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Based on record review and interview, the hospital failed to ensure telephone orders were dated, timed, and authenticated promptly by a practitioner for five (Patient #1, 3, 6, 7, and 9) of 20 records reviewed.

This failed practice had the likelihood to affect the accuracy and quality of care provided to the 35 current inpatients and resulted in five delinquent records.

Findings:
Hospital Policy Nursing #51, "Telephone Orders" (01/19) stated, order would be authenticated by physician per CMS guidelines.

A review of medical records showed:
1. Patient #1, on 06/27/19 at 3:30 pm and 06/29/19 (no time) telephone orders were read back and verified by the nurse taking the orders; the orders were not dated, timed, and authenticated by a practitioner.

2. Patient #3, on 06/11/19 (no time), 06/19/19 at 11:00 am, 06/19/19 at 3:10 pm, and 06/19/19 at 3:50 pm telephone orders were read back and verified by the nurse taking the orders; the orders were not dated, timed, and authenticated by a practitioner.

3. Patient #6, on 06/14/19 at 1:00 pm a telephone order was read back and verified by the nurse taking the order; the order was not dated, timed, and authenticated by a practitioner

4. Patient #7, a telephone order "OK to use PICC" was read back and verified by the nurse taking the order; the order was not dated, timed, and authenticated by a practitioner.

5. Patient #9, on 07/02/19 at 5:00 pm a telephone order was read back and verified by the nurse taking the order; the order was not dated, timed, and authenticated by a practitioner.

On 07/09/19 at 3:00 pm, Staff #A stated the orders weren't signed for patients #1, 3, 6, 7, and 9.

Based on record review and interview, the hospital failed to ensure physicians and licensed independent practitioners completed a history and physical (H&P) within twenty-four (24) hours of admission for 36 (Patient #1-11, 13-19, 22-35, 37, 38, 42, and 45) of 45 patient medical records reviewed according to hospital policy and CMS requirements. The hospital's "Medical Staff Rules & Regulations (undated) showed, an H&P was to be completed and entered in the patient's medical record within 24 hours of admission.

This failed practice had the likelihood to affect medical treatment decisions, discharge planning, care plans and adversely affect patient health outcomes for 36 of 45 patients.

Findings:

Hospital document titled "Medical Staff Rules & Regulations, undated" showed a completed history and physical (H&P) would be entered in the record no more than 24 hours after patient admission.

Of the 45 medical records reviewed, 36 (Patients #1-11, 13-19, 22-35, 37, 38, 42 and 45) H&Ps were not completed and documented in the patient's medical record within 24 hours denying complete and accurate information of the patient to staff making medical decisions related to the care provided.

On 07/09/19 at 8:23 am, Staff D stated undocumented draft H&Ps were sent to the nurses' stations from the transcription company. The electronically signed H&P was sent to medical records; a complete and documented H&P was never placed in the current medical record for use in providing care.

Based on record review and interview, the hospital failed to ensure updated and accurate documentation of:

a. Telemetry Monitoring Renewal Order Form was completd every 72 hours for two (Patient #2 and 10) of 20 patients.

b. Urinary Catheter Necessity Protocol was completed every 24 hours for four (Patient #1, 3, 7, and 9) of 20 patients.

This failed practice had the likelihood to affect the accuracy and quality of care provided to patients by not having updated and accurate information available to allow for complete diagnosis and treatment of the patient.

Findings:

The Telemetry Monitoring Renewal Order Form stated "cardiac monitoring must be reassessed, renewed or discontinue at least 72 hours."

A review of medical records showed:

1. Patient #2, on 07/02/19 and 07/08/19 Telemetry Monitoring Renewal Order Forms were not renewed every 72 hours.

2. Patient #10, on 07/01/19 and 07/07/19 Telemetry Monitoring Renewal Order Forms were not renewed every 72 hours.

On 07/09/19 at 3:00 pm, Staff #A stated the Telemetry Monitoring Renewal Order Forms were to be reinstated every 72 hours; the patient is kept on telemetry until the doctor discontinues it or writes an order for bladder training.

Hospital Policy Nursing #54, "Urinary Catheter Criteria" (01/19) stated, if patient meets criteria for an indwelling catheter, document order, criteria in medical record. Catheter should be removed once criteria no longer met. Notify physician.

1. Patient #1, there was documentation of a Foley catheter in place on 06/24/19. Criteria for a Foley catheter was
not documented every 24 hours on the Urinary Catheter Necessity Protocol Order for 06/25/19, 06/26/19,
6/27/19, and 06/29/19.

2. Patient #3, there was documentation of a Foley catheter in place on 05/31/19. Criteria for a Foley catheter was
not documented every 24 hours on the Urinary Catheter Necessity Protocol Order for 06/03/19, 06/05/19,
06/08/19, 06/12/19, and 06/19/19.

3. Patient #7, there was documentation of a Foley catheter in place on 06/11/19. Criteria for a Foley catheter was
not documented every 24 hours on the Urinary Catheter Necessity Protocol Order for 07/04/19, 07/05/19,
07/06/19, and 07/07/19.

4. Patient #9, there was documentation of a Foley catheter in place on 06/17/19. Criteria for a Foley catheter was
not documented every 24 hours on the Urinary Catheter Necessity Protocol Order for 06/18/19, 06/19/19,
06/21/19, and 06/22/19.

On 07/08/19 at 2:55 pm, Staff #C stated the Urinary Catheter Necessity Protocol Order was required to be renewed every day and the nurse fills out the order form and presents to the physician to sign and the urinary catheter stays in place if the order to renew use was not signed and the urinary catheter was only removed when an order to discontinue its use was written.

On 07/09/19 at 3:00 pm, Staff #A stated the Urinary Catheter Necessity Protocol Order should be placed in the patient's chart by the evening shift and should have been given to the physician in the morning to sign.