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Based on review of documentation and interviews with facility staff, the facility failed to authenticate verbal orders within 48 hours in violation of facility policy as 8 of 22 verbal orders in patient #2's record were not authenticated within 48 hours.

The findings were:
The medical record of patient #2 was reviewed on the morning of 9/7/11. The record contained 22 verbal orders, and 8 of these 22 verbal orders were not authenticated by the physician within 48 hours. The facility policy entitled "Verbal and Written Orders" stated that "Orders that are not written by a practitioner (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt." These findings were verified in an interview with the facility quality manager (staff #1) on the morning of 9/7/11.

Based on review of documentation and interviews with facility staff, the facility failed to document all nursing notes, reports of treatment and other information necessary to monitor the patient's condition as there was no documentation in patient #2's medical record that peripherally inserted central catheter (PICC) dressing changes were performed according to facility policy.

The findings were:
The medical record of patient #2 was reviewed on the morning of 9/7/11. There was no documentation found that patient #2's peripherally inserted central catheter (PICC) dressing changes were performed. The medical record contained a form entitled "24 Hour Patient Record" which had a section entitled "Intravenous Therapy" in which were boxes to document location of the intravenous site, the patency, the appearance, review of line necessity and dressing changes. There were no dressing changes for the PICC line documented in the Intravenous Therapy section of the 24 Hour Patient Record. In an interview with the facility infection control nurse (staff #6) on the morning of 9/7/11, she stated that the usual procedure was to document PICC line dressing changes on the Medication Administration Record (MAR). Review of Patient #2's Medication Administration Records (MAR) revealed that no PICC line dressing changes were documented. The facility policy entitled "Central Lines" stated that "PICC: Dressing Change, Change 24 hours after insertion, then every 7 days unless dressing becomes loose, wet, or dirty." These findings were verified in an interview with the facility infection control nurse (staff #6) on the morning of 9/7/11.

Based on review of documentation and interviews with facility staff, the facility failed to complete medical records within 30 days of discharge in violation of facility policy as the discharge summary for patient #2 was not completed until 61 days following discharge.

The findings were:
The medical record of patient #2 was reviewed on the morning of 9/7/11. Patient #2 was discharged on 4/25/11. Review of the discharge summary revealed that it was dictated by staff #7 on 6/25/11, which is 61 days following the discharge of patient #2. The facility policy entitled "Discharge Summary" stated that "A discharge summary will be completed within 72 hours (inclusive of the day of discharge) of patient discharge from the facility." These findings were verified in an interview with the facility quality manager (staff #1) on the morning of 9/7/11.