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Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure practioners orders were complete, dated, timed and authenticated for 8 of 39 in-patients (#1, #4, #6, #14, #16, #28, #32, and #49) whose records were reviewed. This had the potential to impede the ability of the facility to quickly identify order interpretation and transcription errors. Findings include:

1. The policy "Physician Orders and Critical Reports (Includes 'Read Back')," dated 1/28/12, stated "Authentication of verbal and telephone orders will be considered compliant when: The physician/PA/NP/CNM signs, dates, and times the order within 48 hours." Additionally, the policy noted "Orders must be written by a member credentialed by the medical staff." Verbal and telephone orders were not written and signed in accordance with hospital policy as follows:

a. Patient #14 was a 71 year old female admitted to the hospital on 1/02/14 with generalized weakness, unresponsiveness, and hypotension. She was discharged to a nursing home on 1/09/13. Her medical record contained the following unauthenticated orders:

- A telephone order written by an RN, dated 1/03/14 at 4:15 PM, ordered the start of sliding scale low dose insulin and diet as ordered by speech therapy. The order also stated to apply a sequential compression device and compression stockings. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A verbal order, dated 1/04/14 at 1:00 PM, to discontinue telemetry and intermediate care unit status was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A telephone order, dated 1/04/14 at 3:50 PM, to administer Lantus 10 units subcutaneous every night starting 1/04/13 was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A telephone order, dated 1/05/14 at 1:30 AM, to administer 25 mg of Benadryl IV now and then every six hours, as needed, for itching, was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A verbal order, dated 1/07/14 at 1:25 PM, to discontinue hydrocortisone cream and use Triamcinolone Acetide cream 0.1% with a one to one ratio "acetifil" plus 0.25% menthol cream after bathing and, as needed for itching, sarna lotion as needed for itching and Zyrtec 10 mg by mouth at night, as needed, for itching was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A "PHYSICIANS ORDERS" form contained orders, dated 1/08/14 at 9:00 AM,
for a renal panel and complete blood count to be drawn every morning and to discontinue oral sodium bicarbonate. The orders were not signed. It was unclear who had written the orders. There was no further documentation to indicate the orders were signed by a physician or that a verbal or telephone order had been obtained. The orders were noted by a nurse on 1/08/14 at 9:20 AM. At the time of the survey on 1/10/14, a physician had not authenticated the order.

The RN Clinical Analyst reviewed the record and was interviewed on 1/10/14 at 10:30 AM. She confirmed the orders listed above had not been authenticated by a physician.

Verbal and telephone orders were not authenticated.

b. Patient #32 was a 63 year old male admitted to the hospital on 10/01/13 for aortic valve replacement and coronary artery bypass graft. He was discharged from the hospital on 10/08/13. His medical record contained the following unauthenticated orders:

- A telephone order, dated 10/08/13 at 10:50 AM, for an echocardiogram to evaluate the replaced valve prior to discharge was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A telephone order, dated 10/08/13 at 2:15 PM, to discontinue Digoxin was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

The RN Clinical Analyst reviewed the record and was interviewed on 1/10/14 at 10:30 AM. She confirmed the orders listed above had not been authenticated by a physician within 48 hours in accordance with hospital policy.

Telephone orders were not authenticated.

c. Patient #49 was a 75 year old female admitted to the hospital on 10/09/13 for placement of an arteriovenous graft for dialysis. She was discharged from the hospital on 10/09/13.

- A telephone order, dated 10/09/13 at 11:20 AM, to discharge Patient #49 to home was written by an RN on behalf of the physician. The physician authenticated the order on 10/17/13, 8 days after Patient #49 was discharged.

The RN Clinical Analyst reviewed the record and was interviewed on 1/10/14 at 10:30 AM. She confirmed the telephone order had not been authenticated within 48 hours in accordance with hospital policy.

Telephone orders were not authenticated.

d. Patient #16 was a 66 year old female admitted to the hospital on 1/02/14. She was discharged from the hospital on 1/09/14. Her medical record contained the following unauthenticated orders.

- A verbal order, dated 1/03/14 at 7:00 AM, to discontinue intravenous fluids, portable chest x-ray and echocardiogram both this am, was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A telephone order, dated 1/03/14 at 1:00 PM, for EKG and cardiac enzymes now, was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

- A telephone order, dated 1/03/14 at 5:00 PM, to administer Norco 5 mg po q 3 h prn-pain, was written by an RN on behalf of the physician. At the time of the survey on 1/10/14, the physician had not authenticated the order.

The RN Clinical Analyst reviewed the record and was interviewed on 1/10/14 at 10:15 AM. She confirmed a physician had not authenticated the orders listed above

Verbal and telephone orders were not authenticated.

e. Patient #28 was a 37 year old male admitted to the hospital on 7/29/13. His medical record contained the following unauthenticated orders.

- A telephone order, dated 9/04/13 at 3:00 PM, to replace potassium per pharmacy, was written by an RN on behalf of the physician assistant. The physician assistant authenticated the order on 10/10/13 at 6:57 AM, 35 days later.

The RN Clinical Analyst reviewed the record and was interviewed on 1/10/14 at 10:15 AM. She confirmed a physician assistant had not authenticated the orders listed above within 48 hours.

Telephone orders were not authenticated within 48 hours.

f. Patient #4 was a 43 year old male, admitted to the facility on 9/05/13, following a hemorrhagic stroke. He was admitted via the ED, and transferred to the ICU. Patient #4 expired on 9/09/13.

- A telephone order, dated 9/6/13 at 2:10 AM, read "Make pt DNR." Although the telephone order was signed, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

During an interview on 1/10/14 beginning at 9:10 AM, the Executive Director of Quality and Risk Management reviewed Patient #4's record and confirmed the telephone order for DNR. She stated the physician had not authenticated the order in accordance with hospital policy.

Telephone orders were not authenticated properly.

g. Patient #6's record documented a 26 year old male admitted to the facility on 6/25/13 after being found unresponsive at home. Patient #6 expired 7/28/13.

- A verbal order, dated 7/27/13 at 11:45 AM, included an insulin infusion protocol to be initiated. Additionally, the order stated Propranolol was to be held. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A verbal order, dated 7/27/13 at 12:30 PM, stated only "RfP now." Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A telephone order, dated 7/27/13 at 12:50 AM, to start a levophed drip with parameters for maintaining Patient #6's blood pressure, Vancomycin, and Zosyn (antibiotics). Although the telephone order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A telephone order, dated 7/26/13 at 10:20 PM, to administer a 1000 cc bolus of normal saline with blood pressure parameters, and instruction to repeat if needed. Although the telephone order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A verbal order, dated 7/02/13 at 7:45 PM, instructed to hold the 6:00 AM dose of Heparin. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A telephone order, dated 6/26/13 at 9:20 PM, to give Fentanyl and Ativan as needed. Although the telephone order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A verbal order, dated 6/26/13 at 12:15 AM, to start a Dopamine infusion to maintain a systolic blood pressure >90. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

During an interview on 1/10/14 beginning at 10:20 AM, the Executive Director of Quality and Risk Management reviewed Patient #6's record and confirmed telephone and verbal orders. She stated the physician had not authenticated the orders in accordance with hospital policy.

Telephone and verbal orders were not authenticated properly.

h. Patient #1's record documented a 16 year old male admitted to the facility on 8/27/13 following a motor vehicle accident which resulted in a closed head injury. Patient #1 expired on 8/30/13.

- A verbal order was written on 8/28/13 at 7:30 PM, to administer Albumin, wean Vasopressin off, to start Levophed drip with parameters to maintain his blood pressure. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A verbal order was written on 8/28/13 at 8:40 AM, to place Patient #1 on a cooling blanket with parameters to maintain his temperature. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A telephone order was written on 8/29/13 at 3:30 AM, to administer Albumin and for morning labs. Although the telephone order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

- A verbal order was written on 8/29/13 at 8:15 AM, to administer Albumin and parameters to maintain his blood pressure. Although the verbal order was signed by the physician, the signature was not accompanied with a time or date to indicate when it had been signed as per the facility policy.

During an interview on 1/10/14 beginning at 10:40 AM, the Executive Director of Quality and Risk Management reviewed Patient #1's record and confirmed the telephone and verbal orders. She stated the physician had not authenticated the orders in accordance with hospital policy.

i. Patient #6's record documented a 26 year old male admitted to the facility on 6/25/13 after being found unresponsive at home. Patient #6 had a tracheostomy placed during his hospitalization.

- An order was written on 7/16/13 at 8:10 AM, detailing instructions for tracheostomy wound care, which included frequency, wound care products, and technique to minimize pressure. The order was written and signed by an RN, who was identified as a wound care nurse. The order was noted by a unit secretary and respiratory therapist. The order was not written as a verbal or telephone order and was not signed by a physician.

During an interview on 1/10/14 at 9:00, the wound care nurse team lead stated she would occasionally write orders, but would write them as a verbal or telephone order. She stated if the order included a chargeable item, it would require a physician's signature.

During an interview on 1/10/14 beginning at 10:20 AM, the Executive Director of Quality and Risk Management reviewed Patient #6's record and confirmed the telephone and verbal orders were written by a nurse that was not credentialed to write orders. She confirmed the order was not written correctly and was not properly authenticated. The Executive Director of Quality and Risk Management stated the order for tracheostomy care written by the wound care nurse required a physician's signature.

Orders were written and signed by non credentialed nursing staff.

Based on review of patient records and staff interview, it was determined the hospital failed to ensure significant allergy information was included in the record for 1 of 39 in-patients (#10) whose records were reviewed. Failure to document allergies in the patient's record has the potential for medications to be administered which result in allergic reactions. Findings include:

Patient #10 was a 20 year old female who was admitted to the hospital on 12/10/13, for the induction of labor and delivery of her baby.

Patient #10's record contained clinic obstetrical records that noted she had an allergy to Penicillin G which resulted in anaphylaxis. In addition, two order sets written by her obstetrician included notation of her allergy. Two sets of pre-printed orders "PRE-ECLAMPSIA PHYSICIAN ORDERS," signed and dated 12/10/13 at 5:30 PM, and "POST DELIVERY PHYSICIAN ORDERS," signed and dated 12/11/13 at 8:00 AM, noted her allergy of "PCN" [Penicillin]. Both sets of orders had a stamped notation of "SCANNED," which indicated the orders had been scanned and sent electronically to the pharmacy.

The form "Transfer Order Medication Profile," dated 12/11/13 at 5:29 AM, noted " No Known Allergies." The form was part of the electronic medical record, and was generated by pharmacy.

The form "Discharge Order Medication Profile," dated 12/13/13 at 3:39 AM, documented "No Known Allergies." The form was part of the electronic medical record, and was generated by pharmacy.

During an interview on 1/10/14 beginning at 9:45 AM, the Executive Director of Quality and Risk Management reviewed Patient #10's medical record and confirmed the nursing staff and pharmacy staff did not enter the physician documented allergy to Penicillin into the electronic medical record.

Based on record review and staff interview, it was determined the facility failed to ensure patient records included a discharge, transfer, or death summary for 4 of 24 discharged patients (#4, #20, #21, and #23). Failure to ensure a discharge summary for each patient has the potential to interrupt post hospital provision of care due to a lack of information related to their hospitalization. Findings include:

A policy titled "Discharge Summary Guidelines for Inpatients and Observation Patients," dated 7/31/13, stated discharge summaries are required for patients with a length of stay greater than 48 hours, death or transfer. The policy had an exception for inpatients with a length of stay of less than 48 hours, a discharge note was then required. The facility did not ensure discharge summaries or notes documented and included in patients' records as follows:

1. Patient #4 was a 43 year old male admitted to the facility on 9/05/13, for care related to a hemorrhagic stroke. Patient #4 expired on 9/09/13. His medical record did not include a discharge or death summary.

During an interview on 1/10/14 beginning at 9:10 AM, the Executive Director of Quality and Risk Management reviewed Patient #4's record and confirmed his record did not contain a discharge or death summary.

2. Patient #21 was a 6 day old female infant admitted to the facility on 12/11/13 for phototherapy treatment related to neonatal jaundice. She was discharged on 12/13/13. Her medical record did not include a discharge summary or discharge note.

During an interview on 1/10/14 beginning at 10:40 AM, the Executive Director of Quality and Risk Management reviewed Patient #21's record and confirmed her record did not contain a discharge summary or discharge note.

3. Patient #23 was a newborn, delivered at the facility 12/03/13 and found to have a congenital malformation. He required transport to a facility with a higher level of care. Patient #23 was transported on 12/03/13. His medical record did not include a discharge or transfer summary.

During an interview on 1/10/14 beginning at 10:55 AM, the Executive Director of Quality and Risk Management reviewed Patient #23's record and confirmed his record did not contain a discharge or transfer summary.

4. Patient #20 was a 3 day old male infant admitted to the facility on 12/10/13 for phototherapy treatment related to neonatal jaundice. He was discharged on 12/12/13. His medical record did not include a discharge summary or discharge note.

During an interview on 1/10/14 beginning at 11:00 AM, the Executive Director of Quality and Risk Management reviewed Patient #20's record and confirmed his record did not contain a discharge summary or discharge note.

The facility did not ensure discharged patient records included discharge summaries.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure medical history and physicals were reviewed and updated prior to patients' procedures for 4 of 5 sample patients who underwent endoscopies at the hospital's off-site endoscopy center (#45, #46, #47, and #48). This resulted in the potential for surgical complications due to a lack of information regarding the patients' current health conditions. Findings include:

The hospital's "HISTORY AND PHYSICAL POLICY," dated 11/07/2013, stated when a patient is admitted to the hospital, "A comprehensive history and physical must be completed and documented within 30 days prior to admission or with in 24 hours following admission or prior to surgery, whichever comes first. Even though a history and physical performed prior to admission may be accepted, it must be accompanied by durable, legible documentation. This document must indicate the history and physical was reviewed, and note changes, if any, in the patient's condition. An updated examination must be completed and documented within 24 hours after admission or prior to surgery/procedure when utilizing such a history and physical. This would be done through the use of either the stamp for no changes or the history and physical update form for significant changes. Outpatient procedures/surgeries: A history and physical, including all updates and assessments, must be included in the patients' medical record." This policy was not followed at the endoscopy center. Examples include:

1. Patient #45 was a 52 year old male who had a colonoscopy on 1/08/14. The record contained no documented evidence of a comprehensive history and physical.

The Executive Director of Quality and Risk Management confirmed this on 1/10/14 at 10:15 AM. A current comprehensive history and physical was not present.

2. Patient #46 was a 44 year old female who had an esophagogastroduodenoscopy on 1/08/14. The record contained no documented evidence of a comprehensive history and physical.

The Executive Director of Quality and Risk Management confirmed this on 1/10/14 at 10:15 AM. A current comprehensive history and physical was not present.

3. Patient #47 was a 71 year old male who had a colonoscopy on 1/08/14. The record contained no documented evidence of a comprehensive history and physical.

The Executive Director of Quality and Risk Management confirmed this on 1/10/14 at 10:15 AM. A current comprehensive history and physical was not present.

4. Patient #48 was a 79 year old female who had a colonoscopy on 1/08/14. The record contained no documented evidence of a comprehensive history and physical.

The Executive Director of Quality and Risk Management confirmed this on 1/10/14 at 10:15 AM. A current comprehensive history and physical was not present.

The hospital failed to ensure that patients' medical records included history and physicals prior to endoscopy procedures.

Based on review of facility policies and medical records and staff interview it was determined the facility failed to ensure 1 of 8 patients (#50 ), whose records were reviewed and who were discharged home on the day of surgery, received a post-anesthesia evaluation. Failure to provide a post-anesthesia evaluation had the potential to result in patients being prematurely discharged from the facility and increased the potential for negative patient outcomes. Findings include:

The hospital policy "ANESTHESIA DISCHARGE CRITERIA," dated 11/29/12, stated "All patients will be discharged from PACU by order of an anesthesia provider...The anesthesia provider will document the order on the Anesthesia Post-Op Order sheet...."

The Manager of Perioperative Services was interviewed during a tour of PACU on 1/08/13 beginning at 8:15 AM. She stated an anesthesia provider would evaluate patients prior to discharge from PACU and document their assessment on the "ANESTHESIA EVALUATION NOTE." She stated the anesthesia provider would also order discharge from PACU on the "ANESTHESIA POST-OP ORDERS" per hospital policy. The post anesthesia evaluation was not completed and discharge orders were not completed per policy as follows:

1. Patient #50 was a 17 year old female admitted to the hospital on 12/11/13 for cauterization of bleeding after a tonsillectomy performed at the hospital 12/10/13.

The anesthesia record, signed by the CRNA on 12/12/13, documented Patient #50 received general anesthesia during the surgery and was under the care of the CRNA from 1:13 AM until 1:35 AM, at which time she was taken to the PACU. The electronic health record section titled "PHASE II" documented Patient #50 was discharged from the hospital to home tolerating fluids and with stable vital signs on 12/12/13 at 3:40 AM.

The "ANESTHESIA EVALUATION NOTE," initiated and signed by the CRNA on 12/12/13 at 12:58 AM, contained a section titled "POST ANESTHESIA NOTE." The section allowed the CRNA to choose from three boxes, labeled "Patient without anesthesia complications or complaints," "See Progress Note" or "Outpatient surgery - see follow-up RN call." None of the boxes were checked. The section also contained a line for the CRNA to sign, date, and time when the post anesthesia evaluation was completed. The signature, date and time lines were blank. There was no documentation to indicate a post-anesthesia evaluation had been performed on Patient #50.

In addition, the form "ANESTHESIA POST-OP ORDERS," signed by the CRNA on 12/12/13 at 1:00 AM, was reviewed. The form contained orders for medication to be administered to Patient #50 during her recovery from anesthesia. The form also contained a section titled "Discharge," which included two boxes for the CRNA to check, one labeled "The patient may be discharged from the PACU when discharge criteria are met as per policy. If these criteria are not met notifiy anesthesiology for further instructions." The other box was labeled "Do not discharge the patient from PACU without first reporting the patient's status to anesthesiology." The section also contained a box labeled "Other" where the CRNA could write specific instructions. None of the boxes were checked, and there was no documentation to indicate the CRNA had ordered Patient #50 to be discharged from the PACU.

The Regulatory Compliance Manager reviewed the record and was interviewed on 1/10/13 at 10:40 AM. He confirmed there was no documentation to indicate a member of anesthesia had evaluated Patient #50's response to anesthesia prior to her discharge from the hospital. He also confirmed there was no documentation to indicate an anesthesia provider had discharged Patient #50 from PACU.

Patient #50 was not discharged from PACU in accordance with hospital policy.