HospitalInspections.org

Based on interviews with facility staff, review of 30 of 30 patient medical records, and policy and procedure review, it was determined that nursing failed to ensure all patients received nursing services in accordance with individualized plans of care.

Findings include:

1) In 30 of 30 patient medical record reviews, nursing did not develop a nursing care plan which included assessment, goals, interventions and evaluation of patient care. (See A396).

The cumulative effect of this systemic failure, creates an unsafe and disorganized nursing service which impacts all patients.

Based on interviews with facility staff, medical record review, review of medical staff rules and regulations, policy and procedure review, it was determined that:

1) The facility failed to ensure care plans are completed and in the patient record. See tags A396.

2) The facility failed to ensure that all entries into the clinical record are dated, timed, and authenticated. See Tag A450.

3) The facility hospital failed to ensure that medical orders are written completely and authenticated by the physician with a date and time. See Tags A454.

4) The facility failed to ensure that general consents for treatment/procedures were properly executed, including date and time they were signed, and that procedural consents had documented risks and benefits. See Tag A466.

5) The facility failed to ensure all medical records included a discharge summary or discharge note. See Tag A468.

6) The facility failed to ensure all medical records were complete within 30 days of discharge. See Tag A469.

7) The facility failed to ensure documentation of surgical prep dry time, in the time out process, was documented. See Tag A709.

8) The facility failed to ensure a History and Physical is completed within 30 days and documented in the record, prior to surgical procedures. See Tag 952.

9) The facility failed to ensure the post-anesthesia note is completed and post anesthesia recovery notes include required content. See Tag 1005.

The cumulative effect of these systemic clinical record deficiencies resulted in the facility's inability to ensure that all clinical records are completed and secured in accordance with federal requirements and hospital policies.

Based on observation and interview, staff interviews, and review of maintenance records, the facility failed to construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" chapter 18 of this code. This deficiency occurred in 2 of the 2 smoke compartments, and would affect all of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:

It was observed that the facility had the following life safety deficiencies: K011, K012, K017, KO18, K029, K038, K050, K056, K062 and K147. Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41(b).

Based on review of medical records, review of policy and procedure and interview with staff, in 10 of 21 medical records (MR) of Patient 18 years and older (#1, 2, 6, 7, 8, 10, 12, 14, 22 and 23), out of a total of 30 records, the facility failed to ensure there is documentation the patient did or did not have an Advanced Directive (AD), received information on ADs and/or was assisted in developing an AD.

Findings include:

Facility policy titled Advanced Directives state under II. A. "If the patient states that he/she has executed advance directives, and there is no copy in the patient's previous medical record or the document has been revised, the RN (Registered Nurse) will attempt to obtain a copy of the existing advance directives. B. If the patient does not have a copy of their advanced directives at the hospital, the patient will be given an opportunity to express wishes, treatment preferences, etc. The RN will document the intent of the advance directives in the medical record. The RN will notify the physician of the intent to assist in discussions with the patient/significant other. The physician will write an order for any specifics related to the advanced directives." Under III. "If a patient does not have advance directives, the patient will be asked if he/she would like additional information and/or assistance. If so, a referral will be forwarded to the Case Management Department for forms, addition information, and assistance in completing the document. If the patient does not wish to make verbal or written advance directives, the decision is noted on the Patient Admission Assessment."

Patient (Pt) #1's MR reviewed by surveyor 18816 on 2/9/10 at 7:45 AM revealed the Maternal Physical/Psychological Assessment (MPPA) completed on 8/12/09 indicates an attempt was made to obtain her AD. There is no documentation in the record Pt #1 provided the AD, and no documentation of the patients wishes in the event of an emergency regarding ADs. This is confirmed in interview with Director of Pt Services (DPS) B and Manager (M) C on 2/10/10 at 9:00 AM.

Pt # 2's MR reviewed by surveyor 18816 on 2/9/10 at 8:15 AM revealed the MPPA completed on 8/25/09 indicates Pt #2 wanted more information on ADs. There is no documentation in the record Pt #1 was given AD information or offered assistance with completing an AD. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR reviewed by surveyor 18816 on 2/9/10 at 10:15 AM revealed the MPPA that is not dated, indicates Pt #6 has an AD at home. There is no documentation in the record regarding Pt #6's wishes in the event of an emergency regarding ADs. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #7's MR reviewed by surveyor 18816 on 2/9/10 at 10:30 AM revealed the MPPA dated 1/5/10 states "No" in the AD section. There is no documentation in the record Pt #1 was given AD information or offered assistance with completing an AD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #8's MR reviewed by surveyor 18816 on 2/9/10 at 10:45 AM revealed the MPPA dated 1/7/10 has no documentation if Pt #8 does or does not have an AD. There is no documentation in the record Pt #1 was given AD information or offered assistance with completing an AD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR reviewed by surveyor 18816 on 2/9/10 at 11:15 AM revealed the MPPA dated 1/10/09 states "has info". There is no documentation that Pt #10 was offered assistance with completing an AD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #12's MR reviewed by surveyor 18816 on 2/9/10 at 12:15 PM revealed the MPPA dated 5/25/09 has a line drawn through the section regarding ADs. There is no documentation whether Pt #12 does or does not have an AD, and no documentation information or assistance was offered to complete an AD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #14's MR reviewed by surveyor 18816 on 2/9/10 at 11:45 AM revealed the MPPA dated 1/26/09 does not have documentation whether Pt #14 does or does not have an AD, and no documentation information or assistance was offered to complete an AD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed the Pre-op/Post-op Assessment does not have documentation whether Pt #22 does or does not have an AD, and there is no documentation information or assistance was offered to complete an AD. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed the Pre-op/Post-op Assessment does not have documentation whether Pt #23 does or does not have an AD, and there is no documentation information or assistance was offered to complete an AD. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Based on tour and staff interview, this hospital failed to secure potentially harmful items and substances, allowing a potentially unsafe environment for patients.

Findings include:

Per surveyor 18816 tour of the facility on 2/8/10 between 1:00 PM and 2:30 PM with President (P) A and Manager (M) C the following was noted: Storage room 1550 was unsecured and had syringes, needles and suture sets; the soiled room across from patient room 36 was unsecured and contained cleaning chemicals; and soiled room 1644 was unsecured and is used to store biohazard materials. This was confirmed during the tour with P A and M C.

Based on review of medical records, review of policy and procedures and interview with staff, in 8 of 30 records (#2, 3, 4, 6, 9, 10, 12 and 29) the facility failed to ensure pain assessments, interventions and response to the interventions are assessed per policy.

Findings include:

Facility policy titled Pain Management states under X. "B. The 0-10 numerical scale with 0 being no pain and 10 being the worst possible pain is the primary pain measurement tool..." D. "Pain intensity and relief must be reassessed and documented in the medical record at regular intervals. Following an intervention or procedure, pain is released within one hour."

Patient (Pt) #2's medical record (MR) review by surveyor 18816 on 2/9/10 at 8:15 AM revealed the following: on 8/29/09 at 5:40 AM Pt #2 rated her pain as 7-8, she was given Ibuprofen (pain medication) and Percocet (narcotic), there is no documentation of the response to the medication. At 12:00 PM, 3:00 PM and 6:00 PM Pt #2 rated her pain as a 3-4, she was given Ibuprofen and Percocet, there is no documentation of the response to the medication. On 8/30/09 Pt #2 rated her pain as follows: at 12:30 AM Pt #2 rated her pain as 7, she was given Ibuprofen and Percocet, there is no documentation of the effectiveness of pain intervention. At 6:30 AM she rated pain as 5, was given Ibuprofen, there is no documentation of the effectiveness of pain intervention. At 5:00 PM she rated her pain as 5, was given Percocet and there is no documentation of the effectiveness of the intervention. At 6:30 PM she rated her pain 5 and was given Ibuprofen, there is no documentation of the effectiveness of the intervention. At 8:00 PM and 11:10 PM Pt #2 rated her pain as 3 and 8 respectively, there is no documentation on the effectiveness of the intervention. This is confirmed in interview with Director of Patient Services (DPS) B and Manger (M) B on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 at 8:35 AM revealed Pt #3 rated her pain as a 4 on 12/14/09 at 4:45 PM. Pt #3 was given Percocet. The post evaluation was not conducted until 7:00 PM against policy. This is confirmed in interview with DPS B and M B on 2/10/10 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 2/9/10 at 9:00 AM revealed she received self administered bedside medications. Per the Self Medication Documentation (SMD), she had Ibuprofen twice on 12/28/09, Tylenol three times and Ibuprofen twice on 12/29/09 and Tylenol once on 12/30/09. There is no documentation by the nursing staff of pain assessment or reassessment corresponding with the SMD. This is confirmed in interview with DPS B and M B on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed she received self administered bedside medications. Per the SMD she had Ibuprofen 6 times on 5/9/09 and 2 times on 5/11/09. There is no documentation by the nursing staff of pain assessment or reassessment corresponding with the SMD. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM, revealed she rated her pain on 1/12/09 at 8:30 AM as a 5. Pt #9 was given Ibuprofen and Percocet, there is no documentation of the effectiveness of the medication. Pt #9 rated her pain as 3 at 12:10 PM, and received Percocet, and received Ibuprofen at 2:45 PM for a pain rating of 3. There is no documentation of the effectiveness of the given medications. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM, revealed she rated her pain on 1/12/09 at 11:20 PM as a 6. Pt #10 was given Ibuprofen and Percocet, there is no documentation of the effectiveness of the medication. Pt #10 rated her pain as 5 on 1/13/09 at 1:00 AM, and received Percocet, there is no documentation of the effectiveness of the medication. At 1:15 PM Pt #10 rated her pain at 5, received Percocet, there is no documentation of the effectiveness of the medication. On 1/14/09 at 4:00 AM Pt #10 rated her pain as 6, received Ibuprofen and Percocet, there is no documentation of the effectiveness of the given medications. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed on 5/27/09 she rated her pain as 5, received Ibuprofen and Percocet, there is no documentation of the effectiveness of the medication. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #29's MR review by surveyor 18816 on 2/9/10 at 12:55 PM revealed she received self administered bedside medications. Per the SMD she had Ibuprofen 3 times on 2/7/10 and 5 times on 2/8/10. There is no documentation by the nursing staff of pain assessment or reassessment corresponding with the SMD. This is confirmed in interview with DPS B and M B on 2/9/10 at 2:30 PM.

Based on record review, review of policy and procedures and interview with staff, in 30 of 30 records (#1, 2, 3, 4, 5, 6, ,7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) the facility failed to ensure there is a Nursing Care Plan (NCP) including assessment, goals, interventions and evaluation of patient care.

Findings include:

Facility titled Plan for Providing Nursing Care states "II. Nursing care will include assessment, diagnosis, outcome identification, planning, implementation and evaluation...V. documentation of the nursing process will be reflected throughout the patient record."

Patient (PT) #1's medical record (MR) reviewed by surveyor 18816 on 2/9/10 at 7:45 AM revealed there is no NCP. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/10/10 at 9:00 AM.

Pt #2's MR reviewed by surveyor 18816 on 2/9/10 at 8:15 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #3's MR reviewed by surveyor 18816 on 2/9/10 at 8:35 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #4's MR reviewed by surveyor 18816 on 2/9/10 at 9:00 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #5's MR reviewed by surveyor 18816 on 2/9/10 at 9:45 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR reviewed by surveyor 18816 on 2/9/10 at 10:15 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #7's MR reviewed by surveyor 18816 on 2/9/10 at 10:30 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #8's MR reviewed by surveyor 18816 on 2/9/10 at 10:45 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #9's MR reviewed by surveyor 18816 on 2/9/10 at 11:00 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR reviewed by surveyor 18816 on 2/9/10 at 11:15 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #11's MR reviewed by surveyor 18816 on 2/9/10 at 11:30 AM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #12's MR reviewed by surveyor 18816 on 2/9/10 at 12:15 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #13's MR reviewed by surveyor 18816 on 2/9/10 at 12:30 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #14's MR reviewed by surveyor 18816 on 2/9/10 at 11:45 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #15's MR reviewed by surveyor 18816 on 2/9/10 at 1:45 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #16's MR reviewed by surveyor 18816 on 2/9/10 at 1:10 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR reviewed by surveyor 18816 on 2/9/10 at 1:20 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #18's MR reviewed by surveyor 18816 on 2/9/10 at 1:30 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR reviewed by surveyor 18816 on 2/9/10 at 1:40 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #20's MR reviewed by surveyor 18816 on 2/9/10 at 2:00 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #21's MR reviewed by surveyor 18816 on 2/9/10 at 2:10 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #22's MR reviewed by surveyor 18816 on 2/9/10 at 2:05 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR reviewed by surveyor 18816 on 2/9/10 at 2:15 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #42's MR reviewed by surveyor 18816 on 2/9/10 at 2:25 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR reviewed by surveyor 18816 on 2/9/10 at 2:30 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26 MR reviewed by surveyor 18816 on 2/9/10 at 4:10 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #27's MR reviewed by surveyor 18816 on 2/9/10 at 1:55 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #28's MR reviewed by surveyor 18816 on 2/9/10 at 1:45 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #29's MR reviewed by surveyor 18816 on 2/9/10 at 12:55 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #30's MR reviewed by surveyor 18816 on 2/9/10 at 12:50 PM revealed there is no NCP. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Based on record review, review of policy and procedures and interview with staff, in 30 of 30 records (#1, 2, 3, 4, 5, 6, ,7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) the facility failed to ensure all entires are dated, signed and/or timed.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under Process I. B. "Every medical record entry shall be legible, permanently recorded in ink (preferably black), dated, timed, and the author identified and authenticated with name and title."

Patient (Pt) #1's medical record (MR) review by surveyor 18816 on 2/9/10 at 7:45 AM revealed the Obstetric Discharge Summary (ODS) is not dated and timed when signed by the Medical Doctor (MD), the Labor and Delivery Summary (LDS) is not timed when the MD signed and not dated and timed when the Registered Nurse (RN) signed, and Progress Notes (PN) written on 8/14/09 are not timed. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/10/10 at 9:00 AM.

Pt #2's MR review by surveyor 18816 on 2/9/10 at 8:15 AM revealed the LDS is not dated and timed when signed by the MD and RN, the PNs written on 8/30/09 are not timed, and the multiple page order sets for anesthesia and analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 at 8:35 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not dated and timed when the RN signed, the Postpartum Discharge Instructions (PDI) is not dated and timed when signed by the RN, and the multiple page order set for anesthesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 2/9/10 at 9:00 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not dated and timed when signed by the MD and RN, the PN note written on 12/30/09 is not timed, and the multiple page order set for analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #5's MR review by surveyor 18816 on 2/9/10 at 9:45 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not dated and timed when signed by the MD and RN, a PN note written on 3/7/09 is not timed, the PDI is not timed when signed on 3/7/09, and the multiple page order set for analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not timed when signed by the MD and not dated and timed when signed by the RN, the PDI is not dated and timed when signed, the Postpartum Discharge Instructions (PDI) are not dated and timed by the RN, the Maternal Physical/Psychological Assessment (MPPA) is not signed, dated and timed by the RN, and the multiple page order set for analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #7's MR review by surveyor 18816 on 2/9/10 at 10:30 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not timed when signed by the MD and not dated and timed when signed by the RN, the Obstetric Admission Assessment (OAA) is not timed when signed by the RN, the PDI are not timed when signed, and the multiple page order set for analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 2/9/10 at 10:45 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not dated and timed when signed by the MD and RN, the PDI is not timed when signed, and the multi-paged analgesia order set is does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM revealed the LDS is not dated and timed when signed by the MD and RN, PNs written on 1/10/09 and 1/11/09 are not timed, and the multi-paged analgesia order set is does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM revealed the LDS is not dated and timed when signed by the MD and RN, PNs written between 1/10/09 and 1/12/09 are not timed, and the multi-paged analgesia order set is does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed the ODS is not dated and timed when signed by the MD, the LDS is not signed, dated and timed by the MD and not dated and timed when signed by the RN, the PN written on 1/13/09 is not timed, the PDI is not timed when signed, and the multi-paged analgesia order set is does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed the LDS is not signed, dated and timed by the MD and RN, there are no discharge instructions, and the multi-paged analgesia order set is does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 12:30 PM revealed the ODS is not dated and timed when signed by the MD, the LDS is not signed, dated and timed by the MD and not dated and timed by the RN, PNs dated 6/1/09 and 6/4/09 are not timed when written, the PDI is not timed when signed, and the multiple page order sets for anesthesia and analgesia do not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #14's MR review by surveyor 18816 on 2/9/10 at 11:45 AM revealed there are no discharge instructions in the record. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #15's MR review by surveyor 18816 on 2/9/10 at 1:45 PM revealed the Newborn Circumcision Record (NCR) does not have the "time out" section complete, and has no time when signed by the MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #16's MR review by surveyor 18816 on 2/9/10 at 1:10 PM revealed the NCR does not have have the "time out" section complete, and has no time when signed by the MD, has PNs written on 9/11/09 without a time. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR review by surveyor 18816 on 2/9/10 at 1:20 PM revealed PNs written on 10/15/09 are not timed, and Newborn Discharge Instructions (NDI) are not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #18's MR review by surveyor 18816 on 2/9/10 at 1:30 PM revealed the NDI are not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR review by surveyor 18816 on 2/9/10 at 1:40 PM revealed the NDI are not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #20's MR review by surveyor 18816 on 2/9/10 at 2:00 PM revealed the NDI are not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #21's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed the NDI are not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed the History & Physical (H & P) is not timed, Post Operative/Procedure Progress Note (PPPN) is not timed, the Pre-op/Post -op Assessment (PPA) is not timed when completed by the RN, and the Outpatient Surgery Discharge Instructions (OSDI) is not timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:15 PM revealed the PPPN is not dated and timed when completed, the OSDI is not timed when completed, the Pre-op Nursing Flowsheet (PNF) is not dated or timed by the RN. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed the H & P is not signed, dated or timed by the MD, the PPPN is not dated and timed when completed by the MD, the PNF is not dated and timed by the RN, the OSDI is not timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed the PPPN is not timed when completed by MD, the PNF is not dated and timed when signed by the RN, the OSDI is not timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed the PPA is not signed, dated or timed by the RN. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #27's MR review by surveyor 18816 on 2/9/10 at 1:55 PM revealed the LDS is not dated and timed when signed by the MD and RN, and the multi-paged analgesia order set does not have each page initialed, dated and timed by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 2:30 PM.

Pt #29's MR review by surveyor 18816 on 2/9/10 at 12:55 PM revealed the ODS is not dated and timed when signed by the MD, the LDS is not timed when signed by the MD and not dated and timed by the RN, PDI is not timed when completed. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #30's MR review by surveyor 18816 on 2/9/10 at 12:50 PM revealed the PNs written on 2/7/10 are not timed, and the Newborn Initial Assessment Record is not timed. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Based on review of medical records, review of policy and procedures and interview with staff, in 22 of 30 records (#2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25 and 26) the facility failed to ensure all orders are written completely, with date, times; all telephone, verbal and standing orders are written per policy and authenticated by the Medical Doctor (MD) with a signature, date and time.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under Orders VII. A. "All orders shall be written clearly and completely...10...Verbal and telephone orders must be authenticated by the ordering practitioner within forty-eight (48) hours from when the order was given, to include the ordering practitioner's name and title, and the date and time the order was authenticated."

Patient (Pt) #2's MR review by surveyor 18816 on 2/9/10 at 8:15 AM revealed there are telephone orders written between 8/25/09 and 8/27/09 that are signed by the MD without a date and time. There are MD orders written on 8/26/09 and 8/30/09 without a time. This is confirmed in interview with Director of Patient Services (DPS) B and Manger (M) C on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 at 8:35 AM there is a verbal order written on 12/14/09 that is not authenticated by the MD with a date and time. There is an MD order written on 12/16/09 that is not timed. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed there are orders written on 5/8/09 that are not timed by the MD. There is a telephone order written on 5/8/09 that is not authenticated by the MD with a date and time. There are standing orders written by the Registered Nurse (RN) that are not written as standing orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #7's MR review by surveyor 18816 on 2/9/10 at 10:30 AM revealed there are orders written on 1/16/10 that are not timed by the MD. There are telephone orders written on 1/15/10 that are not authenticated by the MD with a date and time. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 2/9/10 at 10:45 AM revealed there are telephone orders written on 1/7/09 that are not authenticated by the MD with a date and time. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 MA revealed there is a telephone order that is not authenticated by the MD, there are MD orders written between 3/9/09 and 3/12/09 with no times. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM revealed there are verbal and telephone orders written between 1/10/09 and 1/14/09 that are not authenticated by the MD with a date and time. There are MD orders written 1/11/09 without a time. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed there are telephone orders between 1/11/09 and 1/14/09 that are not authenticated by the MD with a date and time, there are MD orders written without a time, there are MD orders written by an RN without indication it is a telephone/verbal order. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed there are telephone orders written between 5/25/09 and 5/28/09 that are not authenticated by the MD with a date and time, there are MD orders written without a time, and there is an MD order written by an RN without indication it is a telephone/verbal order. This is confirmed in interview with DPS B and M C 2/9/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 12:30 PM revealed there are MD orders written between 5/30/09 and 6/4/09 with no times, there are telephone orders that are not authenticated by the MD with a date and time. There are MD orders written by an RN without indication they are telephone/verbal orders. This is confirmed in interview with DPS B and M C 2/9/10 at 3:45 PM.

Pt #14's MR review by surveyor 18816 on 2/9/10 at 11:45 AM revealed an MD order was completed by an RN on 1/26/09 without indication it is telephone/verbal order, and is authenticated by the MD on 1/27/09 without a time. This is confirmed in interview with DPS B and M C 2/9/10 at 3:45 PM.

Pt #15's MR review by surveyor 18816 on 2/9/10 at 1:45 PM revealed there is a telephone order on 1/17/09 that is not authenticated by an MD. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #16's MR review by surveyor 18816 on 2/9/10 at 1:10 PM revealed there telephone orders written between 9/10/09 and 9/12/09 that are not authenticated by an MD, there are MD orders written by an RN without indication they are telephone/verbal orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR review by surveyor 18816 on 2/9/10 at 1:20 PM revealed between 10/15/09 and 10/16/09 there are telephone orders not authenticated by the MD, and there are MD orders written by an RN without indication they are telephone orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #18's MR review by surveyor 18816 on 2/9/10 at 1:30 PM revealed there are MD orders written between 1/5/09 and 1/9/09 by an RN without indication they are telephone orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR review by surveyor 18816 on 2/9/10 at 1:40 PM revealed there are MD orders written between 5/8/09 and 5/10/09 by an RN without indication they are telephone orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #20's MR review by surveyor 18816 on 2/9/10 at 2:00 PM revealed there are MD orders written between 2/18/09 and 2/21/09 by an RN without indication they are telephone orders. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #21's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed there is a telephone order written on 2/19/09 that is not authenticated by the MD with a date and time. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed there are MD orders written without a date and time. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed the Pre-operative orders are not signed by the MD with a date and time. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed the Pre-operative orders written on 4/9/09 are not signed by the MD with a time. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed she had outpatient surgery for a tubal ligation on 5/7/09. The Pre and Post-operative orders are dated 10/4/07 and 10/5/07 respectively by the MD. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Based on record review, review of policy and procedures, and interview with staff, in 30 of 30 records (#1, 2, 3, 4, 5, 6, 7, 8, ,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) the facility failed to ensure consents for procedures and/or treatment are dated and/or timed; and in 12 of 13 records requiring a procedure consent (#2, 9, 10, 11, 12, 13, 15, 16, 21, 24, 28 and 30) the facility failed to ensure documentation of risks and benefits were discussed prior to signing the consent per policy.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under Surgical Documentation XIII. A. 3. "...It is the responsibility of the operating surgeon to ascertain that a written, witnessed informed consent was obtained prior to any surgical or invasive procedure and to document in the medical record that the risks and benefits of the procedure were discussed with the patient."

Facility form titled Authorization and Consent to Operation/Procedure (COP) has a que for the Medical Doctor (MD) to sign "if informed consent not documented in patinet's medical record".

Patient (Pt) #1's medical record (MR) review by surveyor 18816 on 2/9/10 at 7:45 AM revealed the consent for treatment is not timed when signed on 8/12/09. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) B on 2/10/10 at 9:00 AM.

Pt #2's MR review by surveyor 18816 on 2/9/10 at 8:15 AM revealed the consent for treatment is not timed when signed on 8/25/09. The COP for Cesarean Section (C/S) is not signed by the Medical Doctor (MD) and there is no statement in the Operative Report (OR), dictated 8/26/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 at 8:35 AM revealed the consent for treatment is not timed when signed on 12/13/09. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 2/9/10 at 9:00 AM revealed the consent for treatment is not timed when signed on 12/27/09. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #5's MR review by surveyor 18816 on 2/9/10 at 9:45 AM revealed the consent for treatment is not timed when signed on 3/5/09. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed the consent for treatment is not timed when signed on 5/8/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #7's MR review by surveyor 18816 on 2/9/10 at 10:30 AM revealed the consent for treatment is not timed when signed on 1/15/10. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 2/9/10 at 10:45 AM revealed the consent for treatment is not timed when signed on 1/15/10. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM revealed the consent for treatment is not timed when signed on 1/9/09. The COP for C/S is not signed by the MD and there is no statement in the OR, dictated 1/9/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM revealed the consent for treatment is not timed when signed on 1/10/09. The COP for C/S is not signed by the MD, is not dated and timed, and there is no statement in the OR, dictated 1/10/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed the consent for treatment is not timed when signed on 1/11/10. The COP for C/S is not signed by the MD, is not timed, and there is no statement in the OR, dictated 1/11/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed the consent for treatment is not timed when signed on 5/25/09. The COP for C/S is not signed by the MD, is not dated and timed, and there is no statement in the OR, dictated 5/27/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 12:30 PM revealed the consent for treatment is not timed when signed on 5/30/09. The COP for C/S is not signed by the MD, and there is no statement in the OR, dictated 5/31/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #14's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed the consent for treatment is not timed when signed on 1/26/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #15's MR review by surveyor 18816 on 2/9/10 at 1:45 PM revealed the consent for treatment is not timed when signed on 1/15/09. The COP for circumcision is not timed when signed on 1/17/09 and witnessed on 1/19/09, two days after the parent signature. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #16's MR review by surveyor 18816 on 2/9/10 at 1:10 PM revealed the consent for treatment is not timed when signed on 9/8/09. The COP for circumcision is not timed when signed on 9/11/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR review by surveyor 18816 on 2/9/10 at 1:20 PM revealed the consent for treatment is not timed when signed on 10/15/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR review by surveyor 18816 on 2/9/10 at 1:40 PM revealed the consent for treatment is not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #20's MR review by surveyor 18816 on 2/9/10 at 2:00 PM revealed the consent for treatment is not timed when signed. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #21's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed the consent for treatment is not timed when signed on 2/18/09. The COP for circumcision is not timed when signed on 2/18/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:20 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed the consent for sterilization is not timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:15 PM revealed the consent for treatment is not timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed the consent for treatment is not timed when signed on 3/24/09. The COP for Orchidectomy is not signed by the MD, and there is no statement in the Procedure Report, written 3/24/09, that the risks and benefits were discussed with the patient. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed the consent for treatment is not timed when signed on 4/9/09. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed the consent for a tubal ligation is nto dated and timed when completed. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #27's MR reviewed by surveyor 18816 on 2/9/10 at 1:55 PM revealed the consent for treatment is not timed when signed on 2/8/10. This is confirmed in interview with DPS B and M C on 2/9/09 at 2:30 PM.

Pt #28's MR reviewed by surveyor 18816 on 2/9/10 at 1:45 PM revealed the consent for treatment is not timed when signed on 2/8/10. The COP for circumcision is not timed when signed on 2/8/10. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #29's MR reveiwed by surveyor 18816 on 2/9/10 at 12:55 PM revealed the consent for treatment is not timed when signed on 2/7/09. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Pt #30's MR reviewed by surveyor 18816 on 2/9/10 at 12:50 PM revealed the consent for treatment is not timed when signed on 2/7/09. The COP for circumcision is not timed when signed on 2/7/10. This is confirmed in interview with DPS B and M C on 2/9/10 at 2:30 PM.

Based on review of medical records, review of policy and procedure and interview with staff, in 10 of 26 closed medical records (MR) (#11, 16, 17, 18, 19, 22, 23, 24, 25 and 26 ), out of a total 30 records reviewed, the facility failed to ensure all records included a discharge summary or discharge note per policy.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under XI. A. "A discharge summary must be written or dictated on every patient at the time of discharge....B. A final progress note may service as the discharge summary in the case of patients with problems of a minor nature that require less than a forty-eight (48) hour period of hospitalization. The Medical Staff definition of 'problems and interventions of minor nature' includes those conditions 'requiring less than a forty-eight (48) hour period of hospitalization and, if anesthesia is required, requiring nothing more than local anesthesia and/or moderate sedation' Under theses circumstances, the final progress note shall contain the following: 1. Reason for admission; 2. Procedures performed; 3. Outcome of the hospitalization; 4. Discharge instructions to the patient and family; 5. Disposition of case; and 6. Final diagnosis, written in the terminology of a recognized system of disease nomenclature. C. The discharge summary/note must be authenticated by the author as soon as possible but no later than thirty (30) days post patient discharge."

Patient (Pt) #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed she was discharged on 1/14/09. The Discharge Summary (DS) is dictated 2/27/09. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/9/10 at 3:45 PM.

Pt #16's MR review by surveyor 18816 on 2/9/10 at 1:10 PM revealed he was discharged on 9/12/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR review by surveyor 18816 on 2/9/10 at 1:20 PM revealed she was discharged on 10/10/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #18's MR review by surveyor 18816 on 2/9/10 at 1:30 PM revealed she was discharged on 1/9/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR review by surveyor 18816 on 2/9/10 at 1:40 PM revealed she was discharged on 5/10/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed he had an outpatient vasectomy (sterilization) on 1/16/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed she had an outpatient hysteroscopy (sterilization) on 2/6/09. There is no discharge summary per policy. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed he had an orchidectomy (testicles removed) on 3/24/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed he had a vasectomy on 4/9/09. There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed she had a tubal ligation (sterilization). There is no discharge note per policy. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Based on review of medical records, review of policy and procedure and interview with staff, in 20 of 26 closed medical records (MR) (#2, 3, 4, 5, 6, 8, 9, 11, 12, 13, 15, 16, 17, 18, 19, 22, 23, 24, 25 and 26 ), out of a total 30 records reviewed, the facility failed to ensure all records were complete within 30 days of discharge.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under XI. A. "A discharge summary must be written or dictated on every patient at the time of discharge....B. A final progress note may service as the discharge summary in the case of patients with problems of a minor nature that require less than a forty-eight (48) hour period of hospitalization. The Medical Staff definition of 'problems and interventions of minor nature' includes those conditions 'requiring less than a forty-eight (48) hour period of hospitalization and, if anesthesia is required, requiring nothing more than local anesthesia and/or moderate sedation' Under theses circumstances, the final progress note shall contain the following: 1. Reason for admission; 2. Procedures performed; 3. Outcome of the hospitalization; 4. Discharge instructions to the patient and family; 5. Disposition of case; and 6. Final diagnosis, written in the terminology of a recognized system of disease nomenclature. C. The discharge summary/note must be authenticated by the author as soon as possible but no later than thirty (30) days post patient discharge." XV. Medical Records Completion A. "Medical records must be competed within thirty (30) days of patient discharge."

Patient (Pt) #2's MR review by surveyor 18816 on 2/9/10 at 8:15 AM revealed she was discharged on 8/30/09. There are telephone orders written between 8/25/09 and 8/27/09 that are signed by the Medical Doctor (MD) without a date and time not ensuring they were signed prior to 30 days after Pt #2's discharge. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 at 8:35 AM revealed she was discharged on 12/16/09. There is a verbal order written on 12/14/09 that is not authenticated by the MD with a date and time; the Labor and Delivery Summary is not signed, dated or timed by the MD resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 2/9/10 at 9:00 AM revealed she was discharged on 12/30/09. There is a telephone order written on 12/27/09 that is authenticated by the MD without a date and time, not ensuring they were signed prior to 30 days after Pt #2's discharge. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #5's MR review by surveyor 18816 on 2/9/10 at 9:45 AM revealed she was discharged on 3/7/09. There is a standing order written on 3/5/09 and a telephone order written on 3/6/09, that are not authenticated by the MD, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed she was discharged on 5/9/09. There is a telephone order written on 5/8/09 that is not authenticated by the MD with a date and time; the Medication Reconciliation Physician Order Form is not dated and timed by the MD; the Maternal Physical Assessment is not signed, dated and timed by the Registered Nurse (RN); resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/0/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 2/9/10 at 10:45 AM revealed she was discharged on 1/10/09. There are telephone orders written on 1/7/09 that are not authenticated by the MD with a date and time, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C 2/10/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM revealed she was discharged on 1/12/09. There is a telephone order written on 1/9/09 that is not authenticated by the MD with a date and time; and a order set dated 1/9/09 that is authenticated by the MD without a date and time, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C 2/10/10 at 3:30 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed The Labor and Delivery Summary is not signed by the MD there are telephone/standing orders written between 1/11/09 and 1/13/09 that are not authenticated by the MD with a date and time, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C 2/9/10 at 3:45 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed she was discharged on 5/29/09. The Labor and Delivery Summary is not signed by the MD; there are orders written as telephone/standing orders between 5/31/09 and 6/2/09 that are not authenticated by the MD with a date and time, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/0/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 11:45 AM revealed she was discharged on 6/4/09. There are telephone orders written on 5/25/09 that are not authenticated by the MD with a date and time, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/0/10 at 3:45 PM.

Pt #15's MR review by surveyor 18816 on 2/9/10 at 1:45 PM revealed he was discharged on 1/25/09. There is a telephone order that is written on 1/17/09 that is not authenticated by the MD, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS BN and M C on 2/9/10 at 3:00 PM.

Pt #16's MR review by surveyor 18816 on 2/9/10 at 1:10 PM revealed he was discharged on 9/12/09. There is a telephone order written on 9/12/09 that is not authenticated by the MD and no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #17's MR review by surveyor 18816 on 2/9/10 at 1:20 PM revealed she was discharged on 10/10/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #18's MR review by surveyor 18816 on 2/9/10 at 1:30 PM revealed she was discharged on 1/9/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #19's MR review by surveyor 18816 on 2/9/10 at 1:40 PM revealed she was discharged on 5/10/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/9/10 at 3:00 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed he had an outpatient vasectomy (sterilization) on 1/16/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:10 PM revealed she had an outpatient hysteroscopy (sterilization) on 2/6/09. There is no discharge summary per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed he had an orchidectomy (testicles removed) on 3/24/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed he had a vasectomy on 4/9/09. There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed she had a tubal ligation (sterilization). There is no discharge note per policy, resulting in an incomplete record over 30 days old. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Based on tour of the facility and interview with staff, the facility failed to ensure 2 of 2 observed crash carts containing medications are appropriately stored, and secure from unauthorized use or tampering.

Findings include:

Per surveyor 18816 tour of the facility on 2/8/10 between 1:00 PM and 2:30 PM with President (P) A and Manager (M) C, a pediatric crash cart is stored in the nursery with breakaway lock; there is an adult crash cart with a breakaway lock stored in an alcove down the corridor from the nurses station.

Per interview with P A on 2/10/10 at 3:30 PM, the nursery is cleaned by housekeeping, without staff present, allowing for unauthorized access to the cart; and the crash cart in the corridor is not always observed by staff from the nurses station.

Based on tour of the facility, review of policy and procedures and interview with staff, the facility failed to ensure outdated and unusable medications are not available to patients.

Findings include:

Facility policy titled Medication Use:Multi-dose Vials, Handling & Disposal states under VI. "Discard multi-dose vials when empty or after 28 days, whichever is sooner."

Per surveyor 18816 tour of the facility on 2/8/10 between 1:00 PM and 2:30 PM with President (P) A and Manager (M) C the following Labor/Delivery/Recovery/Postpartum (LDRP) rooms had open undated multidose vials of Sodium Chloride: #31, 32, 34, 38 and 39. LDRP room #33 had a MDV of Sodium Chloride with a date 1/16 and no year. These were confirmed during tour with P A and M C. P A confirmed in interview on 2/10/10 at approximately 2:00 PM the policy infers MDVs are to be dated when opened.

Based on observation, staff interviews, and review of maintenance records, the facility failed to construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" chapter 18 of this code. This deficiency occurred in 2 of the 2 smoke compartments, and would affect all of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies: K011, K012, K017, KO18, K029, K038, K050, K056, K062 and K147. Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41(b).


18816

Based on review of medical records (MR), review of policy and procedure, and interview with staff, in 12 of 12 surgery MRs reviewed (2, 9, 10, 11, 12, 13, 22, 23, 24, 25, 26 and 27)) out of total of 30 MR reviewed, the hospital failed to ensure that surgical patients are protected from fire.

Findings include:

Facility policy titled Time-Out Procedure revised 05/2006, does not direct surgery staff to ensure that the alcohol based skin prep is dry during the time-out process or that this step is documented in the patient's MR.

Patient (Pt) #2's MR review by surveyor 18816 on 2/9/10 at 8:15 AM revealed the SurgiNet OR (operating room) Nursing Record (SNR) does not include the surgical prep is dry prior to draping in the "time-out." This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/10/10 at 9:00 AM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 12:30 PM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 3:45 PM.

Pt #22's MR review by surveyor 18816 on 2/9/10 at 2:05 PM revealed the Pre-op Nursing Flowsheet (PNF) does not include surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:15 PM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed the PNF does not include surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed the PNF does not include surgical prep is dry prior to draping in the "time out", the Intra-op pre-procedure Briefing (used as a 'time out' document) does not include the documentation the surgical prep is dry. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #27's MR reviewed by surveyor 18816 on 2/9/10 at 1:55 PM revealed the SNR does not include the surgical prep is dry prior to draping in the "time out". This is confirmed in interview with DPS B and M C on 2/9/10 at 2:35 PM.

Based on a tour and interview with staff, the facility failed to ensure all patients and visitors are protected from the spread of potential sources of infections.

Findings include:

Per surveyor 18816 tour of the facility on 2/8/10 between 1:00 PM and 2:30 PM with President (P) A and Manager (M) C the following was noted:

The lounge refrigerator had staff and patient family's food items allowing for potential cross contamination.

The Triage room had a Serum Vacutainer expired (exp) 7/09; a Chlamydia, Mycoplasma, Ureaplasma culture tube exp 12/09; 2 Female Catheter Kits one exp 10/09 and one exp 11/08. These were confirmed with PA and M C during the tour.

Based on medical record review (MR), review of policy and procedures and interview with staff, in 3 of 5 outpatient surgical records, (#23, 24 and 25) out of a total of 30 records reviewed, the facility failed to ensure there is a History & Physical (H &P) completed and in the record prior to a surgical procedure per policy.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under VIII. D. C. An appropriate history and physical examination must be in the chart of every patient prior to surgery...."

Patient (Pt) #23's MR review by surveyor 18816 on 2/9/10 at 2:15 PM revealed there is no H & P on file prior to a sterilization procedure. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed the short H & P is not dated and timed, to ensure it was done within 30 days of admission and reviewed prior to an orchidectomy procedure. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed there is no History and Physical (H & P) on file prior to a sterilization procedure. This is confirmed in interview with DPS B and M C on 2/10/10 at 8:45 AM.

Based on review of medical records, review of rules and regulations and interview with staff, in 16 of 18 records requiring anesthesia (#2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 23, 24, 25 and 26) out of a total 30 records reviewed, the facility failed to ensure the post-anesthesia evaluation includes a date and time when completed and contains at least but not limited to Respiratory function, including Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used.

Findings include:

Facility policy titled Medical Records: Documentation Requirements for Medical Staff and Allied Health Professionals states under XIII. B. 1."For all inpatient admission, the anesthesiologist or anesthesia provider shall maintain a complete anesthesia record to include...evidence of the patient's readiness for discharge from postanesthesia care. A post anesthetic follow-up of the patient's condition must be recorded within forty-eight (48) hours following surgery." 2. "For all outpatient admissions, the anesthesiologist or anesthesia provider shall maintain a complete record to include...evidence of the patient's readiness for discharge from postanesthesia care."

Patient (PT) #2's medical record (MR) review by surveyor 18816 on 2/9/10 at 8:15 AM revealed Pt #2 had a cesarean section (C/S) on 8/26/09 with a bolused epidural (analgesic delivered by catheter in spinal area). The anesthesia ended at 6:55 PM, the post-anesthesia note timed 6:57 PM is illegible. This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with Director of Patient Services (DPS) B and Manager (M) B on 2/10/10 at 9:00 AM.

Pt #3's MR review by surveyor 18816 on 2/9/10 revealed she received an epidural for pain control during labor. The post-anesthesia note written on 2/14/09 at 3:15 PM states "ep (epidural) cath (catheter) pulled with tip intact see progress note." The progress note written at the same time, stated more medications were given prior to removal of the catheter, and "no complications noted at this time". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/10/10 at 9:00 AM.

Pt #4's MR review by surveyor 18816 on 2/9/10 at 9:00 AM revealed she received an epidural for pain control during labor. There is a note written on 12/28/09 at 5:30 AM stating "Epidural out intact." This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/10/10 at 9:00 AM.

Pt #5's MR review by surveyor 18816 on 2/9/10 at 9:45 AM revealed she received an epidural for pain control during labor. There are two post-anesthesia note written on 3/5/09 that are not timed one states "(no) problems voiced" the other "Pt seen. VSS (vital signs stable) (no) problems voiced." This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/10/10 at 9:00 AM.

Pt #6's MR review by surveyor 18816 on 2/9/10 at 10:15 AM revealed she received an epidural for pain control during labor. There are two post-anesthesia notes written, one dated 5/8/09 with no time states "Pt seen (no) problems" the other note is not dated, timed at 5:00 PM states "Epidural catheter removed tip intact." This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #7's MR review by surveyor 18816 on 2/9/10 at 10:30 AM revealed she received an epidural for pain control during labor. The post-anesthesia note written on 1/15/10 at 6:10 AM states "no complications" This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #8's MR review by surveyor 18816 on 2/9/10 at 10:45 AM revealed she received an epidural for pain control during labor. The post-anesthesia note written on 1/8/09 with no time states "no complications". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #9's MR review by surveyor 18816 on 2/9/10 at 11:00 AM revealed she received a spinal for a scheduled C/S. The post-anesthesia note has no date and time and states "No anesthetic (complications) post-op-PACU (post anesthesia care unit). This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #10's MR review by surveyor 18816 on 2/9/10 at 11:15 AM revealed she received an epidural, to relieve pain during labor and C/S. The surgery ended on 1/10/09 at 9:21 PM, the post-anesthesia note timed 9:30 PM is illegible. This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:30 PM.

Pt #11's MR review by surveyor 18816 on 2/9/10 at 11:30 AM revealed she received a spinal for a C/S on 1/11/09. The surgery ended at 10:38 PM, the post-anesthesia note timed 10:40 PM states "(illegible) Duramorph". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:45 PM.

Pt #12's MR review by surveyor 18816 on 2/9/10 at 12:15 PM revealed she received general anesthesia for an urgent C/S on 5/26/09. The surgery ended at 2:08 AM, the post-anesthesia note written at 2:15 PM states "Extubated in OR no complications". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:45 PM.

Pt #13's MR review by surveyor 18816 on 2/9/10 at 12:30 PM revealed she received an epidural and had a C/S on 3/31/09. The surgery ended at 6:08 PM, the post-anesthesia note timed 6:08 PM states "No Anesth (anesthesia) cop Report given to RN". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/9/10 at 3:45 PM.

Pt #23's MR review by surveyor 18816 on 2/9/10 at 2:15 PM revealed she had outpatient surgery for sterilization on 2/6/09. The post-anesthesia note is not dated and timed and states "no complications". This is confirmed in interview with DPS B and M B on 2/10/10 at 8:45 AM.

Pt #24's MR review by surveyor 18816 on 2/9/10 at 2:25 PM revealed he had outpatient surgery for orchidectomy on 3/24/09. The Post-operative Procedure Progress Note (PPPN) stated "Complications:none, Patient Condition: good", there is no time indicating the patient recovered from anesthesia and to be discharged. This is confirmed in interview with DPS B and M B on 2/10/10 at 8:45 AM.

Pt #25's MR review by surveyor 18816 on 2/9/10 at 2:30 PM revealed he had outpatient surgery for vasectomy on 4/6/09. The Post-operative PPPN stated "Complications:none, Patient Condition: good", there is no time indicating the patient recovered from anesthesia and to be discharged. This is confirmed in interview with DPS B and M B on 2/10/10 at 8:45 AM.

Pt #26's MR review by surveyor 18816 on 2/9/10 at 4:10 PM revealed she had a tubal ligation on 5/7/09 under general anesthesia. The surgery ended at 8:28 AM, the post-anesthesia note is not timed and states "no complications (illegible)". This does not constitute a complete post-anesthesia evaluation including, but not limited to:Respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; and Postoperative hydration and sensation depending on type of anesthesia used. This is confirmed in interview with DPS B and M B on 2/10/10 at 8:45 AM.