HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the medical staff bylaws were adapted to reflect a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Findings Included:

The Medical Staff Bylaws dated 07/29/85 reflected, "A complete history and physical examination, shall, in all cases, be written 24 to 48 hours after admission of the patient..."

On 01/06/11 at 10:00 AM [Staff #12] was interviewed. [Staff #12] was asked by the surveyor to review the Medical Staff Bylaws provided to the surveyor. [Staff #12] stated she could not find when changes were made to the Medical Staff Bylaws and when changes were reported and documented. regarding the above requirement. [Staff #12] acknowledged the Medical Staff Bylaws provided were not current and in compliance.

Based on interview and record review, nursing services failed to ensure 2 of 3 nurses [Staff #48 and #49] who administered blood transfusions to Patient #16 in September 2010 had special training in blood administration.

Findings Included:

Patient #16's "Discharge Summary" transcribed 10/14/10 noted that Patient #16, age 86, was admitted to the hospital on 09/28/10 for "...suspected anemia, likely related to acute blood loss..." The 09/28/10 and 09/29/10 transfusion information for Patient #16 noted that a nurse [Staff #48] administered Unit #2 of blood on 09/28/10 at 12:00 Midnight and Unit #3 of blood on 09/29/10 at 03:30 AM. Patient #16's 09/29/10 "Crossmatch Transfusion Report" indicated that two nurses [Staff #48 and #49] certified the "Key Transfusion numbers" of the blood were checked prior to the start of the transfusion.

During a joint interview at approximately 12:55 PM on 01/06/11, the Chief Nursing Officer [Staff #3] and Clinical Nursing Supervisor [Staff #4] were asked if Licensed Vocational Nurses were allowed to administer blood to patients at the hospital. Staff #3 and #4 reviewed Patient #16's transfusion information and said that Licensed Vocational Nurses [Staff #48 and #49] had administered blood to Patient #16. The surveyor asked if the nurses [Staff #48 and #49] had the required special training for blood administration. [Staff #3 and #4] were in agreement there was no documentation that both nurses [Staff #48 and #49] were trained in blood administration.

The "Blood Transfusion Practice" policy dated 05/02/00 reflected, "Blood or blood products transfusions will be safely administered by nursing personnel for the purpose of replacing lost blood and/or blood components."

Based on interview and record review, the hospital failed to maintain complete medical records for 20 of 20 patients who were [Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20] treated and discharged from the hospital after 06/01/10. The medical record entries were not complete, dated, timed, and/or authenticated according to the hospital policy.

Findings Included:

The "Discharge Summary" physician's signature/authentication was not timed and dated for the following Patients:

Patient #1 - Transcribed 06/28/10
Patient #7 - Transcribed 09/30/10
Patient #8 - Transcribed 09/13/10
Patient #10 - Transcribed 10/13/10
Patient #12 - Transcribed 11/23/10
Patient #13 - Transcribed 09/30/10
Patient #15 - Transcribed 07/26/10
Patient #16 - Transcribed 10/14/10
Patient #18 - Transcribed 10/27/10
Patient #19 - Transcribed 07/22/10
Patient #20 - Transcribed 12/06/10

The "History and Physical" physician's signature/authentication was not dated and timed for the following Patients:

Patient #1 - Transcribed 06/10/10
Patient #8 - Transcribed 09/01/10
Patient #9 - Transcribed 12/22/10
Patient #10 - Transcribed 10/13/10
Patient #12 - Transcribed 11/17/10
Patient #13 - Transcribed 08/24/10
Patient #15 - Transcribed 07/24/10
Patient #16 - Transcribed 09/29/10
Patient #17 - Transcribed 12/03/10
Patient #18 - Transcribed 10/24/10
Patient #19 - Transcribed 07/17/10

The "Consultation Note" physician's signature/authentication was not dated and timed for the following Patients:

Patient #13 - Transcribed 08/25/10
Patient #20 - Transcribed 11/09/10

The "Progress Notes" physician's signatures and nurse's signatures were not dated and/or timed for the following Patients:

Patient #1 - 06/10/10 through 06/18/10 - not timed by physician
Patient #7 - 09/13/10 - not timed by physician, transcribed note 09/15/10 - no date/time by physician
Patient #8 - 08/31/10 - not timed by physician, 09/02/10 - not timed by physician
Patient #9 - 12/22/10 and 12/23/10 - not timed by physician
Patient #10 - Transcribed note 10/10/10 - no date/time by physician
Patient #12 - Transcribed note 11/18/10 - no date/time by physician
Patient #13 - Transcribed note 08/24/10 - no date/time by physician, 08/26/10 - not timed by physician.
Patient #16 - Transcribed 09/30/10 - no date/time by physician, 10/01/10 - not timed by physician.
Patient #17 - 12/03/10 not timed by the nurse.
Patient #19 - Transcribed 07/20/10 - no date/time by physician.
Patient #20 - Transcribed 11/10/10 - no date/time by physician, 11/11/10 - not timed by the physician.

The "Discharge Note" physician's signature/authentication was not dated and timed for the following Patients:

Patient #7 - Transcribed 09/16/10

The "Medication Reconciliation Form" physician's signatures were not dated and/or timed for the following Patients:

Patient #7 - Admit physician's signature dated 09/14/10, Discharge physician's signature dated 09/16/10
Patient #10 - Admit physician's signature dated 10/08/10, Discharge physician's signature dated 10/11/10
Patient #13 - Patient sticker indicated admit date 08/23/10 - Admit physician's signature and discharge physician's signature were not timed and dated
Patient #17 - Admit physician's signature dated 12/03/10, Discharge physician's signature dated 12/03/10
Patient #18 - Admit physician's signature dated 10/24/10, Discharge physician's signature dated 10/27/10

The "Doctor" order signatures were not timed and dated by the physician for the following Patients:

Patient #1 - Order noted by the nurse 06/11/10 - no date/time of physician's signature
Patient #7 - Orders noted by the nurse 09/14/10 and 09/15/10 - no date/time of physician's signatures
Patient #13 - Orders noted by the nurse 08/23/10 - no date/time of physician's signature
Patient #16 - Orders noted by the nurse 09/29/10 - no date/time of physician's signature
Patient #18 - Orders noted by the nurse 10/24/10 - no date/time of physician's signature

The "Doctor" order signatures were not timed by the physician for the following Patients:

Patient #1 - Written and signed by the physician 06/12/10 and 06/13/10
Patient #10 -Written and signed by the physician 10/11/10
Patient #16 - Written and signed by the physician 09/28/10 and 09/29/10
Patient #17 - Written and signed by the physician 12/03/10
Patient #20 - Written and signed by the physician 11/08/10

The "Consent to Operation, Anesthetics and Other Medical Services" hospital witness signatures were not timed for the following Patients:

Patient #1 - 06/10/10
Patient #13 - 08/25/10

The "Operative Report" physician signature/authentication was not dated and timed for the following Patients:

Patient #1 - Transcribed 06/10/10
Patient #9 - Transcribed 12/22/10
Patient #13 - Transcribed 08/26/10

The "Noninvasive Cardiovascular Laboratory Preliminary Findings" technologist's signature/authentication was not dated and timed for the following Patient:

Patient #1 - Exam 06/16/10

The "Noninvasive Cardiovascular Laboratory Echocardiogram Report" technologist's signature/authentication was not dated and timed for the following Patient:

Patient #18 - Exam 10/25/10

The "Radiographic Consultation" report electronic Radiologist's signature/authentication was not dated and timed for the following Patients:

Patient #1 - Report printed 06/16/10
Patient #5 - Report printed 12/28/10
Patient #7 - Reports printed 09/15/10 and 09/16/10
Patient #10 - Report printed 10/12/10
Patient #12 - Report printed 11/17/10
Patient #18 - Report printed 10/28/10

The "Graphic Chart" entries that included temperature, pulse, respiration, blood pressure, and weight were not signed by the person entering the information for the following Patients:

Patient #1 - 06/10/10 through 06/18/10
Patient #7 - 09/13/10 through 09/16/10
Patient #8 - 08/31/10 through 09/03/10
Patient #10 - 10/08/10 through 10/11/10
Patient #11 - 11/21/10 through 11/24/10
Patient #12 - 11/16/10 through 11/23/10
Patient #13 - 08/23/10 through 08/30/10
Patient #15 - 07/22/10 through 07/25/10
Patient #18 - 10/23/10 through 10/27/10
Patient #20 - 11/08/10 through 11/11/10

The "Intake and Output Record" entries that included diet, percentages eaten at breakfast, lunch, dinner, and snack, and intake/output information were not signed for the following Patients:

Patient #1 - 06/16/10 through 06/18/10
Patient #7 - 09/13/10 through 09/15/10
Patient #8 - 08/31/10 through 09/02/10
Patient #10 - 10/08/10 through 10/10/10
Patient #11 - 11/21/10 through 11/24/10
Patient #12 - 11/16/10 through 11/22/10
Patient #13 - 08/23/10 through 08/29/10
Patient #16 - 09/28/10 through 09/30/10

The "Blood Transfusion Sheet" nurse's signature/authentication was not completed by the nurse for the following Patient:

Patient #20 - Date 11/10/10 - no nurse's signature with date/time of signature/authentication

The "Patient/Family Education" report staff signature was not timed for the following Patient:

Patient #10 - 10/08/10 "Nurse Care Safety"

The "Death Note" physician's signature/authentication was not dated and timed for the following Patient:

Patient #17 - Transcribed 12/07/10

The "Patient Admission Data Base" nurse's signature/authentication was not timed for the following Patients:

Patient #1 - 06/10/10
Patient #7 - 09/13/10
Patient #8 - 08/31/10
Patient #10 - 10/08/10
Patient #12 - 11/16/10
Patient #13 - 08/23/10
Patient #16 - 09/28/10

The "Tobacco History and Cessation Counseling" respiratory form's staff signature was not timed for the following Patients:

Patient #7 - 09/13/10
Patient #10 - 10/08/10
Patient #11 - 11/21/10
Patient #12 - 11/16/10
Patient #15 - 07/22/10
Patient #18 - 10/23/10

The "Inpatient Admission Assessment" nurse's signature/authentication was not complete for the following Patients:

Patient #1 - Patient sticker noted the admission was on 06/10/10 - no signature with date and time
Patient #7 - 09/13/10 - no time
Patient #11 - 11/21/10 - no time
Patient #12 - Date of assessment 11/16/10 - no signature with date and time
Patient #13 - 08/23/10 - no time

The "Inpatient Admission Assessment Pressure Wound Risk Assessment" signature/authentication was not complete for the following Patients:

Patient #1 - Date of assessment 06/10/10 - no complete signature with date/time, only initials were entered
Patient #11 - Date of assessment 11/21/10 - no complete signature with date/time, only initials were entered
Patient #12 - Date of assessment 11/16/10 - no complete signature with date/time, only initials were entered
Patient #13 - Date of assessment 08/23/10 - no complete signature with date/time, only initials were entered

The "Patient Care Record Assessment" nurse's signatures/authentications were not dated and timed for the following Patients:

Patient #1 - Date of assessment 06/11/10 AM and PM
Patient #8 - Date of assessment 08/31/10 AM and PM

The "Patient Authorization Record" hospital witness signature was not complete for the following Patients:

Patient #1 - 06/10/10 no complete signature that included time - only initials were entered
Patient #2 - 01/04/11 no complete signature that included time - only initials were entered
Patient #3 - Patient sticker noted the admission was on 12/31/10, there was no complete signature with date and time of signature - only initials were entered
Patient #5 - Patient sticker noted date 12/16/10, there was no complete signature with date and time of signature - only initials were entered
Patient #6 - Signed by the patient 09/23/10 - no complete witness signature that included date and time - only initials were entered
Patient #7 - 09/13/10 no complete signature that included time - only initials were entered
Patient #10 - 10/08/10 - no time
Patient #12 - Signed by patient 11/16/10 - no complete witness signature that included date and time - only initials were entered
Patient #13 - Signed by patient 08/23/10 - no date and time
Patient #18 - Signed by patient 10/23/10 - no complete witness signature that included date and time - only initials were entered

The "Consent to Photograph" witness signature did not include the time for the following Patient:

Patient #13 - 08/23/10

The "Swing Bed Program Activities Screening/Plan Sheet" assessment signature did not include the time for the following Patient:

Patient #14 - 11/29/10

The "Physical Therapy Inpatient/Swingbed Evaluation" therapist signature did not include the time for the following Patient:

Patient #14 - 11/29/10

The "Ordering and Discharge Instruction Sheet" physician's signature was not timed for the following Patient:

Patient #2 - 01/04/11

The "Discharge Instructions" nurse's signature was not timed for the following Patient:

Patient #18 - 10/27/10

The "Physician's Statement of Medical Necessity" physician's signature was not timed for the following Patient:

Patient #2 - 01/04/11

The "Consent To/Refusal of Treatment and Transfer" physician's signature was not timed for the following Patients:

Patient #2 - 01/04/11
Patient #6 - 09/23/10

The "Memorandum of Transfer" physician's signature was not timed and dated for the following Patients:

Patient #2 - Transferring physician secured receiving physician 01/04/11- Physician Certification signature not dated and timed
Patient #6 - Transferring physician secured receiving physician 09/23/10 - Physician Certification signature not dated and timed

The Emergency Department's "Patient Elopement/Left without Being Seen Form" nurse's signature was not dated and timed for the following Patient:
Patient #4 - Time patient left "ED...1545"

The "ER Physician Record" physician's signature was not dated and timed for the following Patient
:
Patient #5 - Date of Emergency Room visit 12/16/10

The "Emergency Physician Record" physician's signature was not dated and timed for the following Patient:

Patient #8 - Time seen 08/31/10

The Emergency Department's "Aftercare Instructions to the Patient..." physician's signature was not dated and timed for the following Patient:

Patient #5 - Patient sticker dated 12/16/10

The "Emergency Nursing Record" nurse's signature was not dated for the following Patient:

Patient #6 - Patient sticker dated 09/23/10

During a joint interview at approximately 1:00 PM on 01/06/11, the Chief Nursing Officer [Staff #3] and Clinical Nursing Supervisor [Staff #4] were asked to review the above medical record information for Patients #1 through #20. [Staff #3] and [Staff #4] agreed the signatures authenticating the medical record entries for Patients #1 through #20 were not dated, timed, and/or signed.

The hospital's "Authentication/Author Identification" policy effective 05/05/10 noted that "Each entry shall be dated, timed and signed..."

Based on observation, interview and record review, pharmacy services failed to ensure all drugs and biologicals where kept in a secure area or appropriately locked, in that, drugs and biologicals had been kept in an unlocked closet in the Emergency Department [ED].

Findings Included:

During a tour of the hospital's ED on 01/04/11 at 2:00 PM, the surveyor observed the following drugs and biologicals in an unlocked closet at the nurses station:

Drugs:
2 - Xylocaine 2%, 20 milliliter bottles
2 - Xylocaine 1%, 20 milliliter bottles
3 - Lidocaine 2%, 20 milliliter bottles
10 - Lidocaine 1%, 20 milliliter bottles

Biologicals:
4 - Bacteriostatic water, 30 milliliter bottles
8 - Sterile water, 10 milliliter bottles
20 - 0.9% Sodium Chloride, 10 milliliter bottles

In an interview at 2:00 PM on 01/04/11 with the Chief Nursing Officer [Staff #3], she agreed the above drugs and biologicals had not been secured and/or locked.

The Pharmacy Department "Drug Storage/Storage temperatures, Refrigeration" policy, dated 08/24/01, noted the following:
-"Drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security."
-Under the Security for Drugs section that "locked storage units or locked medication carts shall be provided for each medication storage area as required...and that, security shall be maintained in accordance with local and state laws."

The Pharmacy Department "Drug Procurement, Inventory Control" policy, dated 08/24/01 noted under the Inspection section:
-"All drug storage areas within the Hospital will be inspected monthly by Pharmaceutical Service Department."

In an interview at 9:00 AM on 01/05/11 with the Regional Director for contracted pharmacy services [Staff #38], he agreed that pharmacy services included ensuring that all drugs and biologicals were secured and/or locked.

Based on observation, interview and record review, pharmacy services failed to ensure outdated drugs and biologicals were unavailable for patient use, in 3 of 5 drug storage areas surveyed [Pharmacy, Surgical and Radiology Services].

Findings Included:

On 01/05/11 at 9:30 AM a tour of the Pharmacy was conducted. The surveyor observed outdated, expired drugs/biologicals in the following area:

Pharmacy:
20 - Jevity 1 Cal, cans of nutritional supplement used for gastric tube feedings, expired 12/10.

In an interview at 9:30 AM on 01/05/11 with the Pharmacy Coordinator [Staff #45], she verified the biologicals (nutritional supplements) in the Pharmacy were expired and not removed from usable stock, and were available for patient use.

On 01/05/11 at 4:30 PM a tour of Surgical Services was conducted. The surveyor observed outdated, expired drugs/biologicals in the following area:

Surgical Areas:
9 - Tracrium, 100 milligrams/10 milliliters, expired 11/10.
1 - Epinephrine, 1 milligram, injectable, expired 07/10.
2 - 0.9% Sodium Chloride, intravenous fluid, 100 milliliters, expired 04/10.
1 - Lidocaine 1%, 20 milliliter bottle, expired 10/10.

In an interview at 4:30 PM on 01/05/11 with the Director of Surgery [Staff #39], she verified the drugs and biologicals in the surgical areas was expired, and were available for patient use.

On 01/06/11 a tour of Radiology Services was conducted. The surveyor observed outdated, expired drugs/biologicals in the following area:

Radiology Area:
2 - Injectable Contrast, expired 12/10.

In an interview at 10:30 on 01/06/11 with the Director of Radiology [Staff #17], she verified the biologicals used in the computerized tomography (CT) room were expired, and were available for patient use.

The hospital "Outdated (Expired) and Other Unusable Drugs and Devices" policy, dated 08/24/01, noted that:
-"to assure that outdated (expired) and other unusable drugs and devices are removed from stock and disposed of appropriately."
-"outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for patient use."
-"the pharmacy shall identify outdated and other unusable drugs and devices and prevent their distribution and administration."
-"the director of pharmacy or qualified designee shall include a surveillance for outed and otherwise unusable drugs in the monthly inspection of medication areas throughout the hospital."

Based on interview, and record review, the medical staff failed to update the hospital's formulary system according to hospital policy, and thus, had not ensured quality pharmaceuticals at current reasonable costs.

Findings Included:

In an interview at 9:00 AM on 01/05/11 with the Regional Director for contracted pharmacy services [Staff #38] was asked to see the hospital's formulary. [Staff #38] showed the surveyor the pharmacy copy, on yellowed paper and dated 1996. He stated his contract pharmaceutical company had only worked with the medical staff on updating approved substitutions for drugs not in stock. [Staff #38] verified they had not reviewed the overall hospital formulary, or the current associated costs of quality drugs included in the formulary.

Review of the currently used hospital formulary, reflected it had last been reviewed in 1996. There was no documentation of more current reviews and/or revisions.

The "Formulary" policy, dated 08/24/01, noted the following:
-"The Medical Staff, through its Pharmacy and Therapeutics function, will develop a system whereby medications are evaluated, appraised, and selected...the criteria for selecting medications included in the formulary will be based on need, efficacy, risks and cost."
-The definition of a formulary drug is "a drug approved by the committee (Pharmacy and Therapeutics) for inclusion on the hospital formulary."
-"The entire formulary is reviewed annually (at end of year) in November and presented to the medical staff in December."
-"The director of pharmacy shall maintain the formulary as a current document and shall completely review it for currentness at least annually and update it as necessary. The medical staff should annually document its review and acceptance of the updated formulary."

The "Drug Procurement, Inventory Control" policy, dated 08/24/01, noted that "the Pharmacy Service Department is responsible for the acquisition of pharmaceuticals...and the pharmacist is responsible for specification as to quality, quantity and source of supply of all drugs used in the hospital."

It was determined based on observation and interview, the hospital failed to ensure the linen/ laundry facility, soiled linen room and dietary work station was in good repair.

Findings Included:

1) On 01/04/11 at 10:15 AM the linen/laundry facility was toured with [Staff #21]. The exterior bricks next to the entrance door to the dryers were missing from around the door. [Staff #21] stated it was never repaired after the door was put in. [Staff #21] stated it has been in this condition at least a year.

The dryers were sitting on unfinished plywood floors. The plywood could not be sanitized. The ramp leading down to the soiled area was made of plywood and unfinished.

Behind the dryers were approximately 3 large pieces of loose insulation sitting on top of the dryer vents and one large piece on the floor.

2) The soiled laundry room's floor was made of cement with strips of unfinished plywood. The floor was described by [Staff #21] as difficult to clean because of the grooves in the cement floor and the unfinished wood.

3) On 01/04/11 at 11:15 AM a tour of the dietary department was conducted with [Staff #5]. The bottom shelf of a metal work table was rusted. Large mixing bowls identified as clean were observed face down on the rusted surface. [Staff #5] reported the shelf had been this way a long time and acknowledged the clean mixing bowls should not be stored on the rusted shelf.

4) On 01/06/11 at approximately 11:30 AM [Staff #2] accompanied the surveyor on observation rounds. The soiled utility room's ceiling had a large hole in the plaster approximately two feet in length.

On 01/06/11 at 12:10 PM [Staff #41] was asked about the above maintenance issues. He stated he had not had a chance to complete all the repairs. [Staff #41] acknowledged the above items needed repair.

Based on observation and interview, the hospital failed to maintain supplies and equipment to ensure an acceptable level of safety and quality. Expired equipment was available for patient use in 3 of 5 areas [Emergency Department, Surgical and Radiology Services].

Findings Included:

On 01/04/11 at 2:00 PM a tour of the Emergency Department was conducted with the Chief Nursing Officer [Staff #3]. The surveyor observed the following expired equipment:

Emergency Department Area:
2 - 18 gauge angiocath needles, expired 08/10.
2 - 18 gauge angiocath needles, expired 12/10.
1 - Cotton umbilical tape, expired 01/10.
2 - Formalin fixative, 30 milliliters, expired 05/05.
3 - Specimen collection kits, expired 09/10.
1 - Mucous trap, expired 05/04.
1 - Mucous trap, expired 03/09.
1 - Hemoccult card, expired 01/10.
1 - SANE (Sexual Assault Nurse Examination) kit, expired 10/09.
1 - Scrub sponges, expired 11/10.
1 - Scrub surgical sponges, expired 05/10.
1 - Pediatric/Adult Lavage system, expired 07/06.
1 - Pneumo Needle, expired 12/10.
1 - Pediatric CO 2 detector, expired 11/10.

In an interview at 2:00 PM on 01/04/11 with the Chief Nursing Officer [Staff #3], she verified the above equipment was expired, and available for patient use.

On 01/05/11 at 3:30 PM a tour of surgical services was conducted with the Director of Surgical Services [Staff #39]. The surveyor observed the following expired equipment:

Surgical Services Area:
2 - Staple removers, expired 05/10.
9 - Bone Wax, expired 01/09.
2 - Arterial Blood Gas kits, expired 02/08.
1 - disposable Electrosurgical Pencil, expired 08/12/09.
1 - 3.0 Chromic gut suture, expired 07/10.
1 - 3.0 Ethilon suture, expired 01/10.
1 - Radial artery catheter, expired 01/06.
1 - Radial artery catheter, expired 09/05.
7 - 18 gauge intravenous (IV) needles, expired 12/06.
5 - 18 gauge spinal needles, expired 08/06.
2 - 18 gauge spinal needles, expired 09/07.
1 - 20 gauge spinal needle, expired 01/08.
1 - 22 gauge spinal needle, expired 12/05.
2 - 22 gauge spinal needles, expired 08/08.
1 - 22 gauge spinal needle, expired 05/09.
1 - Package of EKG (electrocardiogram) pads, expired 12/10.

In an interview at 3:30 PM on 01/05/11 with the Director of Surgical Services [Staff #39], she verified the above equipment was expired, and was available for patient use.

On 01/06/11 at 10:00 AM a tour was conducted with the Director of Radiology [Staff # 17]. The surveyor observed the following expired equipment:

Radiology Services Area:
2 - CO 2 Detectors, expired 11/10.
2 - Packages of EKG (electrocardiogram) pads, expired 03/10.

In an interview at 10:00 AM on 01/06/11 with the Director of Radiology [Staff #17], she verified the above equipment was expired, and was available for patient use.

Based on interview and record review, the Infection Control Officer [Staff #2] did not maintain the hospital's log of infections and communicable diseases for Two of 5 patients [Patients #7 and #8] who were hospitalized after 08/01/10 with infections that were not included as part of the hospital's infection control log.

Findings Included:

Patient #7's "Discharge Summary" transcribed 09/30/10 noted that Patient #7, age 18, was admitted to the hospital on 09/13/10 with diagnoses that included "mononucleosis." The 09/13/10 laboratory report noted Patient #7's "mono test...positive."

Patient #8's "History and Physical" transcribed 09/01/10 noted that Patient #8, age 85, was admitted to the hospital on 08/31/10 for left sided chest pain. Patient #8's physician assessment included "...shingles..." Patient #8's medical record identification sheet dated 09/15/10 noted Patient #8's Principal Diagnosis was "...herpes zoster..."

The hospital's Infection Control Information and Log from August 2010 through December 2010 did not include documentation of Patient #7 and #8's infections as part of the hospital's Infection Control tracking information/Log.

During an interview at approximately 03:00 PM on 01/05/11, the Infection Control Coordinator [Staff #2] was asked if Patient #7 and #8's infection information was included as part of the infection control log. [Staff #2] said Patient #7 and #8's infections were not included in her infection control information and log.

The "Infection Control Plan" policy revised 12/06/03 noted that the "...goal of the Infection Control plan is to identify and reduce the risks of acquiring and transmitting infections among customers..."

Based on interview, and lack of record, the hospital did not have a written policy & procedure, to respond to situations when a particular specialty was not available or the on-call physician could not respond because of circumstances beyond the physician's control.

Findings Included:

In an interview at 1:15 PM on 01/06/11 with the Chief Nursing Officer [Staff #3], when the surveyor asked for the hospital's EMTALA policy to review, [Staff #3] stated the hospital did not have an EMTALA policy.

Based on interview and record review, the hospital failed to track quality indicators for the medical records of 20 of 20 patients [Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20] treated and discharged from the hospital after 06/01/10. The medical record entries were not complete, dated, timed, and/or authenticated according to their own hospital policy.

Findings Included:

The "Discharge Summary" physician's signature/authentication was not timed and dated for the following Patients:

Patient #1 - Transcribed 06/28/10
Patient #7 - Transcribed 09/30/10
Patient #8 - Transcribed 09/13/10
Patient #10 - Transcribed 10/13/10
Patient #12 - Transcribed 11/23/10
Patient #13 - Transcribed 09/30/10
Patient #15 - Transcribed 07/26/10
Patient #16 - Transcribed 10/14/10
Patient #18 - Transcribed 10/27/10
Patient #19 - Transcribed 07/22/10
Patient #20 - Transcribed 12/06/10

The "History and Physical" physician's signature/authentication was not dated and timed for the following Patients:

Patient #1 - Transcribed 06/10/10
Patient #8 - Transcribed 09/01/10
Patient #9 - Transcribed 12/22/10
Patient #10 - Transcribed 10/13/10
Patient #12 - Transcribed 11/17/10
Patient #13 - Transcribed 08/24/10
Patient #15 - Transcribed 07/24/10
Patient #16 - Transcribed 09/29/10
Patient #17 - Transcribed 12/03/10
Patient #18 - Transcribed 10/24/10
Patient #19 - Transcribed 07/17/10

The "Consultation Note" physician's signature/authentication was not dated and timed for the following Patients:

Patient #13 - Transcribed 08/25/10
Patient #20 - Transcribed 11/09/10

The "Progress Notes" physician's signatures and nurse's signatures were not dated and/or timed for the following Patients:

Patient #1 - 06/10/10 through 06/18/10 - not timed by physician
Patient #7 - 09/13/10 - not timed by physician, transcribed note 09/15/10 - no date/time by physician
Patient #8 - 08/31/10 - not timed by physician, 09/02/10 - not timed by physician
Patient #9 - 12/22/10 and 12/23/10 - not timed by physician
Patient #10 - Transcribed note 10/10/10 - no date/time by physician
Patient #12 - Transcribed note 11/18/10 - no date/time by physician
Patient #13 - Transcribed note 08/24/10 - no date/time by physician, 08/26/10 - not timed by physician
Patient #16 - Transcribed 09/30/10 - no date/time by physician, 10/01/10 - not timed by physician
Patient #17 - 12/03/10 not timed by nurse
Patient #19 - Transcribed 07/20/10 - no date/time by physician
Patient #20 - Transcribed 11/10/10 - no date/time by physician, 11/11/10 - not timed by physician

The "Discharge Note" physician's signature/authentication was not dated and timed for the following Patients:

Patient #7-Transcribed 09/16/10

The "Medication Reconciliation Form" physician's signatures were not dated and/or timed for the following Patients:

Patient #7 - Admit physician's signature dated 09/14, Discharge physician's signature dated 09/16/10
Patient #10 - Admit physician's signature dated 10/08/10, Discharge physician's signature dated 10/11/10
Patient #13 - Patient sticker indicated admit date 08/23/10 - Admit physician's signature and discharge physician's signature were not timed and dated
Patient #17 - Admit physician's signature dated 12/03/10, Discharge physician's signature dated 12/03/10
Patient #18 - Admit physician's signature dated 10/24/10, Discharge physician's signature dated 10/27/10

The "Doctor" order signatures were not timed and dated by the physician for the following Patients:

Patient #1 - Order noted by the nurse 06/11/10 - no date/time of physician's signature
Patient #7 - Orders noted by the nurse 09/14/10 and 09/15/10 - no date/time of physician's signatures
Patient #13 - Orders noted by the nurse 08/23/10 - no date/time of physician's signature
Patient #16 - Orders noted by the nurse 09/29/10 - no date/time of physician's signature
Patient #18 - Orders noted by the nurse 10/24/10 - no date/time of physician's signature

The "Doctor" order signatures were not timed by the physician for the following Patients:

Patient #1 - Written and signed by the physician 06/12/10 and 06/13/10
Patient #10 -Written and signed by the physician 10/11/10
Patient #16 - Written and signed by the physician 09/28/10 and 09/29/10
Patient #17 - Written and signed by the physician 12/03/10
Patient #20 - Written and signed by the physician 11/08/10

The "Consent to Operation, Anesthetics and Other Medical Services" hospital witness signatures were not timed for the following Patients:

Patient #1 - 06/10/10
Patient #13 - 08/25/10

The "Operative Report" physician signature/authentication was not dated and timed for the following Patients:

Patient #1 - Transcribed 06/10/10
Patient #9 - Transcribed 12/22/10
Patient #13 - Transcribed 08/26/10

The "Noninvasive Cardiovascular Laboratory Preliminary Findings" technologist's signature/authentication was not dated and timed for the following Patient:

Patient #1 - Exam 06/16/10

The "Noninvasive Cardiovascular Laboratory Echocardiogram Report" technologist's signature/authentication was not dated and timed for the following Patient:

Patient #18 - Exam 10/25/10

The "Radiographic Consultation" report electronic Radiologist's signature/authentication was not dated and timed for the following Patients:

Patient #1 - Report printed 06/16/10
Patient #5 - Report printed 12/28/10
Patient #7 - Reports printed 09/15/10 and 09/16/10
Patient #10 - Report printed 10/12/10
Patient #12 - Report printed 11/17/10
Patient #18 - Report printed 10/28/10

The "Graphic Chart" entries that included temperature, pulse, respiration, blood pressure, and weight were not signed by the person entering the information for the following Patients:

Patient #1 - 06/10/10 through 06/18/10
Patient #7 - 09/13/10 through 09/16/10
Patient #8 - 08/31/10 through 09/03/10
Patient #10 - 10/08/10 through 10/11/10
Patient #11 - 11/21/10 through 11/24/10
Patient #12 - 11/16/10 through 11/23/10
Patient #13 - 08/23/10 through 08/30/10
Patient #15 - 07/22/10 through 07/25/10
Patient #18 - 10/23/10 through 10/27/10
Patient #20 - 11/08/10 through 11/11/10

The "Intake and Output Record" entries that included diet, percentages eaten at breakfast, lunch, dinner, and snack, and intake/output information were not signed for the following Patients:

Patient #1 - 06/16/10 through 06/18/10
Patient #7 - 09/13/10 through 09/15/10
Patient #8 - 08/31/10 through 09/02/10
Patient #10 - 10/08/10 through 10/10/10
Patient #11 - 11/21/10 through 11/24/10
Patient #12 - 11/16/10 through 11/22/10
Patient #13 - 08/23/10 through 08/29/10
Patient #16 - 09/28/10 through 09/30/10

The "Blood Transfusion Sheet" nurse's signature/authentication was not completed by the nurse for the following Patient:

Patient #20 - Date 11/10/10 - no nurse's signature with date/time of signature/authentication.

The "Patient/Family Education" report staff signature was not timed for the following Patient:

Patient #10 - 10/08/10 "Nurse Care Safety"

The "Death Note" physician's signature/authentication was not dated and timed for the following Patient:

Patient #17 - Transcribed 12/07/10

The "Patient Admission Data Base" nurse's signature/authentication was not timed for the following Patients:

Patient #1 - 06/10/10
Patient #7 - 09/13/10
Patient #8 - 08/31/10
Patient #10 - 10/08/10
Patient #12 - 11/16/10
Patient #13 - 08/23/10
Patient #16 - 09/28/10

The "Tobacco History and Cessation Counseling" respiratory form's staff signature was not timed for the following Patients:

Patient #7 - 09/13/10
Patient #10 - 10/08/10
Patient #11 - 11/21/10
Patient #12 - 11/16/10
Patient #15 - 07/22/10
Patient #18 - 10/23/10

The "Inpatient Admission Assessment" nurse's signature/authentication was not complete for the following Patients:

Patient #1 - Patient sticker noted the admission was on 06/10/10 - no signature with date and time
Patient #7 - 09/13/10 - no time
Patient #11 - 11/21/10 - no time
Patient #12 - Date of assessment 11/16/10 - no signature with date and time
Patient #13 - 08/23/10 - no time

The "Inpatient Admission Assessment Pressure Wound Risk Assessment" signature/authentication was not complete for the following Patients:

Patient #1 - Date of assessment 06/10/10 - no complete signature with date/time, only initials were entered
Patient #11 - Date of assessment 11/21/10 - no complete signature with date/time, only initials were entered
Patient #12 - Date of assessment 11/16/10 - no complete signature with date/time, only initials were entered
Patient #13 - Date of assessment 08/23/10 - no complete signature with date/time, only initials were entered

The "Patient Care Record Assessment" nurse's signatures/authentications were not dated and timed for the following Patients:

Patient #1 - Date of assessment 06/11/10 AM and PM
Patient #8 - Date of assessment 08/31/10 AM and PM

The "Patient Authorization Record" hospital witness signature was not complete for the following Patients:

Patient #1 - 06/10/10 no complete signature that included time - only initials were entered
Patient #2 - 01/04/11 no complete signature that included time - only initials were entered
Patient #3 - Patient sticker noted the admission was on 12/31/10, there was no complete signature with date and time of signature - only initials were entered
Patient #5 - Patient sticker noted date 12/16/10, there was no complete signature with date and time of signature - only initials were entered
Patient #6 - Signed by the patient 09/23/10 - no complete witness signature that included date and time - only initials were entered
Patient #7 - 09/13/10 no complete signature that included time - only initials were entered
Patient #10 - 10/08/10 - no time
Patient #12 - Signed by patient 11/16/10 - no complete witness signature that included date and time - only initials were entered
Patient #13 - Signed by patient 08/23/10 - no date and time
Patient #18 - Signed by patient 10/23/10 - no complete witness signature that included date and time - only initials were entered

The "Consent to Photograph" witness signature did not include the time for the following Patient:

Patient #13 - 08/23/10

The "Swing Bed Program Activities Screening/Plan Sheet" assessment signature did not include the time for the following Patient:

Patient #14 - 11/29/10

The "Physical Therapy Inpatient/Swingbed Evaluation" therapist signature did not include the time for the following Patient:

Patient #14 - 11/29/10

The "Ordering and Discharge Instruction Sheet" physician's signature was not timed for the following Patient:

Patient #2 - 01/04/11

The "Discharge Instructions" nurse's signature was not timed for the following Patient:

Patient #18 - 10/27/10

The "Physician's Statement of Medical Necessity" physician's signature was not timed for the following Patient:

Patient #2 - 01/04/11

The "Consent To/Refusal of Treatment and Transfer" physician's signature was not timed for the following Patients:

Patient #2 - 01/04/11
Patient #6 - 09/23/10

The "Memorandum of Transfer" physician's signature was not timed and dated for the following Patients:

Patient #2 - Transferring physician secured receiving physician 01/04/11- Physician Certification signature not dated and timed
Patient #6 - Transferring physician secured receiving physician 09/23/10 - Physician Certification signature not dated and timed

The Emergency Department's "Patient Elopement/Left without Being Seen Form" nurse's signature was not dated and timed for the following Patient:

Patient #4 - Time patient left "ED...1545"

The "ER Physician Record" physician's signature was not dated and timed for the following Patient:

Patient #5 - Date of Emergency Room visit 12/16/10

The "Emergency Physician Record" physician's signature was not dated and timed for the following Patient:

Patient #8 - Time seen 08/31/10

The Emergency Department's "Aftercare Instructions to the Patient..." physician's signature was not dated and timed for the following Patient:

Patient #5 - Patient sticker dated 12/16/10

The "Emergency Nursing Record" nurse's signature was not dated for the following Patient:

Patient #6 - Patient sticker noted date 09/23/10

During a joint interview at approximately 1:00 PM on 01/06/11, the Chief Nursing Officer [Staff #3] and Clinical Nursing Supervisor [Staff #4] were asked to review the above medical record information for Patients #1 through #20. [Staff #3] and [Staff #4] agreed the signatures authenticating the medical record entries for Patients #1 through #20 were not dated, timed, and/or signed.

The hospital's Quality Improvement Information from July 2010 through December 2010 did not include the tracking of missing authentication/signature information that included missing dates and times of signatures.

During a joint interview at approximately 1:15 PM on 01/06/11, the Health Information Management Director [Staff #12] and Director of Quality [Staff #2] were asked if the missing signature information for Patients #1 through #20 which included dates and times of signatures/authentications were tracked for quality improvement. [Staff #12] and [Staff #2] said this information was not tracked.

The hospital's "Authentication/Author Identification" policy effective 05/05/10 noted that "Each entry shall be dated, timed and signed..."