HospitalInspections.org

On the days of the Hospital Validation Survey based on review of the hospital governing body minutes and interviews, the Hospital failed to document of the appointment of a designated Infection Control Officer.


The findings are:


On 9/20/12 at 1015, the DON (Director of Nursing) revealed, "I was appointed the Infection Control Officer at the governing body meeting on May 15, 2012." On 9/21/12 at 0955, review of the May 2012 governing body minutes revealed no documentation or evidence of an appointment of the Director of Nursing as the hospital's Infection Control Officer. On 9/21/12 at 1015, the DON revealed, "it was just an announcement made at the meeting." The findings were verified by the DON on 9/21/12 at 1020.




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On 09/20/12 at 0915, random observations of the Medical floor revealed Housekeeping Aide #6 carried un-bagged laundry to the soiled linen room.

On the days of the Hospital Validation Survey based on interview, record review, review of hospital policy and procedures, the hospital's Activity Director failed to ensure an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psycho-social well - being of each resident for 2 of 3 swing bed residents during their admission to a swing bed at the hospital. (Patient #1 and 4)


The findings are:


On 9/19/12 at 1610, review of Patient #1's chart revealed the patient was admitted to a Swing Bed on 9/17/12. Review of patient's chart showed the patient had no activities scheduled during the patient's admission. There was no documentation that activities were provided or offered to the patient during the patient's inpatient hospital swing bed admission.

On 9/20/12 at 1100, review of Patient #4's chart revealed the patient was admitted to a Swing Bed on 9/03/12. Review of patient's chart revealed only late entry documentation on 9/18/12 and 9/19/12 by hospital staff that activities were offered to the patient on those days. Review of hospital's activity schedules from January 2012 to September 2012 showed activities were scheduled for patients from Sunday-Thursday of each week. There were no activities scheduled for Friday or Saturday. On 9/20/12 at 1200, the Activities Director revealed that he/she had a few activities for swing bed patients but "usually once PT (physical therapy), OT (occupational therapy), and speech worked with them, the patients usually don't want to do anything". The findings were verified by Chief Nursing Officer on 9/21/12 at 1300.

Facility Policy, reads, "Policy # SW-018, Activities Program", reads, "The purpose of an activities program is to provide and to encourage physical, intellectual, social and spiritual challenges according to their abilities and desires and to create an environment that is as near to normal as possible, allowing them to exercise their abilities....A daily attendance record is kept by the staff for group activity and individual programming and the record will be recorded on a calendar....".

On the days of the Hospital Validation Survey based on observations, interview, and review of the hospital policy and procedures, hospital staff failed to ensure that emergency equipment and supplies used in life saving procedures in the emergency department were not expired.


The findings are:


On 09/19/12 at 1320, random observations in the Emergency Department Trauma room revealed the following expired supplies and equipment:
Size 8 adult disposable tracheostomy cannula expired 03/2010
Size 6 adult disposable tracheostomy cannula expired 12/2009
Size 4 adult disposable tracheostomy cannula expired 03/2010
Size 3.0 pediatric disposable tracheostomy cannula expired 01/2010
Size 4.0 pediatric disposable tracheostomy cannula expired 01/2010
Size 4.5 pediatric disposable tracheostomy cannula expired 12/2009
Size 5.5 pediatric disposable tracheostomy cannula expired 01/2010
1 small sterile suction tray 01/03/08
2 sterile autoclaved Cut down trays 03/24/06 and 02/15/07
2 sterile autoclaved Tracheostomy trays 03/25/05 and 02/19/07
1 sterile autoclaved Obstetrics tray 12/23/10
3 4 x 8 Surgicel expired 07/2012

On 09/19/12 at 1330, Registered Nurse #6 who works in the Emergency Department revealed, "We don't even use those anymore. We haven't used those and other things in that particular cabinet. I guess we just need to get rid of them all together."

Hospital policy, "Policy #ND082: Infection Control Measures in the Emergency Department", reads, "....6. Sterilized supplies and packs must be checked every week for sterility, packaged properly with expiration date, and free from tears. Supplies whose sterility is doubtful shall be returned to Central Supply for reprocessing....".

On the days of the Hospital Validation Survey based on observation and interview, the facility failed to ensure that the premises are clean, orderly, and maintained in a sanitary manner for the dietary department, kitchen, sleep lab, and the medical surgical unit.


The findings are:


On 9/19/2012 at 1225, random observations during a tour of the kitchen area revealed peeling paint and plaster along the edge of the ceiling in the food storage area, two long fluorescent lights did not work, a brown substance observed along the corners of the floor inside the food storage area, and missing floor tiles in the food storage area. The finding was verified with the Dietary Supervisor on 9/19/2012 at 1230. On 9/19/2012 at 1515, random observations during a tour of the Pharmacy revealed a dark black area on the ceiling tiles located over the medication storage area. The finding was verified by the Plant Manager on 9/19/2012 at 1515.




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On 9/20/12 at 1315, random observations of the Medical Surgical Unit revealed Housekeeper #6 mopped patient room #14 after the patient's discharge. Observations on 9/20/12 from 1350-1355 showed Housekeeper #6 cleaned and mopped patient room #16 with the same mop and water used when cleaning patient room #14. On 9/20/12 at 1400, Housekeeper #6 revealed, "we don't change mop water or the mops but every three rooms".

Facility policy, "IP-H-001, Infection Prevention-Housekeeping", reads, "B. Discharge Unit 1. Use clean mops, rags, and fresh solutions for each unit....6. Mop water should be changed frequently....".


On 9/19/12 at 1145, random observations on the Medical Surgical Unit revealed a washing machine located on the medical surgical on the floor. During an interview with Housekeeping Supervisor on 9/19/12 at 1200, he/she revealed the washing machine is used to clean the linen in the Sleep Study Room. When asked how the linen is cleaned, the Housekeeping Supervisor stated with Virex 1 cupful.
On 9/19/12 at 1430, a review of Material Safety Data Sheet (MSDS) obtained from housekeeping on 9/19/12 at 1430 revealed Dawn liquid detergent is used. On 9/19/12 at 1430, the Housekeeping Supervisor stated "Virex was not used to wash the linen for the sleep lab. Staff actually use 1/4 cup Dawn to 1 large load to clean the linen." There was no information on the MSDS sheet documenting the antibacterial or tuberculocidal efficacy for Dawn liquid detergent for linen for hospital patient use.

On the days of the Hospital Validation Survey based on observation, interview, and review of the hospital policy and procedures, the Critical Access Hospital failed to ensure safety practices for food handling in the dietary area.


The findings are:


On 9/19/12 at 1200, random observations of the dietary area showed the kitchen cooler showed the following food items that had not been labeled with the date of preparation or date of storage: a large bowl of coleslaw covered with saran wrap, 10 (ten) servings of 3(three)- ounce coleslaw cups, 3 pounds of parmesan cheese wrapped in saran wrap, a bowl of cocktail sauce, 1 gallon container of chocolate ice cream labeled 4/12/12, 1 gallon container of vanilla bean ice cream labeled 4/12/12, and 3 gallon containers of strawberry ice cream labeled 4/12/12, 3 packages of cream of wheat opened 1/10/12, 5 (five) instant oatmeal packages expired 6/1/12, 2(two) boxes of Jiffy Corn Muffin Mix expired 8/14/12, 3 packages of Food Lion gravy mix expired 5/4/12, 1 packet of Ranch salad dressing opened 11/10/11, an 8 ounce bottle of vanilla flavoring opened 12/1/11, a 64-ounce bottle of apple cider vinegar expired 7/15/12, and a 30-ounce bottle of almond extract expired 11/20/11, an employee's green lunch box, a can of Dr. Pepper, and a bottle of opened water. The findings were verified with the Dietary Supervisor on 9/19/12 at 1200.

On the days of the Hospital Validation Survey based on random observations, interview, and review of the hospital policy and procedures, the hospital failed to ensure the integrity of intravenous fluids (IVF) and the removal of expired medication.


The findings are:


On 09/19/12 at 1130, random observation of Pharmacy Department stock revealed 1 bottle of unopened 2% Lidocaine 100 milligrams (20 milligrams per milliliter) expired on 09/01/12. On 09/19/12 at 1155, random observations of pharmacy department stock revealed that the original packages containing Normal Saline 50 milliliter(ml) IVF bags were opened.
On 09/19/12 at 1200, random observations of the pharmacy department stock revealed 6 bags of Dextrose 5% 100 milliliter intravenous fluids were out of the original package container. On 09/19/12 at 1205, random observations of the pharmacy department stock revealed Novolin R and Novolin N 10 ml U (units)-100 labeled as opened on 06/21/12. On 09/19/12 at 1200, the Director of Pharmacy verified insulin is good for 28-30 days after opening. On 09/19/12 at 1235, the Director of Pharmacy stated that Insulin expires 28-30 days after opening."

Hospital policy, "Policy #MP-32: Authorized Area-Outdated and Unstable Drugs", reads, "All medications will be pulled from stock and placed in the designated storage area in the Pharmacy until disposition is decided (returned or destroyed)....".

On the days of the Validation Survey,based on observation, review of the facility policy and procedures, and interview, the Critical Access Hospital failed to ensure safety practices for food handling.

The findings are:

On 9/19/12 at 1655, observation revealed the following food temperatures: Fried okra- 125 degrees, pureed okra- 122 degrees, grilled cheese sandwich- 113 degrees. On 9/20/12 at 0705, observation showed the temperature for scrambled eggs was 100 degrees, but the staff did reheat the eggs prior to serving. The findings were verified with the Dietary Supervisor on 9/19/12 at 1655 and on 9/20/12 at 0705.

On 9/19/12 at 1300, the Dietary Supervisor revealed,"well, I know I should have an emergency food supply, but I don't. I only have 4( four) cases of water stored for an emergency." The findings were verified with the CEO ( Chief Executive Officer) on 9/21/12 at 1330.

On 9/19/12 at 1430, observation and record review revealed hospital used a dietary manual, titled, "Manual of Clinical Dietetics", sixth edition, dated 2000. On 9/19/12 at 1435, the Registered Dietitian revealed, "we do not have a current therapeutic diet manual. Our manual is from 2000. The information is available online but we are not able to access the resources due to the cost."

On 9/19/12 at 1635, an interview with Dietary Aide #1 revealed, "temperatures are not routinely checked on the line because I'm by myself and I need to get on down the hall. I check the food temperatures after I make the trays and they are on the cart."

Review of hospital Policy and Procedure, #DDP-039, reads, ".... Purpose- to ensure holding of foods at proper temperatures....If food temperatures do not meet or exceed 140 degrees- food must be reheated to meet standards....".

On the days of the Hospital Validation Survey based on interview and review of the hospital policy and procedures, the Critical Access Hospital failed to ensure Dietary Policies are reviewed annually.


The findings are:


On 9/19/12 at 1435, the Registered Dietitian revealed, "I'm not sure if our Dietary Policy is reviewed annually or not in the Quality Assurance." On 9/19/12 at 1445, a review of QAPI (Quality Assurance Performance Improvement) for dietary services revealed no evidence that dietary policies were reviewed annually or in QAPI.

On the days of the Hospital Validation Survey based on observation, record review, and interview, the hospital failed to ensure that all needs of the patient were met as evidenced by lack of training, documentation, and care related to the use of the telemetry unit at the nursing station for 4 of 4 patients on the medical surgical unit who had received telemetry monitoring. (Patient #3, 2, 6, and 19)

The findings are:


On 9/21/2012 at 0945, random observation on the medical surgical nursing unit showed the telemetry unit was alarming. Observations showed the Unit Secretary at the desk did not address the alarm. When the Unit secretary was queried about the telemetry unit alarm, the Unit Secretary reported that he/she had a "little" training about the telemetry unit. The Unit Secretary stated, "I call the nurse when the alarm goes off, high rate alarm goes off." When queried if she/she had notified the nurse that the telemetry unit was alarming, the Unit secretary replied "No". When asked if he/she knew why the telemetry unit was alarming, the Unit secretary replied, "No". Observations of the telemetry unit showed the battery light located in the patient's unit was blinking. When the Unit secretary was asked what he/she would do for a blinking battery alarm, the Unit secretary replied, "I will call the Certified Nursing Assistant and he/she can put the battery in. I do not have access to batteries...". The Unit secretary reported, " I just print the strips and put them in a pile on the desk. They are gone when I come back in the next day so I assume that someone looks at them and puts them on the chart...". On 9/21/12 at 1200, review of the Unit secretary's personnel file revealed no evidence of any training or competencies regarding use of the telemetry monitors or documentation regarding an arrhythmia course.

On 9/21/2012 at 1040, the Chief Nursing Officer, stated, "...All Unit Secretaries are trained in basic arrhythmia. They are not to leave the monitors at any time but if they have leave, they are supposed to inform the Charge Nurse so they can watch the monitors. There is only coverage for the telemetry monitors from 0700-2300. On third shift, the nurses watch the monitors. They take turns taking care of the patients and watching the monitors.... We have 1-2 Registered Nurses (RN) or 1 RN and 1 Licensed Practical Nurse (LPN), and 1-2 Certified Nursing Assistants for the night shift staffing.


On 9/20/2012 at 1235, review of the closed chart for Patient #3 revealed the patient was admitted on 3/08/2012 and discharged on 3/14/2012. The patient's chart had physician orders for telemetry to monitor his/her cardiac status. The patient's chart showed the patient was placed on the telemetry monitor at 1429 on 3/08/2012 and taken off the telemetry monitor on 3/09/2012 at 1206. The patient's chart showed that although telemetry strips were run every 4 hours, only one telemetry strip showed no evidence that the cardiac status of the patient was analyzed by a Registered Nurse and the documentation required by the hospital's own policy and procedure was on the strip to include the heart rate, PR interval, QRS interval, QT interval, and the interpretation of the strip by nursing staff every 4 hours. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1240 who stated, "...I just realized that the staff was not following this policy over the weekend, when I worked nights...".

On 9/20/2012 at 1105, review of closed chart for Patient #2 revealed the patient was admitted on 3/26/2012 and discharged on 4/12/2012. The patient's chart showed a physician order for telemetry monitoring for the patient's cardiac status from 3/26/2012 at 2015 through 3/28/2012 at 0349. Although the patient's chart showed telemetry strips were run every 4 hours, there was no documentation of the measurement of the patient's heart rate or rhythm on the strips or other parameters required by the hospital's own policy and procedure to include the heart rate, PR interval, QRS interval, QT interval, and the interpretation of the strip by nursing staff every 4 hours. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1120.





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On 9/20/12 at 1300, review of Patient #6's chart revealed telemetry rhythm strips dated 9/17/12 and 9/18/12 without documentation of the heart rate, PR interval, QRS interval, QT interval, and the interpretation of the strip per the hospital's own policy and procedure by nursing staff every 4 hours.

On 9/21/12 at 1120, review of Patient #19's closed chart revealed telemetry rhythm strips dated 5/30/12 (x 2), 5/31/12 (x 2), 6/6/12 (x 1), 6/4/12 (x 2), 6/6/12 (x 4) and 6/7/12 (x 1) without documentation of the heart rate, PR interval, QRS interval, QT interval, and the interpretation of the strip per the hospital's own policy and procedure by nursing staff every 4 hours.
The findings were verified by the Chief Nursing Officer on 9/21/12 at 1235.

Hospital policy, "Policy # ND020, Cardiac Monitoring/Telemetry, Guidelines, reads, "4. A rhythm strip will be recorded: A. On Admission B. Every four hours C. On MD order to discontinue monitor D. PRN for rhythm changes....5. The following will be documented on each strip: heart rate, PR interval, QRS interval, QT interval and the interpretation of the strip....6. Qualified personnel will monitor the patient for dysrhythmias and changes in electrical conduction and notify a nurse if this occurs....8. The primary nurse is responsible for ensuring these guidelines are followed. He/She is also responsible for ensuring that the initials of the nurse interpreting the strip are on each strip prior to the end of each shift".

On the days of Hospital Validation Survey based on record review and review of facility policy and procedures, hospital staff (Registered Nurses) failed to provide complete, appropriate documentation for and during restraint usage for 3 of 20 patient records reviewed for restraints. (Patient #13, 19, and 20)


The findings are:


On 9/21/12 at 0955, review of Patient #13's chart revealed the patient was admitted on 4/25/12 with a questionable Change in Mental Status, elevated white blood cell count, and chronic Renal Insufficiency. Review of Restraint Flow Sheet on the patient's chart showed the initiation of patient restraints at 1300 on 4/26/12 with documentation of nursing assessments until 1530. Review of the physician order dated 4/26/12 at 1845 discontinuing the restraints. There was no documentation of nursing assessments after 1530 related to restraints or discontinuation of restraints.

On 9/21/12 at 1120, review of Patient #19's chart revealed the patient was admitted on 5/27/12 with Pancreatitis and Abdominal Pain. Review of a physician order sheet showed the physician ordered restraints from 5/30/12 to 6/4/12. Review of Restraint Flow Sheets in the patient's chart revealed there was no documentation of a nursing assessment from 6/1/12 after 1800 until 6/4/12 at 0700 to 1930 which showed removal of the patient's restraints.

On 9/21/12 at 1200, review of Patient #20's chart revealed the patient was admitted on 7/31/12 with Secondary Burns and Malnutrition. Review of a physician orders for Restraints dated 8/2/12, 8/3/12 and 8/6/12 and review of the patient's Restraint Flow Sheets with the same dates showed no documentation of nursing assessment for the initiation and discontinuation of the patient's restraints on those or other dates. The findings were verified by Chief Nursing Officer on 9/21/12 at 1315.

Facility policy, Policy #APO73, Restraint (Physical/Chemical), reads, "9.0 Assessment: 9.1 MONITOR continued need for restraint usage every 8 hours and record on "Restraint Record." This must be done by an R.N. (registered nurse). 9.2 Observe restraint integrity and patient safety q (every) 30 minutes and document on "Restraint Record." This may be done by nursing staff. 9.3 ASSESS restrained extremity every 2 hours for evidence of circulatory restriction (loss of sensation, decreased pulses, change in color, edema) and skin breakdown; if restrained with chest restraint, assess every 2 hours for respiratory restriction....".

On the days of the Hospital Validation Survey based on observations, interview, and record reviews, hospital staff failed to administer medication at the ordered time for 1 of 11 patients for care and services. (Patient #3)


The findings are:


On 09/20/12 at 0900, observation of the medication pass for Patient #3 revealed Glucotrol 5 mg(milligrams) PO(by mouth) was administered at 0900. Review of the Patient #3's chart showed Glucotrol 5 mg po to be administered at 0630 prior to breakfast. On 09/20/12 at 0910, Registered Nurse #4 verified the time frame for administering medication is an hour before and an hour after the medication is ordered.

On the days of the Hospital Validation Survey based on clinical record review and interview, the hospital failed to ensure the patient's care plan was implemented and updated for 9 of 20 closed medical records (Patient #1, 2, 3, 4, 5, 6, 8, 9, and 10) and 1 of 11 concurrent patient charts. (Patient #6)

The findings are:

On 9/20/2012 at 1300, review of Patient #10's (closed)chart revealed the patient was admitted on 3/10/2012 and discharged on 4/12/2012. Review of the patient's plan of care revealed staff failed to revise the patient's plan of care during the patient's admission. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1315.

On 9/20/2012 at 1335, review of Patient #9's (closed)chart revealed the patient was admitted on 3/23/2012 and discharged on 3/26/2012. Review of patient's plan of care showed staff failed to revise the patient's plan of care to reflect progress toward goals or lack of progress toward goals during the patient's admission. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1340.

On 9/20/2012 at 1105, review of Patient #2's (closed) chart revealed the patient was admitted on 3/26/2012 and discharged on 4/12/2012. Review of the patient's plan of care showed staff failed to revise the patient's plan of care to reflect progress toward goals or lack of progress toward goals during the patient's admission. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1110.

On 9/20/2012 at 1235, review of Patient #3's (closed)chart revealed the patient was admitted on 3/08/2012 and discharged on 3/14/2012. Review of the patient's plan of care revealed staff failed to revise the patient's plan of care to reflect progress toward goals or lack of progress toward goals during the patient's admission. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1240.

On 9/20/2012 at 1245, review of Patient #8's (closed)chart revealed the patient was admitted on 3/10/2012 and discharged on 3/11/2012. Review of the patient's plan of care revealed staff failed to revise the patient's plan of care to reflect progress toward goals or lack of progress toward goals during the patient's admission. The finding was verified by the Chief Nursing Officer on 9/20/2012 at 1250.







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On 9/20/12 at 1300, review of Patient #6's (concurrent)chart revealed the patient was admitted on 9/17/12 with Chest Pain. Review of the patient's plan of care revealed staff failed to update and/or revise patient's plan of care. During an interview with Chief Nursing Officer on 9/19/12 at 1640, he/she revealed that the current computer system doesn't show updates to the plan of care. The findings were verified by the Chief Nursing Officer on 9/21/12 at 1315.






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On 9/20/12 at 1030, review of Patient #1's closed record revealed the patient's chart had no plan of care initiated or revised by the RN (Registered Nurse) during the admission.
On 9/20/12 at 1045, review of Patient #4's closed record revealed the patient's chart had no plan of care update or revision by the RN during the admission.
On 9/20/12 at 1100, review of Patient #5's closed record revealed the patient's chart had no plan of care update or revision by the RN during the admission.
On 9/20/12 at 1115, review of Patient #6's closed record revealed the patient's chart had no plan of care update or revision by the RN during the admission. The findings were verified with the Director of Nursing on 9/21/12 at 1130.

On the days of the Hospital Validation Survey based on record review, interview, and review of the hospital policy and procedures, the hospital failed to ensure medical records were accurately completed.


The findings are:


Cross Reference C0307: The hospital to ensure medical records were authenticated, dated, and timed for 7 of 11 concurrent records (Patient #1, 3, 6, 10, 11, 8, and 7) and 6 of 20 closed records. (Patient #12, 16, 17, 18, 19, and 20)

On the days of the Hospital Validation Survey based on record review, interview, and review of hospital policy and procedure, hospital staff failed to complete medical record entries with the time, date, and/or authenticity for 7 of 11 concurrent patient records (Patient #1, 3, 6, 10, 11, 8, and 7) and 6 of 20 closed patient records. (Patient #12, 16, 17, 18, 19, and 20)


The findings are:


On 09/20/12 at 0945, review of the concurrent chart for Patient #3 revealed Patient #3 was admitted on 09/19/12 with the diagnosis of Shortness of Breath and discharged on 09/20/12. There was no discharge diagnosis on recorded on the Discharge Summary in the packet given to patient. The packet had only the following documents:
09/19/12- Emergency Physician orders
09/20/12- Physician discharge order with no time recorded

On 09/20/12 at 1130, review of the concurrent record for Patient #10 revealed Patient #10 was admitted on 09/17/12 with the diagnosis of Dyspnea. The following documents were in the chart:
09/16/12- Emergency Physician orders- no time recorded
Orders for DVT/PE(Deep Vein thrombosis/Pulmonary Embolism) Prophylaxis- no time and date recorded
09/18/12- Physician orders- no time recorded
09/19/12- Physician Progress Record- no time recorded
09/20/12- Physician Progress Record- no time recorded

On 09/20/12 at 1230, review of the concurrent record for Patient #11 revealed Patient #11 was admitted on 09/19/12 with the diagnosis of Congestive Heart Failure. The following documents were in the chart:
09/19/12- Emergency Physician orders- no time recorded
09/19/12- Physician orders- no time recorded

On 09/20/12 at 1250, review of the concurrent record for Patient #8 revealed Patient #8 was admitted on 09/10/11 for Respite Care. The following documents were in the chart:
09/10/11- Physician orders- no time recorded
09/11/11- Physician orders- no time recorded
09/17/11- Physician orders- no MD signature recorded
10/24/11- Physician orders- no MD signature recorded
12/04/11- Physician orders- no MD signature recorded
12/15/11- Physician orders- not signed within 48 hours
12/22/12- Telephone Physician orders- not signed within 48 hours
02/24/12- Telephone Physician orders- not signed within 48 hours, no time recorded
03/20/12- Physician orders- not signed within 48 hours
04/12/12- Verbal Physician orders- not signed within 48 hours

On 09/20/12 at 1345, review of the concurrent record for Patient #7 revealed Patient #7 was admitted on 05/17/12 for Respite Care. The following documents were in the records:
05/17/12- Verbal Physician orders- no MD authentication
05/18/12- Verbal Physician orders- no MD authentication
06/03/12- Telephone Physician orders- no MD authentication
06/13/12- Telephone Physician orders- no MD authentication

On 09/20/12 at 1510, review of the closed record for Patient #16 revealed Patient #16 was seen in the Emergency Department on 09/02/12 for "left ear pain". The following document was in the record:
09/01/12- Emergency Physician orders- no time recorded

On 09/20/12 at 1515, review of the closed record for Patient #17 revealed Patient #17 was seen in the Emergency Department on 08/19/12 for "right foot and toe pain". The following document was in the record:
08/20/12- Emergency Physician orders- no time recorded

On 09/20/12 at 1520, review of the closed record for Patient #12 revealed Patient #12 was seen in the Emergency Department on 07/21/12 for "right foot hurting". The following document was in the record:
07/21/12- Emergency Physician orders- no time recorded

On 09/21/12 at 1135, the Director of Nursing revealed that the Emergency Room order sheets do not have a place for the times, but they would add that to the forms. The Director of Nursing stated, "the physicians didn't think that they needed to put the times on the orders. We have addressed this in the past. I have even purchased a clock and put in their room".

Facility policy, "Policy #0028: Documentation of the ER Record", reads, "....B. All Entries in the Emergency Room Record shall be dated, signed, and recorded in an indelible manner." Facility policy, "Policy #0016: Completion of Medical Records", reads, "1....Signed by the attending physician....Discharge Summary:...1. Final diagnoses....Physician's Orders:...Verbal or telephone orders must be signed within 2 days....".















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On 9/19/12 at 1610, review of Patient #1's (concurrent) chart revealed the patient was admitted to a Swing Bed. The physician's orders dated 9/17/12 and progress records dated 9/19/12 had no times recorded when authenticated.

On 9/20/12 at 1100, review of Patient #4's (closed)chart revealed the patient was admitted to a Swing Bed. Physician orders had no dates and times recorded when authenticated: 9/4/12, 9/5/12, 9/7/12, 9/12/12, 9/15/12, 9/17/12 and 9/18/12. Progress records had no times recorded for entries on: 9/7/12, 9/10/12, 9/11/12, 9/12/12, 9/17/12 and 9/18/12.

On 9/20/12 at 1300, review of Patient #18's (closed)chart revealed the patient was seen in the Emergency Room and the physician's order dated 7/21/12 had no time recorded when authenticated.

On 9/20/12 at 1300, review of Patient #6's (concurrent) chart revealed the patient was admitted to the Medical Surgical Unit, and physician orders dated 9/17/12, 9/18/12 and 9/19/12 had no times recorded when authenticated.

On 9/21/12 at 1120, review of Patient #19's (closed)chart revealed the patient was admitted through the Emergency Room to the Medical Surgical Unit. Physician progress notes dated 5/25/12, 5/29/12, 5/30/12, 6/1/12 and 6/8/12 had no time recorded. Physician order sheets had no time for verbal physician orders when authenticated on 5/30/12, 6/1/12, 6/4/12, 6/6/12 and 6/7/12.

On 9/21/12 at 1200, review of Patient #20's (closed) chart revealed the physician orders dated 8/1/12, 8/2/12, 8/3/12, 8/4/12, 8/6/12, 8/7/12 and 8/9/12 had no dates and times when authenticated by the physician. Progress notes dated 8/1/12, 8/2/12, 8/3/12, 8/4/12, 8/5/12, 8/7/12, 8/8/12 and 8/9/12 had no times for entries when authenticated by the physician. The findings were verified by the Chief Nursing Officer on 9/21/12 at 1255.