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Based on record review and staff interview, it was determined the hospital failed to ensure nursing staffs were trained and evaluated on competency to perform the essential functions of their jobs. This occurred for six of six (Staff B,C, L, N, O, and P) registered nurses (RNs) identified as shift charge/supervisor nurses and one (Staff S) of three nursing aides.

Findings:

1. According to administrative staff interviewed on 05/08/13 and the hospital's plan of correction, the RN identified as charge nurse functioned as the nursing supervisor.

2. Staffing schedules for April and May were reviewed. From this time period six RNs', identified on the staffing schedule as the shift charge nurse, personnel files were reviewed. The personnel files contained signed job descriptions for the specialized position. However, the personnel files did not contain verification the RNs had been trained and evaluated for competency/knowledge base to perform these specialized functions.

3. The personnel file for Staff S did not demonstrate the nursing aide had been evaluated on skills to perform the essential functions of her job.

4. Findings were reviewed with administrative staff during the exit conference. No additional information was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure verbal orders were authenticated and included all the required elements.

Findings:

On 05/08/13, clinical records were reviewed.

The record for patient #7 had no documentation of the person who transcribed verbal orders. The verbal medication orders did not include a route of administration and had no indications for the administration of all "as needed" medications. The physician did not authenticate the date and time of the signature when the orders were authenticated.

At 11:15 a.m., the consulting pharmacist was shown the clinical record and the documentation of verbal orders. She stated the documentation of the orders was incomplete.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the clinical record was complete, readable and useable, and adequately documented all care provided for three (#7, 9 and #10) of ten records reviewed.

Findings:

On 05/08/13, the hospital was asked to provide printed clinical records for patients #7, 9 and #10.

1. The records provided to the surveyors included computer screen shots that did not contain all the information actually documented by the authors. The majority of fields in the screen shots had no documentation, even when it was necessary and required to document information there.

2. Some required forms in the electronic record had no documentation at all. For example, patient #9 had a surgical procedure. The electronic record had no documentation on the intra-operative nursing form.

The surgery manager was asked why there was no documentation of nursing care during the intra-operative period. She stated the nurse did not like using the electronic record.

She was asked if the nurse used a paper form in place of the electronic record. She stated she did not.

3. The pre-operative nursing documentation for patient #9 was found on the electronic record and on a scanned paper record. Neither form contained complete information.

4. The record for patient #9 contained a form titled, "One Day Surgery Report." A limited physical examination was documented on this form by the physician. Not all systems were addressed in the documentation.

For example, the patient was to scheduled to have an esophagogastroduodenoscopy, but the patient's abdomen was not addressed in the physical examination.

5. A scanned anesthesia care record included in the electronic medical record for patient #9 was scanned incorrectly and the staff and patient signatures were not visible.

6. None of the printed records (and none of the records reviewed electronically) for patients #7, 9 and #10 allowed the reader to see a graph or chart of vital signs or of intake and output documentation. It was not possible for another caregiver to see trends or patterns in these areas. A caregiver would have to search multiple pages or scroll through numerous screens to find single notations of vital signs.

7. The health information manager, the surgery manager and the CNO stated records were not audited for complete and adequate documentation.

All staff interviewed stated the electronic medical record was cumbersome and difficult to use and did not allow easy access to all patient care information.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure medical records contained discharge summaries for one (#9) of two clinical record reviewed for discharge summaries.

Findings:

On 05/08/13, the clinical record for patient #9 had no documentation of a discharge plan or discharge summary.

The CNO stated there were instances of non-compliance with documentation.

Based on clinical record review and interview, it was determined the hospital failed to ensure the clinical record documented necessary information to adequately care for the patient for two (#7 and #9) of two records reviewed for nursing documentation.

Findings:

1. On 05/08/13, the clinical record for patient #9 was reviewed. The record did not have a completed nursing pre-operative checklist. There was no documentation of the amount of IV fluid administered to the patient. There was no documentation as to when the IV was discontinued.

There was no intra-operative nursing documentation.

The surgery manager acknowledged the findings and stated one particular nurse had problems with documentation compliance.

2. The clinical record for patient #7 had no documentation of nursing assessment, nurses' notes, vital signs, intake and output, and no documentation of nursing diet and nutritional care.

The CNO stated the hospital had problems with documentation when patients went from acute care to swing bed care.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure all entries in the medical record were timed, dated and authenticated for seven (#1-7) of ten records reviewed.

Findings:

On 05/08/13, ten clinical records were reviewed for entries documented by staff working in the hospital.

Six (#1-#6) clinical records had no documentation of the date and time the physicians' signatures on history and physical examination reports were authenticated. These records also had missing documentation of the time physician orders were written.

Five (#1-#5) records reviewed did not have dates and times of authentication of physician signatures on discharge summaries.

The clinical record for patient #7 had no documentation of who transcribed verbal orders. There was no documentation the physician authenticated these verbal orders.

The health information manager stated the records were not reviewed for dates, times and signatures for all entries.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a discharge plan was implemented for two (#7 and #10) of two swing bed records reviewed for discharge planning services.

Findings:

On 05/08/13, the clinical records for patients #7 and #10 were reviewed.

Record #7 had no documentation of discharge instructions.

Record #10 had no documentation of a list of medications the patient should take after discharge.

The CNO stated there was a problem with swing bed documentation.