HospitalInspections.org
Bringing transparency to federal inspections
BIGFORK VALLEY HOSPITAL
No Description Available
Tag No.: C0307
12828
20012
27598
Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated with a timed and dated signature for 2 of 3 inpatient (P1, P2 ) records reviewed. Findings include:
P1 was admitted to the CAH on 11/11/10. Physician orders and progress notes dated 11/12/10, lacked the time of the entries. The emergency room orders lacked a date, time and signature from the physician. The emergency room orders were electronically signed; however, this was not completed until 11/18/10.
P2 was admitted to the CAH on 11/4/10. The emergency room orders for an x-ray lacked a date, time and signature from the physician. The progress notes dated 11/5/10, lacked the time of the entries. The post-operative note dated 11/5/10, lacked the time of the entry. The physician orders dated 11/4/10, and 11/7/10, lacked the time of the entries.
On 11/22/10, at 1:20 p.m. the medical records manager verified these findings. She stated she was going to start auditing the records in about 1 month, but had not done any yet.