HospitalInspections.org

Based on review of Medical Staff Rules and Regulations and review of medical records, the facility failed to ensure that eight (8) of 24 Physician's Orders were timed and that 20 of 24 Physician's Progress Notes were timed.


Findings include:


18 discharged medical records were selected at random from a list of discharges from November 1, 2011, through March 15, 2012. These 18 records along with three (3) inpatient medical records and the last three (3) discharges from the hospital (for a total of 24 medical records) were reviewed.


Review of the 24 medical records revealed that eight (8) records had orders written by the physician which were not timed and 20 of the medical records had Physician Progress Notes which had not been timed when they were written in the medical record.

Based on staff interview, review of Governing Body Minutes, Utilization Review Committee Minutes and Performance Improvement Committee Minutes, the facility failed to ensure that an annual evaluation of its total program had been performed during the past year.


Findings include:


An interview with the Administrator on 4/17/12 revealed that the facility had performed most of the aspects of an annual evaluation during the past 12 months, but had not compiled the findings in a single report as an Annual Evaluation of the Critical Access Hospital.


Review of the minutes of the Utilization Review Committee, Performance Improvement Committee and Governing Body showed that the facility had performed various requirements of the annual evaluation at different times during the past year and had presented their findings to the Governing Body. The facility had not conducted a review and compiled a report designated as the Annual Evaluation of its total program to encompass all aspects of the evaluation during a specified time period.