E#3 was unable to state what the HACCP guidelines were and/or where they could be located.

b. Between approximately 12:15 PM and 12:25 PM, the following cafeteria line temperatures were taken:
(1) The steam table popcorn chicken and green bean temperatures were checked. The initial temperature of each were 129 F/64.7 F, respectively. E#3 stated, "Our thermometer must not be working." A recheck, with another thermometer, was 134.4 F/150 F, respectively. E#3 stated, "The chicken (popcorn chicken) isn't hot enough, but the green beans are ok." The HACCP temperature guidelines for chicken is 150 to 165 degrees F.

c. Between approximately 12:15 PM and 12:25 PM, the following cafeteria line temperatures were taken: The cold serving table potato salad and salad bar cottage cheese were checked and were 27 F/38.4 F, respectively. E#3 stated, "We don't check those (cold food temperatures before, during, or at the end of service line times)."

2. On 5/29/19, between approximately 11:25 AM and 3:25 PM the policy titled, "Serving Temperatures of Hot Foods"policy (last approved by the CAH 5/2019) was reviewed, The Policy required that: "To ensure that all hot food items are properly cooked and are at a proper serving temperature in accordance with Infection Control Policies and IDPH (Illinois Department of Public Health) Food Services Sanitation Code... Procedure: 1. Foods shall be held in a safe temperature zone after cooking - above 135 degrees F (Fahrenheit). 2. Foods not at the 135 degrees or above shall be reheated immediately to 165 degrees for 15 seconds... All temperatures must reach stated temperatures on the temperature log sheets for industry standards for serving. 3. Cooks shall test the temperature of each hot food prepared for the patients and cafeteria service prior to serving. 4. All temperatures shall be recorded by the cook on the daily temperature sheets... "

3. On 5/29/19, between approximately 11:25 AM and 3:25 PM the policy titled "Dietary Infection Control" policy (last approved by the CAH 12/2018) was reviewed. The policy required that: "Procedure: 1. Dietary will follow all rules and regulations set forth by the Illinois Department of Public Health and follow all HACCP (Hazard Analysis and Critical Control Point) guidelines for: C. Food Storage D. Freezer and refrigerator storage E. Food preparation and handling H. Personnel I. Cleaning, sanitizing, and storage of utensils and equipment J. Universal precautions used.... M. Maximum holding times... Documentation: N/A (not applicable)..."

4. On 5/29/19, between approximately 11:25 AM and 3:25 PM the policy titled: "Cafeteria Service" policy (last approved by the CAH 4/2019) was reviewed on 5/29/19 indicated, "... A;; foods shall be held at proper temperatures throughout service... Procedure:... 4. Foods shall ve (spelled that way in policy) held at 40 degrees F. or above 135 degrees F. 5. Foods are removed after serving and properly stored immediately upon return to the kitchen following HACCP guidelines. 6. All cold food items on cafeteria line are wrapped and dated."

5. On 5/29/19 at approximately 3:25 PM the document titled: "Sbarro HACCP Temperature Chart" from the website chart (HACCP guidelines) was reviewed The chart indicated the following: a. "Holding Time" and listed foods with holding times of two and four hours. b. "Critical Limit" and listed the holding time hot temperature ranges by food category with examples, ranging 135 degrees and over to 160 degrees and over. c. "Critical Limit" and listed the holding time cold temperatures to be 40 degrees or below. d. "Time/Food Temperature" and indicated "Product temperature must be recorded at 2-hour intervals during holding and serving." The CAH policies for hot temperature ranges are not consistent with HACCP guidelines.

6. During an interview conducted with Director of Support Services (E#4) and E#5 on 5/29/19 at 12:30 PM, the above findings were reviewed with E#4 and E#5 and E#4 stated, "Temperatures (holding for both hot and cold foods) should be taken when they are put on the tables (serving line), in the middle of the time, and at the end of the time. I didn't realize these weren't being done. We have work to do." E#4 verbally agreed the CAH policies did not reflect the HACCP guidelines.


B. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure its food storage policy was followed, to prevent the available use of outdated or unlabeled food products. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. An observational tour, with concurrent interview, of the Dietary Department was conducted on 5/29/19, between approximately 11:10 AM and 12:30 PM, with the Dietary Supervisor (E#3) and the Chief Nursing Officer (E#5).
a. In the dry storage room, greater than approximately 95% of canned items lacked a date as to when they arrived and/or when they expired. E#3 stated, "I know the canned food items are in order (FIFO) because I put them there."
b. In the dry storage room, 24 - five and one/half ounce cans of Prune Juice, expired 10/27/18; 6 - eight ounce cans of Cocoa powder, expired 1/2018; 10 - one pound boxes of Baking Soda, expired 5/2018; 12 - twenty four ounce chocolate syrup, expired 5/2017; and 9 - thirty two ounce bags of powdered sugar, expired 1/2019. E#3 stated, "That would have been before my time. We don't bake anymore."
c. In the Walk-In refrigerator, 2 mixing bowls of chunk cheese and grapes with no date as to when they were prepared and/or expired; 1 unsealed, unlabeled plastic bag of a cooked meat without a label as to what it was, when it was cooked/stored, and/or when it expired; 1 unsealed, unlabeled plastic bag of raw green peppers and raw onions with no label as to when it was opened and/or expired; 1 unsealed, unlabeled plastic bag of brown meat type patties with no label as to what it was, when it was cooked/stored, and/or when it expired; 15 homemade cottage cheese cups with pineapple on top with no date as to when it was made and/or when it expired; 1 gray metal tray with one unopened and one open package of lunch meat. The metal container indicated "use by 6/2/19". The open lunch meat lacked the date it was opened, to ensure lack of spoilage.

2. The HACCP "Refrigerator and Freezer Storage Chart" from website was reviewed on 5/29/19 at approximately 3:30 PM. The chart indicated the following refrigeration timeframe's:
a. Raw vegetables: varied from 1 - 2 days to 2 weeks, depending on raw vegetable type.
b. Cottage cheese: 1 week.
c. Lunch meats: unopened - 2 weeks and opened - 3 to 5 days.

3. The CAH policy titled "Storage" (last approved by the CAH 9/2018) was reviewed on 5/29/19 at approximately 3:35 AM. The policy indicated, "Procedure: 1. First In First Out (FIFO) used for all foods stored... 5. All food and non-food items are clearly labeled as to product identification. 6. Foods removed from the original container are labeled unless identity is unmistakable without having to taste... 10. Storage of dry and canned products. A. Open cases of canned or boxed products, check for damage and place in proper area in the store room... C. Badly damaged product shall be put on the back shelf in the store room to be discarded or returned to purveyor for credits..."

4. An interview was conducted with E#3 during the tour. E#3 stated, "I didn't realize I needed to do that (label and date the food items with the date prepared and date expired)."


C. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure dishwasher temperatures were monitored, maintained, and corrective actions were taken when temperature were out of range, to prevent the potential for cross contamination. This has the potential to affect all patients, visitors, and staff of the CAH.

Findings include:

1. An observational tour of the Dietary department was conducted on 5/29/19, between approximately 11:10 AM and 12:30 PM, with E#3 and the E#5. The automatic dishwasher manufacturer guidelines were posted on the dishwasher. The guidelines indicated, "Hot Water Sanitizing Wash Temperature 150 F (Fahrenheit)... Rinse Temperature 180 F..."

2. The "Dietary Dish Machine Log" for April 2019 and May 2019 were reviewed on 5/29/19 at approximately 12:15 PM. The log indicated, "Log wash/rinse/final rinse temperature when washing at each meal to ensure the temperature are properly monitored and controlled..." The log stated that: April 2019; There were no morning wash or final rinse temperatures on twelve of thirteen days the CAH indicated being open for breakfast (Tuesday, Wednesday, Thursday). Five of ten documented morning wash temperatures were below 150 F, ranging 128 F to 144 F and four of ten final rinse temperatures were below 180 F, ranging 170 F to 178 F. The log lacked documentation of corrective action being taken. The log stated that: May 2019: There were no morning wash or final rinse temperatures for eight of thirteen days the CAH indicated being open for breakfast. Six of sixteen morning wash temperatures were below 150 F, ranging 129 F to 143 and five of sixteen final rinse temperatures were below 180 F, ranging 171 F to 179 F, with no documentation of corrective action being taken.

3. During the tour an interview was conducted with E#3 and E #5. E#3 stated that: The CAH provided patient meals, in accordance with patient census needs. The CAH provided cafeteria hours: breakfast 3 days a week (Tuesday, Wednesday, and Thursday); lunch 5 days a week (Monday to Friday); and was not open for supper. E# 3 stated, "We would rerun the load (dishes) if it wasn't hot enough. I don't know why it (the dish machine log) isn't filled out. They must have forgotten, but I know they check it." E#5 stated, "The log isn't complete and it should be. It doesn't say what was done (when the temperatures were low) and it should."


D. Based on observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure dietary food storage was not accessible to unauthorized persons to prevent the potential for cross contamination. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. An observational tour of the Dietary department was conducted on 5/29/19, between approximately 11:10 AM and 12:30 PM, with E#3 and E#5. The dry storage area, which included three refrigerators and a freezer, was observed to be located just inside the Emergency Room entrance, with the door labeled as "STORAGE". The dry storage room was unlocked and accessible to patients, visitors, and staff.

2. An interview was conducted with E#3 during the tour. E#3 stated, "That's just where it is (the storage for dietary foods). No one would go in there (the dietary food storage area)." E#5 stated, "I didn't realize the location and that it didn't have a secured access. We'll have to get that fixed. Anyone could go in there and that's definitely a problem."


E. Based on observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure dietary personnel hair was contained to prevent the potential for cross contamination. This has the potential to affect all patients, staff, and visitors of the CAH.

Findings include:

1. During an observational tour of the Dietary Department conducted on 5/29/19, between approximately 11:10 AM and 12:30 PM, with E#3 and E#5; A male kitchen worker's full beard and mustache were exposed, while working in the food preparation area.

2. An interview was conducted with E#3 during the tour. E#3 stated, "We weren't sure if it was a problem (exposed beard and mustache) and were going to check into it." E#5 stated, "The beard should be covered."

Based on document review and interview, it was determined in 4 of 4 (Pt #2, Pt #7, Pt #9 and Pt #19) surgical patients' records reviewed, the Critical Access Hospital (CAH) failed to ensure proper record authentication per policy. This has the potential to affect approximately 25 patients per month who receive surgical services.

Findings include:

1. The "Medical Staff Rules and Regulations" (revised by the Hospital: 3/2005) were reviewed on 5/30/19. The regulations noted "A Physician's standing orders... shall be reproduced in detail on order sheet of the patient's record, dated, timed, and signed by physician."

2. Pt #2 SOC: 5/1/19
Diagnosis: Umbilical Hernia. The clinical record was reviewed on 5/29/19 at approximately 9:00 AM. The documents titled: Adult Post Anesthesia Orders for PACU (Post Anesthesia Care Unit) Only, Minimal Preoperative Tests for General Anesthesia, Regional Anesthesia and Monitored Anesthesia Care, Adult Anesthesia Pre-Op Orders, Physician's Standing Orders, and the Anesthesia Record lacked a time the documents were authenticated.

3. Pt #7 SOC: 5/8/19
Diagnosis: Foreign Body. The clinical record was reviewed on 5/29/19 at approximately 11:50 AM. The documents titled: History & Physical Examination/Short Stay Record and the Anesthesia Record lacked a time the documents were authenticated.

4. Pt #9 SOC: 5/6/19
Diagnoses: Diverticulitis and Barretts Esophagus. The clinical record was reviewed on 5/29/19 at approximately 12:15 PM. The document titled: History & Physical Review lacked a time the History and Physical Review was authenticated.

5. Pt #19 SOC: 5/29/19
Diagnosis: Morbid Obesity. The clinical record was reviewed on 5/29/19 at approximately 11:20 AM. The documents titled: Adult Post Anesthesia Orders for PACU Only, Laparoscopic Sleeve Gastrectomy Standing Orders, Post Operative Report, and the History and Physical Examination/Short Stay Record lacked a time the documents were authenticated.

6. During an interview on 5/30/19 at approximately 12:00 PM, the Chief Nursing Officer (E#5) verbally confirmed the above findings.