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Based on record review and interview the facility failed to ensure verbal/telephone orders were properly documented in the medical record. The deficient practice is evidence by failure to document phone/ telephone according to policy and procedures in 1 (Pt #3) of the 6 (Pt #1, Pt #2, Pt #4, Pt #5, Pt #6) reviewed medical records.
Findings:

Review of the policy and procedure titled, "Orders: Verbal" effective 1/2007 and most recently revised on 07/01/2022 revealed in part, 2. The receiver: a. documents the order immediately on the physician's order form including the date, time, physician or licensed independent practitioner's name, receiver's name, status, and signature. b. repeats the order back to the physician and/or licensed independent practitioner including the: patient name, drug name and spelling of the drug to avoid an error due to sound alike drugs, dosage pronouncing it in single digits, route, frequency, requests the indication for the medication to assist in avoiding errors, questions the physician if there is any uncertainty regarding the order.

Review of the orders for Patient #3 dated 03/06/2023 at 8:30 p.m. revealed a verbal/telephone order with no documentation of the receiver following policy and procedure for verbal orders. The verbal order did not contain physician's name, receiver's name, status, and signature or that the order was read back to the physician.

In an interview on 08/08/2023 at 1:35 p.m., S3DONLATC verified order written on 03/06/2023 at 8:30 p.m. did not follow policy and procedures for verbal orders.

Based on record review and interview, the hospital failed to follow its policy and procedure to ensure that medical records were completed within 30 days of discharge.
Findings:

Review of the policy and procedure titled, "Documentation Completion Time Frames" effective 03/01/2014 and most recently revised on 02/07/2019 revealed in part:
Policy: The health record documentation shall be completed in an ongoing manner throughout the stay. When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: *incomplete status: any record not complete within 30 days of discharge. *delinquent status: any record not complete beyond the initial 30 days.

Review of Patient #3's medical record revealed admission on 03/03/2023 and discharge on 03/12/2023. Further review revealed a handwritten verbal order on 03/06/2023 at 8:30 p.m. but not scanned into the electronic medical record until 05/25/2023 at 10:14 a.m.

In an interview on 08/08/2023 at 1:35 p.m., S3DONLATC verified handwritten verbal order dated 03/06/2023 at 8:30 p.m. was not scanned into the electronic medical record until 05/25/2023 at 10:14 a.m. which is greater than 30 days from Patient #3's discharge date of 03/12/2023.

Based on record reviews and interviews, the hospital failed to ensure a patient discharge summary was completed within 30-days of discharge for 1 (Pt #4) of 6 (Pt #1, Pt #2, Pt #4, Pt#5, Pt#6) patients sampled.
Findings:

Review of the policy and procedure titled, "Documentation Completion Time Frames" effective 03/01/2014 and most recently revised on 02/07/2019 revealed, in part, Policy: The health record documentation shall be completed in an ongoing manner throughout the stay. When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: *incomplete status: any record not complete within 30 days of discharge. *delinquent status: any record not complete beyond the initial 30 days. Procedure: Physician health record completion responsibilities: discharge summary 30 days after discharge.

Review of Patient #3's medical record revealed an admit date of 03/03/2023 and a discharge date of 03/12/2023. Further review failed to reveal a completed discharge summary for Patient #3 until 05/11/2023.

In an interview on 08/08/2023 at 3:00 p.m. S1ADMN verified that Patient #3's discharge summary was documented greater than 30 days after discharge.

Based on record review and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy as evidenced by failure to document respiratory care for 1 (Pt #3) of 6 (Pt #1, Pt #2, Pt #4, Pt #5, Pt #6) reviewed medical records.
Findings:

Review of the policy and procedure titled, "Mechanical Ventilation" effective date 03/01/2014 revealed in part:
Mechanical ventilation monitoring and documentation should be performed not less than every two hours.

Review of Patient #3's medical record review revealed that the respiratory therapists did not document a minimum of every 2 hours while Patient #3 was on a ventilator.

In an interview on 08/08/2023 at 11:35 a.m., S6RTM verified every 2 hour documentation required by policy and procedure was not followed for a ventilated patient.