The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SOUTH BALDWIN REGIONAL MEDICAL CENTER 1613 NORTH MCKENZIE STREET FOLEY, AL 36535 Jan. 22, 2015
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, the physicians failed to date and/or time orders for Patient Identifier (PI) # 1, PI # 2, PI # 3 and PI # 4. This deficient practice affected four of ten outpatient surgery medical records that were reviewed.

Findings include:

1). PI # 1 was admitted on [DATE] for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Post-Operative orders were not dated or timed by the physicians. The Intra-Operative Standing Orders were not timed by the physician.


2). PI # 2 was admitted on [DATE] for outpatient surgery. A review of the medical record revealed the Pre-Admission orders and the Intra-Operative Standing Orders were not dated or timed by the physicians.

3). PI # 3 was admitted on [DATE] for outpatient surgery. A review of PI # 3's medical record revealed the Post-Operative orders were not dated or timed by the physician.

4). PI # 4 was admitted for outpatient surgery on 1/20/15. A review of PI # 4's medical record revealed the Intra-Operative Standing Orders were not timed by the physician. The Post-Operative orders were not signed or timed by the physician.

During an interview with Employee Identifier (EI) # 1, the Quality Manager confirmed the four medical records noted above were lacking times and/or dates for physician orders.