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Based on observation and a tour of the facility, the hospital did not have a housekeeping and preventive maintenance program to ensure that the premises were clean and orderly.

Findings were:

During a tour of the facility on 3-9-11, an electric floor cleaning/polishing machine was observed stored in the clean laundry room.

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.

Based on a review of documents, the facility did not assure the safety of patients in non-medical emergencies by training staff in evacuation of patients.

Findings were:

A review of the facility ' s fire drill documentation records on 3-8/3-9-11 revealed the following statement, " Evacuation of patients during DRILLS is NOT required. "

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.

Based on observation, a review of documents and a tour of the facility, the hospital did not have a governing body that assumed full legal responsibility for implementing and monitoring policies governing the facility's total operation and for ensuring that those policies were administered so as to provide quality health care in a safe environment.

Findings were:

Facility policy NS 2019 titled CPR/ACLS Nursing Staff Requirements - Code Blue states, in part, " ...In addition, all RNs and LVNs shall maintain current ACLS and PALS certifications. "

During a review of personnel files on 3-8/3-9-11, the files of 7 of 19 licensed nurses lacked documentation of additional required training (ACLS and/or PALS).

Facility policy 20-1000 titled Valid Medication Orders states, in part, " Verbal orders for medications ...must be authenticated (by counter-signature) by the prescribing practitioner within 24 hours. "

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #1, #2, #3, #6, #8, #19, #35 & #36, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not yet been authenticated by the date of the survey.

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #3, #4, #5, #13, #15, #17, #19 & #39, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not been authenticated within 24 hours after the order was written.

Facility policy NS 3001 titled Safety Guidelines for Nursing Service states, in part, " The supply of narcotics is kept in a secured area in the Pharmacy. "

During a tour of the facility on 3-9-11, 31 vials of Ativan were observed in an unlocked and unsecured refrigerator within the pharmacy.

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.

Based on a review of clinical records, the facility did not meet the clinical record requirements with regard to timely authentication of verbal orders or overall record completion.

Findings were:

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #3, #4, #5, #13, #15, #17, #19 & #39, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not been authenticated within 48 hours after the order was written.

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #1, #2, #3, #6, #8, #19, #35 & #36, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not yet been authenticated by the date of the survey.

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.

Based on a review of clinical records, the facility did not maintain a clinical records system in accordance with written policies and procedures.

Findings were:

Facility policy 20-1000 titled Valid Medication Orders states, in part, " Verbal orders for medications ...must be authenticated (by counter-signature) by the prescribing practitioner within 24 hours. "

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #1, #2, #3, #6, #8, #19, #35 & #36, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not yet been authenticated by the date of the survey.

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #3, #4, #5, #13, #15, #17, #19 & #39, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not been authenticated within 24 hours after the order was written.

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.

Based on a review of clinical records, not all records were complete.

Findings were:

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #1, #2, #3, #6, #8, #19, #35 & #36, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not yet been authenticated by the date of the survey.

During a review of clinical records on 3-8/3-9-11, 8 of 30 records (patients #3, #4, #5, #13, #15, #17, #19 & #39, with periods of admission within the months of September 2010 through December 2010) contained verbal physician ' s orders that had not been authenticated within 48 hours after the order was written.

The above was confirmed in a meeting with the Chief Executive Officer and Assistant Director of Nursing on the afternoon of 3-9-11 in the facility conference room.