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TRI-TOWN REGIONAL HEALTHCARE
GOVERNING BODY
Tag No.: A0043
Based on interview and document review, the Board failed to ensure that the facility is in compliance with 42 CFR Conditions of Participation for Hospitals.
Findings:
Based on review of the facility's contract "Employee Leasing Agreement" January 1, 2012 between The Mary Imogene Bassett Hospital (Bassett) and Tri-Town Regional Hospital (TRH), all staff working at the facility is employed by Bassett. They are contracted to provide needed services and staff programs at TRH.
This was confirmed on interview with the Chief Executive Officer on 2/16/12 at 1200.
see 0385 and 0432
NURSING SERVICES
Tag No.: A0385
Based on interview, the facility fails to employ an organized nursing service.
Finding:
Based on interview with the Chief Executive Officer on 2/16/12 at 1200, the current nursing staff is employed by another hospital and contracted to TRH for the provision of 24-hour/7-day nursing services.
ORGANIZATION AND STAFFING
Tag No.: A0432
Based on interview, the facility failed to employ adequate personnel to manage the medical record department.
Finding:
Based on interview with the Chief Executive Officer and the Medical Records Director on 2/16/12 at 1200, TRH contracts with another hospital for it's medical records personnel.
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on review of 20 emergency room medical records the facility failed to ensure that all entries were timed, dated and signed.
Findings:
4 of 20 emergency room records reviewed did not include the time or date of Physicians Orders.
1 of 20 emergency room records reviewed did not include the physician's signature on the Physicians Orders.
1of 20 emergency room records reviewed did not include the time on the Discharge Instruction form.
7 of 20 emergency room records reviewed did not include the time of the providers signature on the Physicians Order form.
20 of 20 emergency room records reviewed did not include a time on the General Consent form.
Emergency room transfer records:
2 of 11 emergency room records reviewed did not include the time and date on the Transfer Consent form.
4 of 11 emergency room records reviewed did not include the time and date on the Transfer Physician Order Form.
2 of 11 emergency room records reviewed did not include the time on the Transfer Consent form.