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Based on document review and interview, the facility failed to provide a History and Physical in 1 out of 10 (Patient 7) medical records (MR) reviewed.

Findings include:

1. Patient was admitted on 05/25/18 at approximately 2:55 pm from a transferring facility. The medical record had a History and Physical dictated on 06/06/18 at 12:01:13 EST. The History and Physical indicates "I was not a participant in this patient's care. Patient was never physically examined by me. Patient was never clinically evaluated by me. HP is being done for clerical purposes only". The medical record had a History and Physical dictated on 06/06/18 at 12:01:13 EST.

2. Review of policy titled: Assessment/Re-Assessment-Interdisciplinary Patient indicates under 1.b. "the responsible practitioner shall complete and record or dictate a History and Physical Examination within 24 hours after admission of the patient".

3. Interview on 06/13/18 at 10:25 am with P60, Director of Quality Management, confirmed the medical record lacked documentation of physician notes and the History and Physical was completed 12 days after discharge.

Based on document review and interview, the facility failed to provide a complete, date and timed medical record in 1 out of 10 (Patient 7) medical records (MR) reviewed.

Findings include:

1. Patient was admitted on 05/25/18 from a transferring facility. The admission date and time was missing on the Nurse to Nurse Admission Report, face sheet and verbal admission orders; unable to verify actual admission time.

2. Review of policy titled: General Documentation Guidelines indicates under 7. "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated and their authors identified".

3. Interview on 06/13/18 at 10:25 am with P60, Director of Quality Management, confirmed that the Nurse to Nurse Admission Report, face sheet and verbal admission orders were not dated or timed.