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Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that all entries are timed when entered in 24 of 28 records reviewed.


Findings include:


Fourteen (14) medical records were selected at random from a list of discharges from January 1, 2012, though June 9, 2012, and reviewed along with 14 inpatient medical records for a total of 28 medical records.


Record review revealed that 24 of 28 medical records reviewed contained entries which had not been timed. This included Physician's Orders (those written by the physician and verbal orders taken by a nurse), Progress Notes handwritten by the physician, Nursing Wound Care Progress Notes, Assessments written by various disciplines and Clinical Notes written by the Physical Therapist, Occupational Therapist, and Speech Therapist.

Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that all verbal orders had been signed within 24 hours in eight (8) of 14 inpatient records reviewed.


Findings include:


Fourteen (14) medical records were selected at random from a list of discharges from January 1, 2012, though June 9, 2012, and reviewed along with 14 inpatient medical records for a total of 28 medical records.


Review of the facility's Medical Staff Rules and Regulations revealed that the physician shall sign phone orders at his next visit, but not later than 24 hours.


Eight (8) of the 14 inpatient records reviewed contained unsigned verbal orders that were older than 24 hours.

Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that a complete history and physical examination was documented within 24 hours of admission for two (2) of 14 discharged records reviewed and four (4) of 14 inpatient records reviewed.


Findings include:


Fourteen (14) medical records were selected at random from a list of discharges from January 1, 2012, though June 9, 2012, and reviewed along with 14 inpatient medical records for a total of 28 medical records.


Record review revealed that two (2) of the 14 discharged medical records reviewed contained a history and physical examination which was documented five (5) days after admission on one (1) of the records and two (2) weeks after admission on the other record.


Four (4) of the 14 inpatient medical records reviewed revealed that a history and physical examination was absent on one (1) of the records, documented three (3) days after admission on another, and had been documented prior to admission and not updated when the patient was admitted on the other two (2) records.

Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that history and physical examinations documented within 30 days prior to admission had been updated in two (2) of the 14 inpatient medical records reviewed


Findings include:


Fourteen (14) medical records were selected at random from a list of discharges from January 1, 2012, though June 9, 2012, and reviewed along with 14 inpatient medical records for a total of 28 medical records.


Record review revealed that two (2) of the 14 inpatient medical records reviewed contained a history and physical examination which had been documented within 30 days prior to admission, and had not been updated within 24 hours of admission to the facility.

Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that all consent forms had been properly executed in three (3) of the five (5) records which contained consents for wound debridement and in two (2) of the four (4) records reviewed which contained consents for blood transfusions.


Findings include:


Fourteen (14) medical records were selected at random from a list of discharges from January 1, 2012, though June 9, 2012, and reviewed along with 14 inpatient medical records for a total of 28 medical records.


Record review revealed that three (3) of the five (5) records which contained consents for wound debridement had a consent form which had not been properly completed as to the name of the physician, name of the patient, the specific area of the body to be debrided, and/or to the signature of the person performing the debridement.


Record review revealed that in two (2) of the four (4) records reviewed which contained consents for blood transfusions the consent form had not been properly completed as to whether the patient was consenting to the transfusion or was refusing the transfusion.

Based on review of Medical Staff Rules and Regulations and record review, the hospital failed to ensure that records of discharged patients are completed within 30 days of discharge.


Findings include:


On 07/10/12 at 1:13 p.m. a count of incomplete medical records was made. There were 49 incomplete medical records that were delinquent over 30 days dating back to November, 2011. The hospital has had a total of 186 discharges as of 07/09/12.

Based on observation and staff interview, the facility failed to ensure that each floor stock medication is appropriately labeled and outdated medications are not available for patient use in one (1) of two (2) medication refrigerators observed.

Findings include:

During a facility tour with a staff Registered Nurse (RN) on 07/10/2012 at approximately 11:00 a.m. the following outdated medications were found in one (1) of two (2) medication refrigerators located within the Supply/Medication Room along with several vials which did not contain the date opened:
1) Labetalol Hd - 100mg/20cc (100 milligram/20 cubic centimeters)
2) Influenza Vaccine - dated 06/2012
3) Aspirin suppositories - dated 06/2012
4) Eight (8) bottles of Diltizam - 50 mg/10cc
5) Promethozine (Phenergan) Suppositories - 25 mg
During these observations the RN stated that pharmacy checks for outdates routinely and that the nurse checks the date on the vials prior to use. The RN removed all undated and out dated vials from the refrigerator and took them to the pharmacy for disposal.