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Based on record review, review of the facility's polices and interviews with the staff, it was determined the physician orders were not completed with dates and times for 5 of 7 records reviewed. This affected Medical Record (MR) #s 1, 2, 3, 5, and 6.

Findings include:

Facility Policy: Telephone or Verbal Orders

Policy: It is the policy of... (hospital name) for verbal or telephone orders to be signed by the physician giving the order within 24 hours or at the next visit to the hospital by the physician.

7. It is the physician's responsibility to sign, date and time the order at the time he/she signs the order.

1. MR # 1 was admitted to the hospital through the Emergency Room with diagnoses including Chest Pain s/p (status post) MVA (motor vehicle accident) on 12/2/11.

Review of the Admission orders dated 12/2/11 revealed Employee Identifer # 3, the CRNP (Certified Registered Nurse Practioner) # 1 wrote the admission order and there was no documentation of the date and time the attending physician counter signed.


2. MR # 2 was admitted to the hospital through the Emergency Room with diagnoses including Midsternal Chest Pain on 1/26/12.

Review of the Admission orders dated 1/26/12 revealed EI # 4, CRNP # 2 wrote the admission order and there was no documentation of the date and time the attending physician counter signed.

Review of the Physician's Orders dated 1/27/12 at 6:15 AM revealed EI # 4 wrote the orders and there was no documentation of the date and time the attending physician counter signed.

3. MR # 3 was admitted to the hospital through the Emergency Room with lower abdominal pain on 1/24/12.

Review of the Admission orders dated 1/24/12 revealed EI # 4, CRNP # 2 wrote the admission order and there was no documentation the physician counter signed the orders.

4. MR # 5 was admitted to the hospital through the Emergency Room with lower abdominal pain on 1/08/12.

Review of the Admission orders dated 1/08/12 9:00 PM revealed EI # 4, CRNP # 2 wrote the admission order and there was no documentation of the date and time the attending physician counter signed.

5. MR # 6 was admitted to the hospital through the Emergency Room with lower abdominal pain on 1/25/12.

Review of the Admission orders dated 1/25/12 11:22 AM revealed EI # 4, CRNP # 2 wrote the admission order and there was no documentation of the date and time the attending physician counter signed.

An interview was conducted on 2/8/12 with EI # 2, the Director of Nursing who verified the above.

Based on observations and interviews with staff, it was determined the facilty failed to ensure the designated area for smoking was safe for patients. This had the potential to affect all patients being served by this facility.

Findings include:

An intial tour of the facility was conducted on 2/8/12 at 8:45 AM. The surveyor requested to go to the courtyard where patients were allowed to smoke. The surveyor noted several stones that were unstable, uneven and not secured. The surveyor asked Employee Identifier (EI) # 2, the Director of Nursing if the stones were stable. EI # 2 stated the stones were not stable.

An interview was conducted with EI # 1, the Charge Nurse on 2/8/12 at 2:30 PM. The surveyor asked, "If I was a patient and wanted to smoke where would I go". EI # 1 stated, " To the courtyard". The surveyor asked, " Would I go by myself". The response was, " If you were a 'walkie talkie' patient you would".