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.

NORTH METRO MEDICAL CENTER 1400 BRADEN STREET JACKSONVILLE, AR 72076 May 25, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and Credential File review it was determined the Facility failed to ensure Physician Assistant #1 had a chaperone while treating patients in order to follow a condition set by the Facility Administration. See A144 and A338. Review of Credential files and Medical Staff Bylaws revealed the Facility failed to ensure the Medical Staff followed the Medical Staff Bylaws in credentialing and privileging one Physician, two Physician Assistants and one Advanced Practice Nurse. This is a recurring deficiency from a complaint survey conducted on 08/22/16. See A338. Review of Medical Staff Bylaws, credential files and interview revealed the Facility failed to ensure privileges were delineated for two Physicians, one Advanced Practice Nurse and two Physician Assistants. This is a recurring deficiency from a complaint survey conducted on 08/22/16. See A339. Review of Medical Staff Committee meeting minutes, Credential Files and Medical Staff Bylaws revealed the Facility failed to ensure provider credential files were complete before being approved for reappointment to the Medical Staff for three Physicians and one Physician Assistant. See A341. Based on review of Medical Staff Bylaws and interview it was determined the Facility failed to ensure the Medical Staff Bylaws were reviewed every 12 months as stated in the Bylaws. See A353.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on clinical record review, policy and procedure review and interview it was determined the Facility failed to protect the rights of patients and failed to provide care in a safe setting. Review of the Complaint Log, Complaint/Grievance Policy and interview revealed the Facility failed to have a process in place for the prompt resolution of patient complaints and grievances. See A120 Review of the Medical Staff Committee Meeting Minutes, Physician Assistant Credential File and interview revealed the Facility failed to ensure Physician Assistant #1 had a chaperone while treating patients. See A144 Based on observation it was determined the Facility failed to ensure the Medication Room on the 2 East Unit was locked. See A144 Based on Medical Staff Bylaws review and interview it was determined the Facility failed to ensure the Medical Staff Bylaws were reviewed every 12 months. See A144 Review of the personnel files for Agency Nurses, policy and procedure and staffing for the Geriatric Psychiatric Unit revealed Agency Personnel were allowed to work before competencies and orientations were verified. This is a recurrent deficiency from a complaint survey conducted 04-27-16. See A144 Observation , interview, clinical record review and policy and procedure revealed Group Therapy was performed with no record of what was presented or how the patient participated. See A144 Review of clinical records and interview revealed the Monitoring Sheet, used to document every 30 minutes the Location, Activity and Mood of the patient on the Geriatric Psychiatric Unit did not accurately reflect Location, Activity and Mood of the patient. This is a recurrent deficiency from a complaint survey conducted 04-27-16. See A144 Review of personnel files and interview revealed the Facility failed to ensure a current license was present in the Director of Nursing's file. See A144
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on review of the Complaint Log, Complaint/Grievance Policy and interview it was determined the Facility failed to have a process in place for the prompt resolution of patient grievances, with Governing Body approval for 7 of 12 complaints reviewed. Findings follow:

A. Review of the Complaint/Grievance Policy revealed "Upon receipt of a complaint, a letter will be mailed to the complainant within seven (7) days. This is to signify to the Complainant that the hospital has received their complaint and is investigating the issue. The complainant will receive a written response of the completion or status of the matter within 30 days."
B. Review of the Complaint Log revealed the following examples:
1) Complaint #5 was received 03-24-17, the letter stating the complaint was received was not sent until 04-07-17 and as of 05-25-17 no additional letter regarding the status or completion of the complaint by the Facility was sent.
2) Complaint #6 was received 03-29-2017, the letter stating the complaint was received was not sent until 05-17-17 and as of 05-25-17 no additional letter regarding the status or completion of the complaint by the Facility was sent.
3) Complaint #7 was received 03-01-17, the letter stating the complaint was received was not sent until 05-17-17 and as of 05-25-17 no additional letter regarding the status or completion of the complaint by the Facility was sent.
C. Interview with the Director of Quality at 1000 on 05-24-17 revealed the following: The Facility determined they were not complying with their own policy regarding Complaints and Grievances. The Facility determined a start date of April 7, 2017 with a plan for monitoring and compliance with an end date of 07-11-17. However because of the lack of the Governing Body approval the Facility failed to implement the Facility plan for compliance and monitoring. Letters documented receipt of the complaint/grievance and promise of notification of followup within 30 days. Because of the lack of approval by the Governing Body there was no evidence regarding followup and closure letter to the Complainant nor was there evidence of monitoring as cited in the action plan determined by the Facility on 04-17-17.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Physician Assistant Credential File review, Medical Staff Committee Meeting Minutes review and interview, it was determined the Facility failed to ensure Physician Assistant (PA) #1 had a chaperone while treating patients in order to follow a condition set by the Facility Administration. The failed practice did not ensure patients received care in a safe setting and was likely to affect any patient treated by PA #1. Findings follow.
A. Review of the Credential File for PA #1 revealed a hire date of 03/11/17.
B. Review of a letter sent from the Facility to PA #1 on 05/19/17 stated PA #1 was to have a Chaperone while examining patients.
C. Review of clinical records revealed Patients #22 and #23 were treated in the Emergency Department by PA #1 on 05/22/17. The clinical records revealed no evidence of a Chaperone.
D. During an interview on 05/24/17 at 1245, the Director of Quality stated there had been a Medical Staff meeting on 05/17/17 and the order for PA #1 to have a Chaperone was discussed. The Executive Assistant stated a plan for a Chaperone was discussed, but no plan was implemented. She confirmed PA #1 had been working without a Chaperone since his hire date of 03/11/17.


Based on observation, it was determined the Facility failed to ensure the Medication Room on the 2 East Unit was locked. The failed practice created the potential for unlicensed personnel to enter the Medication Room and tamper with medications and could affect any patient receiving medications from that Medication Room. Findings follow.
A. A tour was conducted of the 2 East Unit Medication Room on 05/25/17 at 1205. Upon arriving at the Medication Room, Surveyor #1 turned the handle on the door and opened it, without having to enter a code on the keypad. This Surveyor then waited approximately three minutes, exited the room, shut the door and again, turned the handle and entered the room without a code.
B. Surveyor #2 arrived several minutes later and also was able to enter the Medication Room without the use of a code.
C. While inside the Medication Room, two medication carts were observed. The carts contained drawers assigned to each patient, with medications for the next medication pass in each drawer. Those drawers were unable to be locked.
D. The findings were confirmed at the time of the tour by the Director of Quality.


Based on Medical Staff Bylaws review and interview, it was determined the Facility failed to ensure the Medical Staff Bylaws were reviewed every 12 months as stated in the Bylaws. Failure to review the Medical Staff Bylaws every 12 months did not ensure the Medical Staff were current with all procedures set forth within the Bylaws and had the likelihood to affect all patients receiving care in the Facility. Findings follow.
A. Review of Medical Staff Bylaws stated, "These Bylaws shall be reviewed every twelve (12) months by the Bylaws Committee, which is appointed by Medical Executive Committee. Appropriate changes are made and approved through the proper method."
B. Review of the signature page of the Medical Staff Bylaws revealed a signature page dated 11/25/14.
C. During an interview on 05/24/17 at 1245, the Director of Quality confirmed the Bylaws had not been reviewed within the past 12 months.


Based on review of the personnel files for Agency Nurses, to include 4 Registered Nurses, 6 Licensed Practical Nurses and 7 Patient Care Technicians assigned to the Geriatric Psychiatric Unit, review of Policy titled Agency Personnel K 8. 0 and staffing for the Geriatric Psychiatric Unit from 05-05-17, 05-10 thru-15-17 and 05-17 thru 22-17, it was determined the Facility failed to ensure Agency Personnel competencies and orientations were verified prior to being allowed to work. The failed practice did not ensure the patients received care in a safe setting and had the likelihood to affect all patient treated by Agency Personnel. Findings follow.
A. Policy titled Agency Personnel K8.0 revealed "III Procedure: 5 the Assistant to the CNO (Chief Nursing Officer) will begin an Agency personnel file with a checklist to include: ...* A current copy of PPD/TB Test. * Documentation of general orientation or mini-orientation ... *Documentation of completed medication and IV test with at least an 80% passing score (RNs and LPNs) and * Documentation of completed competencies ..."
B. Review of the 17 Agency Personnel Files revealed the following examples:
1) Registered Nurse #1 was hired February 25, 2017 and worked 05-14-17. The personnel file for Registered Nurse #1 failed to have documentation of competencies, medication and IV test with passing score and specific Geriatric Psychiatric Unit orientation to include Crisis Prevention and Intervention (CPI) training.
2) Registered Nurse #2 was hired April 17, 2017 and worked 05-22-17. The personnel file Registered Nurse #2 failed to have documentation of competencies, medication and IV test with passing score, hospital orientation and specific Geriatric Psychiatric Unit orientation to include Crisis Prevention and Intervention (CPI) training.
3) Licensed Practical Nurse #1 was hired May 1, 2017 and worked 05-05-17, 05-17-17 and 05-19-17. The personnel file for Licensed Practical Nurse #1 revealed only a sign in sheet for Agency Orientation dated 05-01-17 and a sign in sheet for Pharmacy dated 05-01-17. There was no evidence of course content or test scores. There was no evidence of orientation specific to the Geriatric Psychiatric Unit to include Crisis Prevention and Intervention (CPI) training.
C. The Director of Quality verified the findings in B at 1315 on May 24, 2017.


Based on observation, interview, policy and procedure review and clinical record review it was determined although Group Therapy was performed there was no documentation of what was presented in the therapy session or how the patient participated. Failure to document the content and patient participation of the therapy sessions did not ensure staff were knowledgeable as to whether the patient was progressing to meet expected goals or regressing. Findings follow:
A. Review of Policy 34 revealed the following: Purpose-" ...rewarding appropriate behavior and providing consequences for inappropriate behaviors ...Group strategies are uniformly applied to all geropsychiatric patients ...Group behavioral programs shape behavior and establish cultural norms for the treatment community by: Establishing consistent, standard expectations for all patients also known as patient guidelines, limits, etc. Establishing consistent, standard consequences for compliance and non-compliance. Establishing a system whereby patients may acquire increasing rewards/privileges as they demonstrate increasing ability to meet expectations and progress in treatment."
B. Interview of Social Worker #1 at 1030 on May 25, 2017 revealed Group Therapy was conducted at 9:30-10:00 in the Morning and 1:30 to 2:00 in the afternoon. Each session was 30 minutes long.
C. Social Worker #1 was asked if there was any documentation that reflected the content of the Group Sessions. The Surveyor was presented with a detailed definition of Group Therapy and a detailed definition of Process Groups but nothing was presented that reflected the content of the Group Therapy Session..
D. Five of five (#1, #3, #4 #6 and #15) patient clinical records revealed no documentation in the clinical record of the Patient's reaction, or the type participation while in Group Therapy.
E. The findings in D were verified by the Director of Quality at 1100 on May 25, 2017.



Based on clinical record review and interview it was determined the Monitoring Sheets, used to document every 30 minutes the Location, Activity and Mood of the patient, on the Geriatric Psychiatric Unit, did not accurately reflect the same Location, Activity and Mood for the patient that was documented on the Transitions Shift Assessment. Failure to accurately reflect Location, Activity and Mood of the Patient did not protect the patient from himself or others. Examples of the finding follow:

A. Review of the clinical record for Patient #15 revealed the Transitions Shift assessment dated [DATE] at 0157 stated "Pt (Patient) keeps getting out of bed trying to find his glasses ...Attempts at redirection unsuccessful. Being hyperverbal with staff." Review of the Monitoring Sheet dated 03-02-17 from 2045 till 0545 reflected Patient #15 was in the bedroom, resting/sleeping and calm.

Review of the clinical record for Patient #15 revealed the Transitions Shift assessment dated [DATE] at 1258-"Pt sat on floor by his bed X2. Assisted off of floor by staff each time. Pt uncooperative and stating he wants to stay on the floor. Assisted Pt to WC (wheelchair) and then to Day Room for lunch. Pt cursing and threatening staff but calmed after a while." Review of the Monitoring Sheet dated 03-07-17 reflected Patient #15 was in the Day Room at 1200, eating and calm. At 1230 Patient #15 was in the Day Room, eating and calm. At 1300 Patient #15 was in the Day Room, sitting and calm.

B. Review of the clinical record for Patient #7 revealed the Transitions Shift assessment dated [DATE] at 0530- ..."Pt has had 8 lose stools so far this shift ...Pt has not slept this shift. He is currently lying in bed naked and calling quietly in a high pitched voice ...". Review of the Monitoring Sheet revealed Patient #7 was in bedroom, asleep and clam 2130-2300, 2330-0100-0130-0330 and 0400-0545.
C. Review of the clinical record for Patient #5 revealed the Monitoring Sheet dated 01-05-17 revealed Patient #5 attended Group Therapy from 1100 to 1130 and 1630. Based on interview with Social Worker #1 and review of the Group Participation Log, Group Therapy is conducted 0930 till 1000 and 130 till 200.



Based on review of personnel files and interview, it was determined the Facility failed to ensure a current license was present in the Director of Nursing's personnel file. The failed practice did not ensure the Director of Nursing had a current license to practice nursing, and was likely to affect all patients receiving care from this nurse. Findings follow.
A. Review of the Director of Nursing's personnel file on 05/24/17 revealed a nursing license with an expiration date of 03/31/17.
B. Findings were confirmed during an interview with the Administrator on 05/25/17 at 1230.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on Physician Assistant Credential File review, Medical Staff Committee Meeting Minutes review and interview, it was determined the Facility failed to ensure Physician Assistant #1 had a Chaperone while treating patients in order to follow a condition set by the Facility Administration. See A338. Based on review of Medical Staff Bylaws, Credential Files, and interview, it was determined the Facility failed to ensure privileges were delineated for two Physicians, one Advanced Practice Nurse, and two Physician Assistants. This is a recurring deficiency from a complaint survey conducted on 08/22/16. See A339. Based on Medical Staff Committee Meeting Minutes review, Medical Staff Bylaws review and provider Credential File review, it was determined the Facility failed to ensure provider Credential Files were complete before being approved for reappointment to the Medical Staff for three Physicians and one Physician Assistant. This is a recurring deficiency from a complaint survey conducted on 08/22/16. See A341. Based on Medical Staff Bylaws review and interview, it was determined the Facility failed to ensure the Medical Staff Bylaws were reviewed every 12 months as stated in the Bylaws. See A353.

Based on Physician Assistant Credential File review, Medical Staff Committee Meeting Minutes review and interview, it was determined the Facility failed to ensure Physician Assistant (PA) #1 had a chaperone while treating patients in order to follow a condition set by the Facility Administration. The failed practice did not ensure patients received care in a safe setting and created the potential to affect any patient treated by PA #1. Findings follow.
A. Review of the Credential File for PA #1 revealed a hire date of 03/11/17.
B. Review of a letter sent from the Facility to PA #1 on 05/19/17 stated PA #1 was to have a Chaperone while examining patients.
C. Review of clinical records revealed Patients #24 and #26 were treated in the Emergency Department by PA #1 on 05/22/17. The clinical records revealed no evidence of a Chaperone.
D. During an interview on 05/24/17 at 1245, the Director of Quality stated there had been a Medical Staff meeting on 05/17/17 and the order for PA #1 to have a Chaperone was discussed. The Executive Assistant stated a plan for a Chaperone was discussed, but no plan was implemented. She confirmed PA #1 had been working without a Chaperone since his hire date of 03/11/17.
VIOLATION: COMPOSITION OF THE MEDICAL STAFF Tag No: A0339
Based on review of Medical Staff Bylaws, provider credential files and interview, it was determined the Facility failed to ensure privileges were delineated for two (#1 and #2) of eight (#1-#8) Physicians, one of one (#1) Advanced Practice Nurse (APN) and two of two (#1 and #2) Physician Assistants (PA). Failure to delineate privileges did not allow guidance for procedures the providers were allowed to perform in the Facility and had the likelihood to affect all patients who received care from those providers. Findings follow.

A. Review of Medical Staff Bylaws revealed the following:
...6.1 Exercise of Privileges
Every physician or allied health practitioner providing direct clinical services or telemedicine services at this hospital by virtue of medical staff membership or otherwise, shall in connection with such practice and except as provided in Section 6.5 be entitled to exercise only those clinical privileges or provide patient care services as are specifically granted by the governing body.
...6.2 Delineation of Privileges
...6.2-1 Requests
Each application for appointment and reappointment to the medical staff must contain a request for the specific clinical privileges desired by the applicant. A request by a medical staff member for a modification of privileges must be supported by documentation of training and experience supportive of the request.
...6.2-2 Bases for Privileges Determination
Requests for clinical privileges shall be evaluated on the basis of the physician's education, training, performance, demonstrated ability and judgment. The basis for privileges determination to be made in connection with periodic reappointment or otherwise shall include documentation of observed clinical performance and the documented results of appropriateness of care review and other quality assessment activities required by these bylaws and the hospital bylaws.
Clinical privileges granted or modified on initial appointment, reappointment or otherwise shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and healthcare settings where a physician exercises clinical privileges. This information shall be added to and maintained in the medical staff file established for a medical staff member.
B. Review of provider credential files for Physician #1 and #2, APN #1 and PA #1 and #2 revealed a form titled Internal Medicine Clinical Privilege Form with check marks under the column labeled "Requested" (privileges), but no checkmarks under the column labeled "Granted" (privileges). All forms were signed by the Department Chairman, and all provider files, with exception of PA #2, were approved for reappointment during the Medical Staff Committee Meeting on 02/15/17.
C. During an interview on 05/25/17 at 1230, the Administrator and Executive Assistant confirmed the privileges were not delineated.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Medical Staff Committee Meeting Minutes review, Medical Staff Bylaws review and provider Credential File review, it was determined the Facility failed to ensure provider credential files were complete before being approved for reappointment to the Medical Staff for three (#2, #7 and #8) of eight (#1-#8) Physicians and one (#1) of two (#1 and #2) Physician Assistants. Failure to ensure credential files were complete before reappointment did not ensure the Facility was allowing licensed, competent providers to practice and did not allow guidance for procedures the providers were allowed to perform in the Facility. The failed practice had the likelihood to affect any patient receiving treatment from those providers. Findings follow.

A. Review of Medical Staff Bylaws revealed the following:
...3.5-3 Appointment to Staff Category
Upon completion of provisional appointment the physician shall be appointed to the category of medical staff to which the individual is seeking appointment subject to meeting the requirements set forth for the category. Thereafter appointments to the medical staff shall be on a bi-annual basis and subject to restrictions for that category of the medical staff as set forth in these bylaws.
...5.4-2 Transmittal for Evaluation
The applicant shall deliver the application to the Medical Staff Services who shall, after determining that the application is complete and all pertinent materials have been secure, transmit the completed form and all supporting materials to the chairman of the department in which the applicant seeks privileges before the next scheduled departmental meeting for his review. After review by the chairman of the department, the completed application form and all of the supporting materials shall be forwarded to the appropriate department of the medical staff for approval.
...5.4-4 Credentialing
Within 120 days after receipt of the completed application for membership, the appropriate department shall make a verbal report of its investigation to the medical executive committee. Prior to making this report, the appropriate department shall examine the evidence of the character, professional competence, qualifications and ethical standing of the physician and shall determine, through information contained in references given by the physician and from sources available to the department, including an appraisal from the department chairman in which privileges are sought, whether the physician has established and meets all of the necessary qualifications for the category of medical staff membership and the clinical privileges requested. Together with its report, the appropriate department shall transmit to the medical executive committee the completed application and a recommendation that the physician be either provisionally appointed to the medical staff with specific privileges or rejected for medical staff membership, or that the application be deferred for further consideration.
...5.4-5 Medical Executive Committee
At its next regular meeting, after receipt of the application and the report and recommendation of the appropriate department, the medical executive committee shall determine whether to recommend to the governing body that the physician be provisionally appointed to the medical staff, that the physician be rejected for medical staff membership, or that the application be deferred for further consideration. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by probationary conditions relating to such clinical privileges.
B. Review of Medical Staff Committee Meeting documentation dated 02/15/17 stated in regard to Physician Assistant #1, "application is pending documentation; however was approved with no derogatory."
C. Review of Medical Staff Committee meeting minutes for 02/15/17 stated, "All credentialing for the month of February was approved and are as follows: Physician #2 was listed among those approved. Review of Medical Executive Committee documentation dated March 2017 stated in regard to Physician #2, "packet not received."
D. Review of Medical Staff Committee Meeting Minutes for 04/19/17 stated, "All credentialing for the month of April was approved and are as follows: Physicians #7 and #8 were listed among those approved. Review of Medical Executive Committee documentation dated April 2017 stated in regard to Physician #7 "Status updated to Inactive due to packet not received."
E. The following was observed in regard to Physician #8
1) Review of Medical Staff Committee Meeting Minutes for 04/19/17 revealed he was approved for reappointment.
2) Review of Medical Executive Committee document dated April 2017 revealed "Packet not yet received."
3) Review of a letter sent from the Facility to Physician #8 dated 04/19/17 (two days after approval) stated, "This letter is to notify you that your status at (Named Facility) has become inactive due to the expiration of your appointment to the Medical Staff. To date we have not received your reappointment application that was emailed and mailed via certified mail to you. Multiple attempts were made to contact you. As of April 21, 2017, you no longer have privileges at (Named Facility)."
4) Review of an email sent from the Credentialing Coordinator to Physician #8 dated 05/03/17 stated, "Your privileging status has been updated to courtesy. Your current appointment to the Medical Staff of this hospital expired on [DATE]. In keeping with our Department meeting schedule, your file will need to be presented at the upcoming departmental meeting(s)."
F. During an interview on 05/25/17 at 1230, the Executive Assistant and the Administrator confirmed the providers were being approved for reappointment before the credential files were completed.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on Medical Staff Bylaws review, and interview, it was determined the Facility failed to ensure the Medical Staff Bylaws were reviewed every 12 months as stated in the Bylaws. Failure to review the Bylaws every 12 months did not ensure the Medical Staff was current with all procedures set forth within the Bylaws and had the likelihood to effect all patients receiving care in the Facility. Findings follow.

A. Review of Medical Staff Bylaws stated, "These Bylaws shall be reviewed every twelve (12) months by the Bylaws Committee, which is appointed by Medical Executive Committee. Appropriate changes are made and approved through the proper method.
B. Review of the signature page of the Medical Staff Bylaws revealed a signature page dated 11/25/14.
C. During an interview on 05/24/17 at 1245, the Director of Quality confirmed the Bylaws had not been reviewed within the past 12 months.


Based on Medical Staff Bylaws review, clinical record review and interview, it was determined the Facility failed to ensure a general consent to treat was obtained for 4 (#2, #3, #18, and #27) of 30 (#1-#30) Emergency Department (ED) clinical records as stated in the Medical Staff Bylaws. Failure to obtain consent did not ensure the Patient was informed of treatments and procedures. This failed practice created the potential to affect all patients admitted to the ED. Findings follow.

A. Review of Medical Staff Bylaws revealed under General Conduct of Care: "A general consent form, signed by or on behalf of every patient admitted to the hospital must be obtained at the time of admission.
B. Review of ED clinical records revealed no evidence a consent to treat was signed for four (#2, #3, #18 and #27) of 30 (#1-#30) Patients.
C. During an interview on 05/24/17 at 1605, the Director of Quality confirmed the lack of consents.


Based on Medical Staff Bylaws review, clinical record review and interview, it was determined the Facility failed to ensure Physician's orders were signed, dated and timed as stated in the Medical Staff Bylaws for 10 (#2, #3, #7, #18, #21, #23 and #28-#31) of 31 (#1-#31) Emergency Department (ED) Patients. Failure to ensure orders were signed, dated and timed did not ensure the orders had been reviewed by a Physician and created the potential to effect any Patient in the ED. Findings follow.

A. Review of Medical Staff Bylaws stated, "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated ...All clinical entries in the patient's medical record shall be accurately dated and authenticated."
B. Review of clinical records reviewed the following:
1) Patient #2 - verbal orders not signed, dated and timed
2) Patient #3 - orders not dated and timed
3) Patient #7 - discharge order not signed
4) Patient #18 - discharge order not signed
5) Patient #21 - orders not dated and timed
6) Patient #23 - orders not dated and timed
7) Patient #28 - orders not dated and timed
8) Patient #29 - orders not dated and timed
9) Patient #30 - orders not dated and timed
10) Patient #31 - orders not dated and timed
C. During an interview on 05/24/17 at 1605, the Director of Quality confirmed the orders were not signed.