HospitalInspections.org

Based on record review and interview, the facility failed to assure all orders and progress notes were dated and timed. Thirteen instances of undocumented date or time were observed in one patient chart.

Findings include:

Review of patient #1 ' s medical record revealed the following missing dates and times:
-Emergency Physician record with no documented time
-Medical Clearance with no documented date
-Medical Clearance with no documented time
-Physician progress with no documented time x3
-Physician order with no documented date x2
-Physician order with no documented time x5

In an interview on 4/19/11 at 10:51am in the administrative offices at 12:45pm, staff #1 reviewed the documents listed above and confirmed the missing dates and times.

Based on record review and interview, the facility failed to assure verbal orders were authenticated within 48 hours. Two instances of delayed authentication of verbal orders were found in one patient chart.

Findings include:

Review of patient #1 ' s medical record revealed the following:
-Verbal order written on 2/23/11 was authenticated on 3/24/11
-Verbal order written on 2/22/11 was authenticated on 4/06/11

In an interview on 4/19/11 at 10:51am in the administrative offices at 12:45pm, staff #1 reviewed the documents listed above and confirmed the delayed authentication.