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Based on observation, staff interview, patient interview, and medical record review the facility failed to provide the patients on the 4th floor neurological unit the right to personal privacy, for 3 of the sampled patients (Patients #24, #39, and #40) and 5 random patients. The facility failed to provide privacy for the patients located on the orthopedic floor during the facility on 3/14/11. The findings include:
1. A tour of the facility 4th floor neurological unit was conducted on 3/14/11 at 1:40 p.m. The unit was noted to have a surveillance monitoring system. The monitor was observed with a split screen. The split screen was monitoring 8 patient rooms. The monitor captured images of each of the 8 patients in the bed.
Patients #24 image was observed on the monitor. The image revealed Patient #24 was in bed with restraints. The patient was without a bed sheet revealing the patient was wearing only briefs (underwear).
The image of Patient #39 revealed the patient was in bed covered and was positioned in bed on the left side. The patient was restrained bilaterally at the wrists and was receiving oxygen through a tracheotomy tube (An airway tube accessed through the trachea in the throat). The patient was in a hospital gown.
Patient # 40 was observed sitting up in the bed. The patient was undressed from the waist up and was in the process of undressing. During this observation a nurse observed the monitor and did enter into the patient room and provided cover for the patient. The floor plan is "U" shaped with the nursing station situated in the middle of the floor. The "U" shaped hallways on the floor provide entrance to the patient rooms. The "U" shape floor plan and the nursing station placement allow for a viewing access of the monitor and the split screen images while in the hallways.
An interview with the staff nurse on 3/14/11 was conducted. The nurse commented the monitors were used for patient safety. An interview with the unit Nurse Director at 10:00 a.m. on 3/15/11 revealed the patients were aware of the camera surveillance and commented the patient was made aware of the monitor device at the nursing station. The nurse director continued by stating the patient is made aware during the patient orientation to the room when admitted to the unit.
An interview with the 2 floor nurses on 3/15/11 was conducted at 2:30 p.m. The nurses were asked about the patient education regarding the cameras. One nurse commented there is not a policy for informing each patient, this was considered a standard of care for the floor. The other nurse commented the information was documented in the education section during admission. When asked the nurses were unable to produce documentation any of the patients on the floor were aware of the monitoring.
On 3/17/11 at 8:30 a.m., 2 random patients were interviewed regarding the monitoring. The patients were not aware of the monitoring.

Patient #40 was interviewed and stated, "I became aware the camera was working just today. I was changing my clothes and a nurse came into the room and asked if I wanted to cover up. I was changing my top, and I asked the nurse how did she know I needed to cover up? " The patient continued by stating," the nurse pointed to the camera. That is how I found out that the camera was in use." The patient continued by stating, "I did not know the camera was on. I think this is a violation of my rights, I mean I have been using the bedside commode, they should have told me, I have been changing my clothes and even using the commode, and that it is not right. I really think they should have told me. I feel like a rat in a cage being watched. I think my rights were violated."
An interview with the Nurse Director on 3/17/11 was conducted. The nurse director commented the images should not be visible to all. The nurse director continued by stating, "We are thinking about moving the monitor to the other side and using a privacy screen." The facility failed to provide the right to privacy for the patients on the neurological floor. 2. A tour of the 2nd floor post operative orthopedic floor was conducted on 3/14/11 at 2:00 p.m. The tour included a visit to the nursing station. The nursing station is located adjacent to the elevators. The elevators are used for community visitors and facility staff. The nursing station counter area was observed with the current patient census in view. The patient census includes (but not limited to) patient identifiers -patient names, admission date, diagnosis, surgical procedures and room numbers. The census was left unattended at the nurse station counter and was in view to anyone passing by the station. A nurse returned to the desk in approximately 3 minutes. The nurse commented, "I am busted; I left this on the counter when I went to help another nurse. I know this is not supposed to be on the counter like this."

Based on clinical record reviews, the facility failed to have physicians orders that were complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. Physicians verbal orders not signed within 48 hours for 11 (Patients #20, #51, #58, #62, #64, #68, #76, #73, #78, #81 and #88) of 92 patients sampled.; physician orders not time and dated for 8 (Patients #23, #24, #27, #32, #39, #40, #72 and #86) of 92 sampled records; physicians dictated discharge summary within 30 days of discharge for 3 (Patients #20, #18, and # 29) of 92 sampled records.
The findings include:
Verbal Orders:
1. Clinical record review was conducted on 3/15/11 for Patient #20 who was admitted to the facility on 1/25/11 and was discharged from the hospital on 1/28/11. Review of the physician orders dated 1/28/11 lacked evidence that the doctor had signed the orders within the specified time frame.

2. On 3/15/11 Patient #51's record was reviewed and revealed multiple medical physician orders that have not been signed by a physician. The hospital has failed to ensure the physician orders for Patient #51 have been promptly signed. The following orders have not been signed: 3/15/11, 2/15/11, and 2/16/11 (two orders) 2/25/11 (six orders), 2/26/11 (two orders), 2/27/11 (four orders), 2/28/11, 3/2/11, and 3/3/11 (two orders), 3/4/11 (four orders), 3/5/11 (two orders), 3/6/11 and 3/7/11 (two orders), 3/8/11 (two orders), 3/9/11 and 3/13/11; total of 33 individual orders with 2 of these orders for blood transfusions and 1 order for electrolyte protocol replacement orders.

3) On 3/15/11 review of records for Patient #58 reveals she was admitted to the facility on 3/7/11 with a diagnosis of acute cholecystitis. Additional diagnosis were also noted as well as an extensive medical history.

Review of physician orders for Patient #58 reveals telephone and verbal orders and also pre-printed orders which were received from the physician and written in the record by licensed and registered nurses on 3/7/11, 3/8/11, 3/9/11, 3/10/11, 3/11/11, 3/12/11, 3/13/11, and 3/14/11 that had not been authenticated, dated, or timed by the ordering practitioner.


4) Review on 3/16/11 of the closed clinical record for Patient #62, who was discharged on 12/17/10, revealed telephone orders received by a Registered Nurse on 12/14/10 clarifying an order for Metamucil and Dulcolax medications. The order was noted by the same RN; however, there is no physician signature, date, or time validating the order is correct. The original order for the above mentioned medications are contained in a previous telephone order on the same date at 10:00 a.m., and also contained a consult to Florida Heart physicians for diagnosis of congested heart failure. This order is also written by an RN and does not contain a physicians signature, date, or time validating the order. Further observation of the clinical record reveals the physician, who issued the above telephone orders, made a visit to the patient on the same day after the telephone orders were written as evidenced by orders written by the physician at 6:00 p.m. 12/14/11 thereby providing opportunity for the physician to cosign all previous telephone orders.

5) Review on 3/16/11 of the closed clinical record for Patient #64, who was discharged 12/21/10, revealed preprinted "Baker Act/Suicidal Patient Care Orders" dated 12/20/10, timed 2015 p.m. and signed as "per Dr. ______" followed by a signature on the line designated for "physician Signature". There is no evidenced documentation of a physicians signature, date, or time authenticating the orders. The physician documented an order the next day rescinding the Baker Act orders because the patient did not meet the criteria.

6) Review on 3/16/11 of a closed clinical record for Patient #68, who was discharged on 1/3/11, revealed an order dated 12/26/10 for 3 grams of Unasyn identified as a verbal order signed by an RN. The order failed to contain a physicians signature, date, or time, the order itself is not timed. Further review of the order reveals it fails to contain the appropriate elements of a medication order. The order does not include route, or directions for administration. Another order dated 12/26/10 written as a telephone order and signed by a registered nurse for a clear liquid diet. There is no evidence of a physician signature, date, or time authenticating the order. Another order found to be a telephone order written by a nurse on 12/26/10 at 1830 p.m. for Tylenol and an incentive spirometry failed to include the signature of a physician authenticating the order. On 12/27/10 at 0930 a.m. a telephone order documented by a nurse was written to transfer the patient to another physicians service. The order was documenting acceptance. The order failed to include the signature, date, or time of the issuing physician thereby failing to authenticate the order.

7) On 3/16/11 review of records for Patient #73 reveals she was admitted to the facility on 1/19/11 with a diagnosis of Pulmonary Edema, Diabetes and Sarcoidosis. She was discharged on 1/22/11.

Review of the physician's orders for Patient #73 reveals pre-printed orders signed by the registered nurse on 1/20/11 that has not been authenticated, dated, or timed by the ordering practitioner.


8) Review on 3/16/11 of the closed clinical record for Patient #76, who expired and discharged 2/15/11. revealed pre-printed restraint orders. The orders are dated 2/14/11 at 0900 a.m., and noted in the line designated for the physicians signature is a documented verbal order notation signed by a registered nurse. There is no physicians signature, date, or time authenticating the order. Also in the clinical record is a verbal order dated 2/14/11 and timed 0100 a.m., to keep systolic blood pressure above 85 signed by a registered nurse. Again there is no physicians signature, date, or time authenticating the order.

9) On 3/16/11 review of records for Patient #78 reveals he was admitted to the hospital on 2/8/11 with a diagnosis of Hirschsprung's. He was discharged home on 2/17/11 with his parents.

Review of physician's orders for Patient #78 reveals telephone orders, verbal orders, and pre-printed orders received from the physician and written in the record by the registered nurse dated 2/9/11, 2/10/11, 2/11/11 and 2/13/11 that have not been authenticated, dated, or timed by the ordering physician. These orders also include narcotics ordered by the advanced registered nurse practitioner (ARNP).

Interview with the Risk Manager on 3/16/11 at approximately 2:30 p.m. after reviewing the physician's orders confirmed the orders were missing signatures of ordering practitioner and also the dates and times of the signatures.

10) Review of the open clinical record for Patient #81 on 3/14/11 revealed Admission orders dated 3/9/11 when the patient was admitted to the facility. The orders have documented a nurses signature indicating the orders were read back telephone orders received by the physician. Further review of the admission orders reveal "adult sliding scale insulin orders also documented by a nurses signature indicating a read back telephone order from the admitting physician. Both admission and insulin orders for 3/9/11 fail to contain a physicians signature, date or time. There is also noted a red arrow sticker stating "sign here" pointing to a black stamp stating "Doctor please" followed by three lines, one line for each date, time, and sign with all three lines being blank. The physician orders also contain a telephone order received 3/10/11 at 18:45 p.m. for the following; contact isolation for c-diff, discontinue Levaquin, send another stool for c-diff, CMP and CBC in am. The order is followed by a stamp for the physicians signature which is observed to be blank with a red sign here sticker pointing to it. Further review of the physicians orders reveal another telephone order received on 3/11/11 at 1400 for the following; social worker to evaluation for SNF (Skilled Nursing Facility) placement. Again there is a red sign here sticker pointing to the black stamp with blank line indicating where the physician is suppose to sign the telephone orders.

Review of the physician progress notes reveal the attending physician was in the hospital on 3/10/11, 3/11/11, and 3/12/11 having opportunity to promptly sign off any verbal orders.

11) Patient #88 was admitted to the facility on 1/31/2011 with a diagnosis, but not limited to Renal Failure secondary Leukocytosis. Further review of the Telephone orders dated 3/07/2011 for "Transfuse one unit over three hours via filter daily times 2," was not signed by the physician. Telephone order dated 3/0/2011 as follows "Insert Dobbhoff and KUB for Dobbhoff placement, STAT," failed to be signed by the Physician. Further review of the Telephone Orders reveals an order dated 3/14 2011 for "DC Estradiol patch" and a Telephone ordered dated 3/14/2011 and timed 1600 "Lopressor 2.5 mg IVP now HR dose not go below 110 mg repeat x 1." Not signed by the Physician. A telephone Order dated 3/15/2011 for "Xanax 0.25 mg via Peg Tube Q 8 PRN for anxiety" failed to be signed by Physician.
Further review of Patient #88's clinical record revealed the following consents were not signed or dated by the Physician. Consent for Sedation dated 2/06/2011. Consent for Anesthesia was not dated signed or timed. Consent for sedation dated 2/17/2011 failed to be signed by the Physician. Further review demonstrated consents were not signed on 2/26/2011 in regards to sedation. Further review reveals the Physician failed to sign Transfusion ordered dated 03/06/2011.
Interview with the Director of Medical Records on 3/15/11 at 1:00 p.m. reveal once a verbal order is received by a nurse the nurse is suppose to stamp the chart and affix a sign me arrow sticker to alert the physician to sign the order.

On 3/16/11 at 11:09 a.m. a risk manager stated, "No matter how hard we try we can't get them to sign the orders" referring to the physicians.

Review of the Medical Staff Rules and Regulations on 3/17/11 reveal in section five labeled physicians orders, paragraph B states "verbal orders shall be countersigned by a practitioner responsible for the care of the patient within forty eight (48) hours."


Time and dated:
1) A review of the clinical record for Patient #23 revealed incomplete physicians orders (signed but not dated and times) for Orthopedic Post-Procedure Orders (1/10/11), Anesthesia Medication Orders (1/10/11, Orthopedic Intra-Procedure Orders (1/10/11) and Orthopedic total Knee/Hip Pre-Procedure Orders (1/10/11)
2) A review of the clinical record for Patient #24 revealed the restraint physician orders for 03/15, 03/14, 03/13, 03/12, and 03/11/2011 were signed by the physician but lacked the documented time of the physician signature.
Physician/Practitioner orders on the facility form entitled "Additional Orders - Dates and Times" for Patient #24 dated 03/11/11 lacked physician/practitioner signatures.
3) Clinical record review for Patient #27 revealed incomplete physicians orders (signed but not dated and times) Physicians orders on 1/14/11, 1/17/11 and 1/18/11.
4) A review of the clinical record for Patient # 32 revealed incomplete physicians orders (signed but not dated and times) physicians orders for 2/23/11 and 2/27/11.5) A review of the medical record for Patient #39 conducted on 03/15/11 revealed Physician/Practitioner Orders for the use of restraints were not dated and timed by the physician/ practitioner on the following dates: 03/09, 03/10, 03/11, 03/12, 03/13 and 03/14/11. A review of the Additional Orders dated: 03/06/11, 03/10/11, and 03/12/11 were not signed by the physician. The insulin sliding scale order dated 03/12/11 by the nurse was not signed by the physician/practitioner. 6) A review of the medical record for Patient #40 conducted on 03/15/11 revealed the physician/practitioner did not sign orders received on 03/12/11.
7) A review of the clinical record for Patient # 72 revealed incomplete physicians orders (signed but not dated and times) for Adult Sliding Scale Insulin Orders 1/14/11, physicians orders 1/14/11, and physicians orders 1/16/11.
8) A review of the medical record for Patient # 86 conducted on 03/16/11 revealed Physician/Practitioner Orders were not signed by the physician/ practitioner on the following dates: 3/08/11 and 03/09/11 .Discharge Summary's
1) Clinical record review conducted on 3/15/11 for Patient #20 who was admitted to the facility on 1/25/11 and was discharged from the hospital on 1/28/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

2) Clinical record review conducted on 3/15/11 for Patient #29 who was admitted to the facility on 1/27/11 and was discharged from the hospital on 1/31/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

3) Clinical record review conducted on 3/14/11 for Patient #18 who was admitted to the facility on 1/28/11 and was discharged from the hospital on 1/31/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

Review of the medical staff rules and regulations reveals in section 8D "The patients medical record shall be completed within 30 days of discharge. If the medical record remains incomplete on the 30th day after discharge, it will be considered delinquent and Health Information Management (HIM) will notify the practitioner. If the practitioners medical records remain delinquent at 60 days from discharge, the practitioner will be contacted (letter with demonstrated proof of delivery and /or telephone call) by the medical director in collaboration with the chairman of the department, and may be given three days to complete them. If the records remain delinquent at the end of the 3 days, the practitioner will have the right of hospital admitting, consulting, and surgical privileges suspended until all records are completed."

An interview was held with the Director of HIM on 3/15/11 at 1:00 p.m. who stated once a patient is discharged the clinical record is reviewed for compliance in order to be considered a closed record. If the record is compliant it is closed immediately and filed. If there are issues then the departments or doctors are given compliance letters. She went on to state that compliance letters are sent weekly to physicians. She also stated if the physician is more than 60 days non-compliant then there is a suspension process. She stated at this time there are no physicians currently under suspension. She stated there are currently 1300 incomplete closed records at the HealthPark facility. She also presented a list of 27 physicians who are "close to being suspended" at the HealthPark facility.

Review of the potential suspension list for march submitted by the HIM Director reveals 10 of the 27 physicians are "over 60 days aging based on the allocation date."

During a second interview with the HIM Director on 3/16/11 at 4:10 p.m. she stated there are no physicians at the Lee Campus on suspension or pending suspension.

Based on clinical record review and interview the facility failed to ensure all verbal orders are authenticated within 48 hours for 11 (Patients #20, #51, #58, #62, #64, #68, #76, #73, #78, #81, and #88) of 92 patients sampled.

The findings include:

1. Clinical record review was conducted on 3/15/11 for Patient #20 who was admitted to the facility on 1/25/11 and was discharged from the hospital on 1/28/11. Review of the physician orders dated 1/28/11 lacked evidence that the doctor had signed the orders within the specified time frame.

2. On 3/15/11 Patient #51's record was reviewed and revealed multiple medical physician orders that have not been signed by a physician. The hospital has failed to ensure the physician orders for Patient #51 have been promptly signed. The following orders have not been signed: 3/15/11, 2/15/11, and 2/16/11 (two orders) 2/25/11 (six orders), 2/26/11 (two orders), 2/27/11 (four orders), 2/28/11, 3/2/11, and 3/3/11 (two orders), 3/4/11 (four orders), 3/5/11 (two orders), 3/6/11 and 3/7/11 (two orders), 3/8/11 (two orders), 3/9/11 and 3/13/11; total of 33 individual orders with 2 of these orders for blood transfusions and 1 order for electrolyte protocol replacement orders.

3) On 3/15/11 review of records for Patient #58 reveals she was admitted to the facility on 3/7/11 with a diagnosis of acute cholecystitis. Additional diagnosis were also noted as well as an extensive medical history.

Review of physician orders for Patient #58 reveals telephone and verbal orders and also pre-printed orders which were received from the physician and written in the record by licensed and registered nurses on 3/7/11, 3/8/11, 3/9/11, 3/10/11, 3/11/11, 3/12/11, 3/13/11, and 3/14/11 that had not been authenticated, dated, or timed by the ordering practitioner.


4) Review on 3/16/11 of the closed clinical record for Patient #62, who was discharged on 12/17/10, revealed telephone orders received by a Registered Nurse on 12/14/10 clarifying an order for Metamucil and Dulcolax medications. The order was noted by the same RN; however, there is no physician signature, date, or time validating the order is correct. The original order for the above mentioned medications are contained in a previous telephone order on the same date at 10:00 a.m., and also contained a consult to Florida Heart physicians for diagnosis of congested heart failure. This order is also written by an RN and does not contain a physicians signature, date, or time validating the order. Further observation of the clinical record reveals the physician, who issued the above telephone orders, made a visit to the patient on the same day after the telephone orders were written as evidenced by orders written by the physician at 6:00 p.m. 12/14/11 thereby providing opportunity for the physician to cosign all previous telephone orders.

5) Review on 3/16/11 of the closed clinical record for Patient #64, who was discharged 12/21/10, revealed preprinted "Baker Act/Suicidal Patient Care Orders" dated 12/20/10, timed 2015 p.m. and signed as "per Dr. ______" followed by a signature on the line designated for "physician Signature". There is no evidenced documentation of a physicians signature, date, or time authenticating the orders. The physician documented an order the next day rescinding the Baker Act orders because the patient did not meet the criteria.

6) Review on 3/16/11 of a closed clinical record for Patient #68, who was discharged on 1/3/11, revealed an order dated 12/26/10 for 3 grams of Unasyn identified as a verbal order signed by an RN. The order failed to contain a physicians signature, date, or time, the order itself is not timed. Further review of the order reveals it fails to contain the appropriate elements of a medication order. The order does not include route, or directions for administration. Another order dated 12/26/10 written as a telephone order and signed by a registered nurse for a clear liquid diet. There is no evidence of a physician signature, date, or time authenticating the order. Another order found to be a telephone order written by a nurse on 12/26/10 at 1830 p.m. for Tylenol and an incentive spirometry failed to include the signature of a physician authenticating the order. On 12/27/10 at 0930 a.m. a telephone order documented by a nurse was written to transfer the patient to another physicians service. The order was documenting acceptance. The order failed to include the signature, date, or time of the issuing physician thereby failing to authenticate the order.

7) On 3/16/11 review of records for Patient #73 reveals she was admitted to the facility on 1/19/11 with a diagnosis of Pulmonary Edema, Diabetes and Sarcoidosis. She was discharged on 1/22/11.

Review of the physician's orders for Patient #73 reveals pre-printed orders signed by the registered nurse on 1/20/11 that has not been authenticated, dated, or timed by the ordering practitioner.


8) Review on 3/16/11 of the closed clinical record for Patient #76, who expired and discharged 2/15/11. revealed pre-printed restraint orders. The orders are dated 2/14/11 at 0900 a.m., and noted in the line designated for the physicians signature is a documented verbal order notation signed by a registered nurse. There is no physicians signature, date, or time authenticating the order. Also in the clinical record is a verbal order dated 2/14/11 and timed 0100 a.m., to keep systolic blood pressure above 85 signed by a registered nurse. Again there is no physicians signature, date, or time authenticating the order.

9) On 3/16/11 review of records for Patient #78 reveals he was admitted to the hospital on 2/8/11 with a diagnosis of Hirschsprung's. He was discharged home on 2/17/11 with his parents.

Review of physician's orders for Patient #78 reveals telephone orders, verbal orders, and pre-printed orders received from the physician and written in the record by the registered nurse dated 2/9/11, 2/10/11, 2/11/11 and 2/13/11 that have not been authenticated, dated, or timed by the ordering physician. These orders also include narcotics ordered by the advanced registered nurse practitioner (ARNP).

Interview with the Risk Manager on 3/16/11 at approximately 2:30 p.m. after reviewing the physician's orders confirmed the orders were missing signatures of ordering practitioner and also the dates and times of the signatures.

10) Review of the open clinical record for Patient #81 on 3/14/11 revealed Admission orders dated 3/9/11 when the patient was admitted to the facility. The orders have documented a nurses signature indicating the orders were read back telephone orders received by the physician. Further review of the admission orders reveal "adult sliding scale insulin orders also documented by a nurses signature indicating a read back telephone order from the admitting physician. Both admission and insulin orders for 3/9/11 fail to contain a physicians signature, date or time. There is also noted a red arrow sticker stating "sign here" pointing to a black stamp stating "Doctor please" followed by three lines, one line for each date, time, and sign with all three lines being blank. The physician orders also contain a telephone order received 3/10/11 at 18:45 p.m. for the following; contact isolation for c-diff, discontinue Levaquin, send another stool for c-diff, CMP and CBC in am. The order is followed by a stamp for the physicians signature which is observed to be blank with a red sign here sticker pointing to it. Further review of the physicians orders reveal another telephone order received on 3/11/11 at 1400 for the following; social worker to evaluation for SNF (Skilled Nursing Facility) placement. Again there is a red sign here sticker pointing to the black stamp with blank line indicating where the physician is suppose to sign the telephone orders.

Review of the physician progress notes reveal the attending physician was in the hospital on 3/10/11, 3/11/11, and 3/12/11 having opportunity to promptly sign off any verbal orders.

11) Patient #88 was admitted to the facility on 1/31/2011 with a diagnosis, but not limited to Renal Failure secondary Leukocytosis. Further review of the Telephone orders dated 3/07/2011 for "Transfuse one unit over three hours via filter daily times 2," was not signed by the physician. Telephone order dated 3/0/2011 as follows "Insert Dobbhoff and KUB for Dobbhoff placement, STAT," failed to be signed by the Physician. Further review of the Telephone Orders reveals an order dated 3/14 2011 for "DC Estradiol patch" and a Telephone ordered dated 3/14/2011 and timed 1600 "Lopressor 2.5 mg IVP now HR dose not go below 110 mg repeat x 1." Not signed by the Physician. A telephone Order dated 3/15/2011 for "Xanax 0.25 mg via Peg Tube Q 8 PRN for anxiety" failed to be signed by Physician.
Further review of Patient #88's clinical record revealed the following consents were not signed or dated by the Physician. Consent for Sedation dated 2/06/2011. Consent for Anesthesia was not dated signed or timed. Consent for sedation dated 2/17/2011 failed to be signed by the Physician. Further review demonstrated consents were not signed on 2/26/2011 in regards to sedation. Further review reveals the Physician failed to sign Transfusion ordered dated 03/06/2011.
Interview with the Director of Medical Records on 3/15/11 at 1:00 p.m. reveal once a verbal order is received by a nurse the nurse is suppose to stamp the chart and affix a sign me arrow sticker to alert the physician to sign the order.

On 3/16/11 at 11:09 a.m. a risk manager stated, "No matter how hard we try we can't get them to sign the orders" referring to the physicians.

Review of the Medical Staff Rules and Regulations on 3/17/11 reveal in section five labeled physicians orders, paragraph B states "verbal orders shall be countersigned by a practitioner responsible for the care of the patient within forty eight (48) hours."

Based on clinical record review the facility failed to ensure all closed clinical records contained discharge summary's.

The findings include:

1. Clinical record review conducted on 3/15/11 for Patient #20 who was admitted to the facility on 1/25/11 and was discharged from the hospital on 1/28/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

2. Clinical record review conducted on 3/15/11 for Patient #29 who was admitted to the facility on 1/27/11 and was discharged from the hospital on 1/31/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

3. Clinical record review conducted on 3/14/11 for Patient #18 who was admitted to the facility on 1/28/11 and was discharged from the facility on 1/31/11 revealed the resident's discharge summary was not completed within 30 days of discharge.

Review of the medical staff rules and regulations reveals in section 8D "The patient's medical record shall be completed within 30 days of discharge. If the medical record remains incomplete on the 30th day after discharge, it will be considered delinquent and Health Information Management (HIM) will notify the practitioner. If the practitioner's medical records remain delinquent at 60 days from discharge, the practitioner will be contacted (letter with demonstrated proof of delivery and /or telephone call) by the medical director in collaboration with the chairman of the department, and may be given three days to complete them. If the records remain delinquent at the end of the 3 days, the practitioner will have the right of hospital admitting, consulting, and surgical privileges suspended until all records are completed."

An interview was held with the Director of HIM on 3/15/11 at 1:00 p.m., who stated once a patient is discharged the clinical record is reviewed for compliance in order to be considered a closed record. If the record is compliant it is closed immediately and filed. If there are issues then the departments or doctors are given compliance letters. She went on to state that compliance letters are sent weekly to physicians. She also stated if the physician is more than 60 days non-compliant then there is a suspension process. She stated at this time there are no physicians currently under suspension. She stated there are currently 1300 incomplete closed records at the Healthpark facility. She also presented a list of 27 physicians who are "close to being suspended" at the Healthpark facility. Review of the potential suspension list for march submitted by the HIM Director reveals 10 of the 27 physicians are "over 60 days aging based on the allocation date."

During a second interview with the HIM Director on 3/16/11 at 4:10 p.m. she stated there are no physicians at the Lee Campus on suspension or pending suspension.

Based on the observations and interviews during the facility tour, the facility failed to maintain patient care equipment in a clean and safe operating condition, for the patient and staff populations using blood sugar monitoring equipment. the findings include:
During the tour on 03/14/2011 the following Accu Check blood sugar monitoring equipment was not maintained in a clean and safe manner:1. Surgical Intensive Care Unit (SICU)- At 9:30 a.m. the Accu Check monitoring devices were observed. The Accu Check device and the cradles were examined for function and cleanliness. The Accu-check monitoring device with the identifying number L8N SICU5 was observed with a dark red blood like streak on the device. The cradle was observed with dark debris at the bottom of the cradle bowl.
The education nurse stated, "This is not supposed to be like this." The nurse cleaned the unit device and cradle with an OSHA approved wipe. The education nurse inspected the other Accu Check monitoring devices and agreed the devices need to be cleaned by stating, "I will get someone to clean these."
2. Medical Intensive Care Unit (MICU) - At 9:45 a.m. the MICU was toured. During this tour the Accu Check devices were observed with bright red spots on the monitoring device (L7N MICU 4B). The cradles were noted to have black debris at the bottom of the cradle bowl. 3. The 4th floor neurological unit was observed with the Accu Check device # L4NSU2D was with brown spots and debris in the cradle. The medical 4th floor unit was observed to be using Accu Check monitoring device L4 North 2D was cracked and was with brown red spots and debris in the cradle.
4. The second floor Accu Check HUB 1B and HUB 2B were observed with dirt like residue in the cradles. The L2 ORTHO 3C Accu Check monitoring device is with dirt like residue in the cradle and is not secure to the wall.
5. The oncology unit located on the 6th floor observation of the Accu Check monitoring device # L6 North 1 B is cracked. The device # L6 North 2 C is with dirt like residue in the base and brown spots on the device. The wall holder for the device is loose and coming away from the wall.
6. The 5th floor Accu Check monitoring devices L5 North 1 E and L5 North 3 are observed with black debris in the cradle. The 5 North Medical Floor- 2 Accu Check Devices are noted with debris in the cradle base and one device has 3 cracked areas on the base. The other is cracked and has debris in the cradle.