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Based on tour of the facility and interview with staff, in 1 of 1 tours, the facility failed to ensure the crash cart containing medications in the operating suite (OS) was secure from unauthorized access.

Findings include:

Per surveyor 18816 tour of the facility OS on 5/25/10 at 11:45 AM with Surgery Manager E, and confirmed by SM E at the same time, the crash cart located in the Patient Anesthesia Recovery Unit was sealed with a breakaway lock. Per SM E at 11:45 AM during the tour, the crash cart is not attended at all times and housekeeping has access when the OS is closed.

Based on review of medical records, review of policy and procedures and interview with staff, in 3 of 6 medical records (#1, 5 and 6) the facility failed to ensure all orders are dated and timed by the Medical Doctor (MD), and verbal orders are written by the Registered Nurse (RN) as verbal orders, and authenticated by the MD.

Findings include:

Facility policy titled Medical Records: Documentation effective 12/12/2008 states under Authentication "A practitioner signing an order assumes the responsibility of that order and is validating that the order is complete accurate and final based on the patient's condition."

Facility policy titled Orders: Written and Verbal effective 1/27/2009 state under Verbal Orders "Verbal orders are dated and timed by the discipline above who accepts the order....Verbal orders are signed by the person to whom dictated with the name of the physician per his/her own name...These orders are signed, dated, and timed by a physician within 48 hours for inpatients, and within 14 days for all other patients."

Patient (Pt) #1's medical record review by surveyor 18816 on 5/25/10 at 8:35 AM revealed the following: The Pre-op (pre-operative) Orders are not dated and timed when signed; the code sheets do not have a signature space for the MD to authenticate verbal orders given during a code, including a date and time. There is a verbal order for epinephrine (a bronchodilator) on 5/13/10 that is not written as a verbal order by the RN and authenticated by the MD. This is confirmed in interview with Surgical Manager (SM) E on 5/25/10 at 1:35 PM.

Pt #5's medical record review by surveyor 18816 on 5/25/10 at 1:00 PM revealed the following: The Pre-Op Orders are not dated and timed when signed by the MD. There is a verbal order for 0.5% Marcaine with epinephrine (anesthetic and vasoconstrictor) on 4/15/10 that is not written as a verbal order by the RN and is not authenticated by the MD. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #6's medical record review by surveyor 18816 on 5/25/10 at 12:40 PM revealed the following: The Pre-Op Orders are not dated and timed when signed by the MD. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Based on review of medical records, review of policy and procedures and interview with staff, in 6 of 6 medical records (#1, 2, 3, 4, 5 and 6) the facility failed to ensure all entries have a signature/date and/or time.

Findings include:

Facility policy titled Medical Records: Documentation effective 12/12/2008 states under Authentication "...All clinical entries in the medical record are accurately dated, timed, and individually authenticated."

Patient (Pt) #1's medical record review by surveyor 18816 on 5/25/10 at 8:35 AM revealed the following: The general consent to treat is not timed when signed on 5/13/10, the consent to surgery is not timed when signed on 5/13/10, the transfer form is not dated and timed when signed by the Medical Doctor (MD) and has no consent signature from the authorized representative, and the Patient Medical History Form is not dated and time when competed. This is confirmed in interview with Surgical Manager (SM) E on 5/25/10 at 1:35 PM.

Pt #2's medical record review by surveyor 18816 on 5/25/10 at 12:30 PM revealed the following: The general consent to treat is not timed when signed on 6/10/09, the consent to surgery is not timed when signed on 6/10/09, the anesthesia assessment is not timed when signed on 6/10/09, the perioperative report is not timed when signed on 6/10/09. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #3's medical record review by surveyor 18816 on 5/25/10 at 12:40 PM revealed the following: The general consent to treat is not timed when signed on 12/16/09, the consent to surgery is not timed when signed on 12/16/09, the Discharge Instructions are not timed when signed on 12/16/09, and the perioperative record is not timed when signed on 12/16/09. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #4's medical record review by surveyor 18816 on 5/25/10 at 12:40 PM revealed the following: The general consent to treat is not timed when signed on 1/12/09, the consent to surgery is not timed when signed on 1/12/09, the History & Physical completed by a Physician's Assistant on 1/8/10 is not authenticated with a date and time by the MD. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #5's medical record review by surveyor 18816 on 5/25/10 at 12:50 PM revealed the following: The general consent to treat is not timed when signed on 4/15/10, the consent to surgery is not timed when signed on 4/15/10, the Surgical Checklist is not signed dated or timed by the RN, and the perioperative record is not timed when signed on 12/16/09. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #6's medical record review by surveyor 18816 on 5/25/10 at 12:35 PM revealed the following: The general consent to treat is not timed when signed on 1/20/09, the consent to surgery is not timed when signed on 1/20/09, the Patient Teaching Sheet is not timed when signed on 1/20/09, the Discharge Instructions are not timed when signed on 1/20/09. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Based on review of medical records, review of policy and procedures and interview with staff, in 5 of 6 medical records ( #2, 3, 4, 5 and 6) the facility failed to ensure there is a comprehensive post anesthesia note that includes at minimum: cardiopulmonary status, level of consciousness, follow-up care and/or observations and any complications.

Findings include:

Facility policy titled Medical Records: Documentation effective 12/1/2008 states under Operative Reports, Procedure Progress Notes, and Post-procedure/Operative Documentation D. "The post anesthesia follow-up report must be written on all inpatients and outpatients prior to discharge from surgery and anesthesia services. The post-anesthesia evaluation must be written by the UHH (Upland Hills Health), and must include at minimum: Cardiopulmonary status; Level of consciousness; Any follow-up care and/or observations; and any complications occurring during post-anesthesia recovery."

Patient (Pt) #2's medical record review by surveyor 18816 on 5/25/10 at 12:30 PM revealed Pt #2 had a LEEP (loop electrocautery excision procedure) on 6/10/09, under general anesthesia. There is no post anesthesia recovery evaluation in the record. This is confirmed in interview with Surgical Manager (SM) E on 5/25/10 at 1:35 PM.

Pt #3's medical record review by surveyor 18816 on 5/25/10 at 12:40 PM revealed Pt #3 had a LEEP on 1/20/10 under conscious sedation. There is no post anesthesia recovery evaluation in the record. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #4's medical record review by surveyor 18816 on 5/25/10 at 12:50 PM revealed Pt #4 had a LEEP on 12/16/09 under general anesthesia. There is no post anesthesia recovery evaluation in the record. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #5's medical record review by surveyor 18816 on 5/25/10 at 1:00 PM revealed Pt #5 had a LEEP on 12/12/09 under general anesthesia. There is no post anesthesia recovery evaluation in the record. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.

Pt #6's medical record review by surveyor 18816 on 5/25/10 at 1:05 PM revealed Pt #6 had a LEEP on 4/15/10 under general anesthesia. There is no post anesthesia recovery evaluation in the record. This is confirmed in interview with SM E on 5/25/10 at 1:35 PM.