HospitalInspections.org

Based on record reviews, staff interview and a review of the administrative policies, the facility failed to maintain properly executed consent forms to include signatures, dates and/or timed entries for 5 of 30 patients in the case sample.

Findings include:

1. Record review done in the afternoon of 12/13/12 found one closed emergency department (ED) record for Patient #16, which included the patient's signature on the "General Consent Form for Out-Patient and In-Patient Services." On the form, there was a space and wording for date and time next to the patient signature line. However, it was left blank and there was no date and time documented on the consent form.

2. An ED closed record review for Patient #21 on 12/13/12, found a "Consent To Transfer" form signed and dated by the patient's spouse on 9/25/12. However, there was no "time" documented on the form. In addition, Patient #2, signed and dated a "Consent To Transfer" form on 10/8/12, but there was no specific time entry documented on this form as well.

3. An ED closed record review for Patient #13 on 12/13/12 found a "Condition For Treatment" form signed and dated by the patient on 12/12/12. The form had "Date/Time" next to the patient's signature line, but there was no specific time entry documented on the form.

4. An ED closed record review for Patient #12 on 12/13/12 found a "Condition For Treatment" form signed by the patient. The form had a "Date/Time" next to the patient's signature line, but there was no date and time documented on the form.

On 12/14/12, review of the hospital's Medical Records Rules and Regulations found, "B. 8 All clinical entries in the patient's medical record shall be accurately dated and authenticated." On 12/14/12 at 8:30 A.M., the hospital President stated that authentication of medical record entries, "includes signature, date and time" by the author of the entry.

Based on record reviews and staff interview, the facility failed to ensure all entries in the medical record were authenticated by the attending physician and/or licensed professional staff for 2 of 30 patients in the case sample.

Findings include:

1. On 12/13/12, an ED closed record review for Patient #13 found the "General Discharge Instructions Emergency/Urgent Care" included the patient's, physician's and nurse's signatures, but did not have the date and time documented on the form.

2. Another ED closed record review completed for Patient #21 found the "Physicians Certificate For Transfer" was signed and dated by the attending ED physician on 9/25/12. However, there was no specific time entry documented on the form.

On 12/14/12, review of the hospital's Medical Records Rules and Regulations found at "B. 8 All clinical entries in the patient's medical record shall be accurately dated and authenticated." On 12/14/12 at 8:30 A.M., the hospital President stated that authentication of medical record entries, "includes signature, date and time" by the author of the entry.

Based on record review and staff interviews, the facility did not have an ongoing program of activities by a qualified professional/activities director (AD), for 1 of 30 patients who was swing bed status in the case sample.

Finding includes:

On 12/13/12 at 8:11 A.M., a closed chart review was completed for Patient #20, who was a swing bed status patient during his/her admission the previous quarter. During the patient's hospitalization, an activities program was not formally provided to the patient as the facility did not have an AD/qualified professional. According to the physical therapist (PT), it was difficult to fill the position for an AD due to the Island's small population coupled with the difficulty in recruiting someone who met the required qualifications.

Interview with the hospital President on 12/14/12 revealed there was a prospective individual for the AD position they were considering to hire in the near future. The President also acknowledged this was cited on their recent long term care survey as they likewise did not have an AD for the skilled nursing unit.