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Based on medical record review, staff interview and review of hospital policies and procedures it was determined the hospital failed to ensure protection of the medical records from water damage (A-438), ensure all entries in the medical records were signed, dated and timed promptly (A-450), ensure verbal orders were authenticated with 48 hours (A-457), ensure the patient's allergy information was listed on the front of the patient's medical record as per hospital policy (A-465), ensure that informed consents were clear as to the proposed procedure and the practitioner who would be performing the procedure and that the patient was informed of the risks and benefits of the procedure (A-466) and that all delinquent medical records were accounted for including those with unsigned physician orders (A-469). The cumulative effect of these deficient practices was the inability of the hospital to ensure an updated and complete medical record was maintained for all patients receiving services at the hospital.

Based on staff interview, observations, and policy review, this Condition of Participation of Physical Environment was not met in regards to life safety from fire. This was in regards to exit directional signs, patient room doors not resisting the passage of smoke, exit discharge lighting, dirty sprinkler heads, generator inspections, and the fire watch plan for the fire alarm and sprinkler systems. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 39 patients.

Findings include:

Refer to A0709 for Life Safety from fire requirements not met.

Based on medical record review, staff interview, and review of the hospital policy and procedures. The hospital failed to ensure that a physician's order was obtained for restraints. This affected Patient #5 out of a sample of twenty six records reviewed. The current active census at the time of the survey was thirty nine.

Findings include:

The Clinical Services of Policy and Procedure, Number R02-N Restraints and Seclusion was reviewed on 5/29/13 at 1:44 PM. Review of the policy required a physicians order prior to the application of a restraint. In an emergency application situation, the need for restraint may occur. A written order, based on an examination of the patient by the MD/DO or LP is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate.

The medical record for Patient #5 was reviewed the afternoon of 5/28/13. Patient was a 52 year-old female admitted on 5/24/13 for continued ventilator support and local wound care following peritonitis secondary to ruptured diverticulitis and sepsis. The nursing care plan revealed documentation that the patient was in bilateral wrist restraints on 5/25/13 from 7:00 AM through 10:00 AM. Nursing documentation revealed that the patient was released from the restraints from 11:00 AM through 5:00 PM. The nursing documentation in the progress notes revealed that the patient was placed back in bilateral wrist restraints at 6:40 PM. The medical record lacked documentation of any physicians' orders for the application of the restraints during the morning and the evening of 5/25/13. This was confirmed by Staff C on 5/29/13 at 3:40 PM.

Based on review of personnel files, policy review, and staff interviews, the hospital failed to follow their policy and medical staff bylaws related to the evaluation of professional staff for reappointment and when the practitioner had no clinical activity. The hospital also failed to ensure the policy for dependent practitioners included timeframes for completion of the professional evaluation. This affected 4 of 8 practitioners' credentialing records reviewed (Staff G, H, I, and J). The census on the first day of survey was thirty-nine patients.

Findings include:

On 05/30/13, a review was conducted of eight practitioners' credentialing records. Interviews were conducted with Staff A, E, and F on 05/30/13 between 12:10 PM and 12:30 PM, and between 2:20 PM and 2:40 PM.

The review conducted of Policy CR-200 for credentialing of medical staff revealed the following:

a) All credentialed practitioners are subject to Ongoing Professional Practice Evaluations (OPPE) on a quarterly basis for blood utilization, activity, number of admissions, consultations and procedures performed, customer satisfaction, and medical record completion.

b) On a quarterly basis, the physician stats report is produced from the HMS system reflecting all procedures and activity rendered by credentialed physicians in the hospital over the past quarter.

c) The dependent practitioner quarterly review grid is populated with the names of dependent practitioners (PA, NP, etc) who have been active with their collaborating physician over the past quarter.

d) The stats report and dependent practitioner grid is presented to the Medical Executive Committee (MEC) and the Medical Director for review.

e) A Focused Professional Practice Evaluation (FPPE) is to evaluate a practitioner's overall performance within the hospital over a specified period of time. The FPPE review period for a new practitioner will be for a period of one year and will begin on the date the practitioner was approved for clinical privileges by the Governing Board (GB).

f) If a practitioner has had no clinical activity, the focused or ongoing performance improvement reviews are unable to be completed. When this is the case, the quality file must be noted as such.

g) Once the review is completed, the Medical Director signs the review forms where required. Upon completion of FPPE, a signature page is created and signed by the MEC and GB. The signature page is placed with the credentials file.

h) All quality review forms are filed with the practitioners quality file.

This policy was silent to timelines for the evaluation of dependent Allied Health Practitioners (Physician Assistants, Nurse Practitioners), stating "it is recommended that dependent Allied Health Practitioners are evaluated in conjunction with their supervising or collaborating physician".

The credentialing/quality file for professional staff G (physician) revealed the physician was hired on 08/21/08. The physician was initially appointed to the staff for a one year period from 07/01/10 to 07/20/11. The physician received a professional evaluation on 04/24/11; however, the next reappointment approval by the MEC was over 13 months later, on 06/04/12, and by the Governing Board on 06/20/12 for the two year period of 07/01/12 to 06/30/14. The physician's quality file was silent to quarterly evaluations of the practitioner for the third quarter of 2011, the first, second, and third quarter of 2012, and the first quarter of 2013. This was verified with Staff F at 2:30 PM, who stated ongoing professional practice evaluation should have been completed after 07/01/12 for this practitioner.

The credentialing/quality file for Staff H (certified nurse practitioner) revealed the employee was hired on 12/08/11. Although the policy stated a year evaluation should be completed after approved for credentialing, the personnel file was silent to this evaluation. Interview with Staff E and F revealed this employee had not provided clinical services to this hospital; however, there was no documentation of this in the practitioner's quality file.

Review of Staff I's (certified nurse practitioner) credential/quality file revealed a date of hire of 07/01/10. This staff member was reappointed for a two year period for 07/01/12 through 06/30/14. This was recommended by the MEC on 06/04/12 and the GB on 06/20/12. The last Medical Staff Performance review was dated 04/26/11 for the second quarter of 2011. Interviews with Staff E and F revealed this practitioner had not provided services in 2011 and 2012. Review of the quality file was silent to this documentation. On 05/30/13 at 12:10 PM, when asked for documented evidence of this information, Staff F provided the surveyor with a physician stats detail report for 07/01/11 through 06/30/12 which stated no records found. The run date/time on this report was 05/30/13 at 12:25 PM.

Review of Staff J's (nurse practitioner) credentialing/quality file revealed Staff J was hired on 03/25/10. A professional evaluation was conducted more than 6 months prior to the recredentialing date of 03/24/12. When Staff A, E, and F were questioned as to the timeframes for completing the professional evaluation prior to reappointment, these employees were unable to verbalize the hospital policy time frames for these reviews. A review of Policy CR-200 revealed the policy was silent to these time frames.

On 05/30/13, between 2:20 PM and 2:40 PM, Staff A, E,and F verified the aforementioned credentialing and quality files, and the facility policies.

Based on observation and staff interview it was determined the hospital failed to ensure the protection of medical records from water damage in the case of fire or sprinkler engagement. This potentially affects all patients serviced at the hospital. The current census at the time of the survey was 39.

Findings include:

Tour of the medical records department was completed on 05/30/13 at 10:00 AM. The surveyor noted the medical records were stored in metal shelving that did not have doors or covering. The medical records were stored in a sprinklered room that contained six sprinklers. The medical records were not protected from water damage should the sprinklers activate and spray water.
This finding was confirmed with the CEO, the health information manager and the director of quality management on 05/30/13 at 10:20 AM.

Based on medical record review and staff interview it was determined the hospital failed to ensure entries in the medical record were authenticated in writing by the responsible practitioner for five of 26 (Patient #'s 13, 16, 20, 25 and 26) records reviewed. The current census at the time of the survey was 39.

The medical record review for Patient # 13 was completed on 05/30/13. This patient was admitted to the hospital on 03/14/13 for diagnoses that included ulcerative colitis and anemia. A verbal order for bilateral wrist restraints was accepted by the registered nurse on 03/15/13 (time not noted). A verbal order for bilateral wrist restraints was accepted by the registered nurse on 03/18/13 at 10:45 AM. At the time of the review of this closed record the physician had not yet authenticated either of these orders.

The medical record review for Patient # 25 was completed on 05/30/13. This patient was admitted to the hospital on 04/09/13 for diagnoses that included status post pericardial tamponade. The patient was discharged on 04/17/13. The discharge summary was dictated by the physician on 05/12/13 at 10:19 AM. At the time of the medical record review on 05/30/13 the physician had not yet authenticated the discharge summary with his/her signature.

The medical record review for Patient # 26 was completed on 05/30/13. This patient was admitted to the hospital on 03/29/13 with diagnoses that included chronic obstructive pulmonary disease. The patient was discharged on 04/09/13. The discharge summary was dictated by the physician on 05/24/13 and signed by the physician on 05/30/13 at 2:00 PM. This closed record revealed multiple unsigned physician entries in the medical record since the patient's discharge on 04/09/13.

Review of the hospital's medical staff by-laws was completed on 05/30/13. The by-laws revealed all medical records are to be completed by the responsible practioner within 30 days of the patient's discharge from the hospital.

These findings were confirmed with the Health Information Manager on 05/30/13 at 10:00 AM.


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The medical record for Patient #16 was reviewed the morning of 5/29/13. The patient was a 74 year-old female admitted to the hospital on 5/20/13 for multiple medical complications. The physician completed patient's history and physical was dictated on 5/21/13 at 6:40 PM and transcribed on 5/22/13 at 4:41 AM. The medical record lacked documentation that the entry was signed and dated by the physician providing care. This was confirmed with Staff C on 5/29/13 at 10:45 AM.

The medical record for Patient # 20 was reviewed on the morning of 5/29/13. The patient was a 78 year-old male admitted on 5/21/13 for rehabilitation and profound weakness and other medical related issues. The history and physical was dictated by the physician on 5/22/13 at 6:13 AM and transcribed on 5/22/13 at 2:08 PM. The medical record lacked documentation that the entry was signed and dated by the physician providing care. This was confirmed with Staff C on 5/29/13 at 10:55 AM.

Based on medical record review, staff interview, and review of the hospital policies and procedures. The hospital failed to ensure that verbal orders were signed and dated by the physician within forty eight hours. This affected Patient's # 4 and #6 in a sample of twenty six medical records reviewed. The current active census at the time of the survey was thirty nine.

Findings include:

The medical record for Patient # 4 was reviewed the afternoon of 5/28/13. The patient was a 70 year-old male admitted on 5/16/13 for respiratory support. Verbal orders obtained by the registered nurse on 5/23/13 for Ativan 1 mg intravenous push, and a clarification order for Ativan 1 mg intramuscularly were not signed by the physician. The verbal order lacked the physician's signature including the date and time within forty eight hours. This was confirmed with Staff C on 5/28/13.

The medical record for Patient #6 was reviewed on the afternoon of 5/28/13. The patient was admitted on 5/23/13 status post cerebrovascular accident, aphasia, and partial epilepsy. Review of the medical record revealed the registered nurse obtained verbal admission orders on 5/24/13 at 1:30 AM. The verbal order lacked the physician's signature including the date and time within forty eight hours. This was confirmed with Staff C on 5/28/13.

Based on medical record review, staff interview, and review of the hospital policies and procedures. The hospital failed to ensure that allergy labels were placed on the front of the medical records. This affected Patients #4, #6, #10, #11, and #12 in a sample size of twenty six records reviewed. The current active census at the time of the survey was thirty nine.


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Findings include:

The Clinical Services Policy and Procedure, Number A02-G Allergies, Identification of Patient was reviewed on 5/29/13 at 2:11 PM. The policy revealed that allergy labels are to be placed on the front of all medical records ......... regarding patient allergies to inform all members of the healthcare team to decrease the risk of a patient receiving any substance to which he/she has a known allergy.

The medical record for Patient #4 was reviewed the afternoon of 5/28/13. The patient was admitted on 5/16/13 for multiple medical issues. The medical record revealed the patient was being treated for alcohol withdrawal syndrome.
The medical record revealed on admission, and on the medication administration record that the patient was allergic to penicillin and plavix. The medical record lacked identification of these allergies on the front of the medical record. This was confirmed with Staff C on 5/28/13 at 2:53 PM.

The medical record for Patient # 6 was reviewed the afternoon of 5/28/13. Review of the physician's history and physical that was dictated on 5/23/13, revealed the patient stated she was allergic to iodine and contrast dye. The medical record lacked identification of these allergies on the front of the patient's medical record. This was confirmed with Staff C on 5/28/13 at 3:13 PM.

The medical record for Patient #10 was reviewed the afternoon of 5/28/13. The patient was a 62 year-old female admitted on 5/22/13. The patient demographics form indicated the patient has an allergy to adhesive tape and shellfish derived products. The medical record lacked identification of these allergies on the front of the patient's medical record. This was confirmed with Staff C on 5/28/13.

The medical record for Patient #11 was reviewed the afternoon of 5/28/13. The patient was a 70- year-old female admitted on 4/17/13. Review of the physician's history and physical revealed the patient has allergies to Codeine, Lipitor, Lodine, Lortab, Vicodin and Voltaren. The medical record lacked identification of the allergies on the front of the patient's medical record. This was confirmed with Staff C on 5/28/13.

The medical record for Patient #12 was reviewed the morning of 5/28/13. The patient was a 69 year-old was admitted on 5/1/13. The history and physical revealed the patient had allergies to ace inhibitors, amylodipine, vancomycin, and ancef. The medical record lacked identification of the allergies on the front of the patient's medical record. This was confirmed with Staff C on 5/28/13.

Based on medical record review, staff interview and policy and procedure review it was determined the hospital failed to ensure the informed consent form contained the procedure to be performed written out (Patient # 14) and failed to indicate the practioner performing the procedure and that the risks and benefits of the procedure were discussed with the patient prior to consent being given (Patient #'s 7, 12, 14 and 21). The current census at the time of the survey was 39. The total sample size was 26.


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Findings include:

The Administration Policy and Procedure for Consents for Medical Treatment, Number C08-A was reveiwed on 5/28/13. Policy stated, " The Hospital recognizes that the patient has the right to reasonable and informed participation in decisions involving his/her health care including collaboration with his/her physician in making these decisions. Except for emergencies, the physician should obtain the voluntary, competent and understanding consent of the patient or the patient consent of his/her legally authorized representative prior to the start of any procedure or treatment."

The medical record for Patient #7 was reviewed the afternoon of 5/29/13 at 12:45 PM. The patient was a 71 year-old female that was admitted on 5/13/13, with a feeding tube in place. The medical record revealed the speech language pathologist obtained a signed informed consent from the patient on 5/24/13 at 12:40 PM for a Fiberoptic Endoscopic Evaluation of Swallowing. The medical record lacked documentation of the physician's signature including date/time on the informed consent. The consent for operative and invasive procedures form did not identify who was to perform the procedure. The facility failed to ensure the physician hade informed the patient of the risks, benefits, and alternatives of the proposed treatment or procedure. This was confirmed with Staff C on 5/29/13 at 3:30 PM.

The medical record for Patient #12 was reviewed the morning of 5/29/13. The patient was a 69 year-old female admitted to the facility on 5/1/13 with diagnoses of hypertensive nephrosclerosis. The patient was status post a failed renal transplant and had been receiving dialysis on Mondays, Wednesdays, and Fridays on admission. Consent was obtained by the registered nurse on 5/8/13, for hemodialysis. The facility failed to ensure the physician had informed the patient or legal representative of the risks, benefits, and alternatives of the proposed treatment/ procedure. The medical record revealed the patient received dialysis on 5/3/13. This was confirmed with Staff C on 5/28/13 at 3:40 PM.

Review of the medical record for Patient # 14 was completed on 05/30/13. This patient was admitted to the hospital on 05/15/13. The medical record contained a "consent for operative and invasive procedures" with the name of the physician for whom the patient was consenting to perform the procedure. The procedure was listed as "QM". The patient and a registered nurse witness signed the form on 05/18/13 at 2:20 PM. The line provided for the physician's signature, date and time was blank.
This finding was confirmed with the director of quality management on 05/29/13 at 4:15 PM.

The medical record for Patient #21 was reviewed the morning of 5/29/13. Patient was admitted on 5/19/13 for multiple medical conditions. Review of the medical record revealed the speech language pathologist obtained a signed, informed consent from the patient on 5/21/13, for a Fiberoptic Endoscopic Evaluation of Swallowing. The medical record lacked documentation of the physician's signature including date/time on the informed consent. The consent for operative and invasive procedures form did not identify who was to perform the procedure. The facility failed to ensure the physician had informed the patient of the risks, benefits, and alternatives of the proposed treatment or procedure. This was confirmed with Staff C on 5/29/13 at 10:50 AM.

Based on medical record review, policy review, medical staff by-laws review and staff interview it was determined the hospital failed to ensure all medical records were completed within 30 days following discharge. This affected three (Patients #13, #25 and #26) of three patients, whose discharges, occurred greater than 30 days prior to the closed record review. The total sample size was 26 and the current census at the time of the survey was 39.

Findings include:

The medical record review for Patient # 13 was completed on 05/30/13. This patient was admitted to the hospital on 03/14/13. The patient died on 03/18/13. A verbal order for bilateral wrist restraints was accepted by the registered nurse on 03/15/13 (time not noted). A verbal order for bilateral wrist restraints was accepted by the registered nurse on 03/18/13 at 10:45 AM. As of 05/30/13, the date of the review of this closed record, 73 days past discharge, the physician had not yet authenticated either of these orders.

The medical record review for Patient # 25 was completed on 05/30/13. This patient was admitted to the hospital on 04/09/13. The patient was discharged on 04/17/13. The discharge summary was dictated by the physician on 05/12/13 at 10:19 AM. At the time of the medical record review on 05/30/13, 43 days after the patient's discharge, the physician had not yet authenticated the discharge summary with his/her signature.

The medical record review for Patient # 26 was completed on 05/30/13. This patient was admitted to the hospital on 03/29/13. The patient was discharged on 04/09/13. The discharge summary was dictated by the physician on 05/24/13 and signed by the physician on 05/30/13 at 2:00 PM. The closed record revealed multiple unsigned physician entries in the medical record since the patient's discharge on 04/09/13.

Review of the hospital's medical staff by-laws was completed on 05/30/13. The by-laws revealed all medical records are to be completed by the responible practioner within 30 days of the patient's discharge from the hospital.

Interview with the health information manager (Staff E) on 05/30/13 at 10:15 AM revealed the hospital had one delinquent medical record currently. When questioned about the multiple tabs indicating a physician signature was needed in the medical record of Patient # 26, Staff E replied that if all the unsigned orders were included in what considered a medical record delinquent, he could never keep track of all that. Staff E presented a hospital policy to the surveyor defining delinquent records as those with History and Physicals, Consults, Hospital Procedures and Discharge Summaries not completed and authenticated within 30 days of discharge.

These findings were confirmed with the Health Information Manager on 05/30/13 at 10:20 AM.

Based on observation, staff interview, review of temperature logs and policies and procedures, the hospital failed to ensure food temperatures were maintained before delivery to the patient. One patient tray was affected with the possibility of 39 patient trays affected.

Findings include:

Observation of hospital's food tray line was conducted on 05/30/13 starting at 11:45 AM. A sample tray was requested to ensure temperatures of the hot and the cold foods were maintained from the time it left the food service area to the time it arrived on the inpatient unit.

The sample tray provided was a microwaved pureed tray, and all the temperatures of the items on the tray were within the acceptable temperature range.

A request was made to check the temperature of a patient tray containing cooked ground beef in the form of sloppy joe on 05/30/13 at approximately 12:05 PM. Staff D performed the temperature check which revealed the sloppy joe meat was 133 degrees Fahrenheit, outside of the lower acceptable temperature range.

Review of the temperature log conducted on 05/30/13 at 11:50 AM, indicated the sloppy joe meat temperature was 169 degrees while in the pan, and the temperature of the sloppy joe meat was 133 degrees on the inpatient unit at the point where it would be given to the patient.

Review of the hospital's policy and procedure for food preparation was conducted on 05/30/13 at approximately 1:30 PM, revealed "All hot food must be at a temperature of 140 degrees Fahrenheit (F.) or higher".
Review of the temperature log was conducted a second time on 05/30/13 at approximately 1:45 PM, revealed "If hot food items drop below 135 degrees F. they must be reheated to 165 degrees F and corrective action must be documented".
This finding was confirmed with Staff D on 05/30/13 at approximately 1:50 PM.

Based on observations, staff interviews, and review of the generator log, and fire watch plan, the hospital failed to ensure life safety from fire requirements were met. This was in regard to patient room doors not resisting the passage of smoke, exit directional signs, exit discharge lighting, dirty sprinkler heads, generator inspections, and the fire watch plan for the fire alarm and sprinkler systems. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 39 patients.

Findings include:

During this visit, on 05/28/13 and 05/29/13, tour was conducted in the hospital facility with Staff A, K, and L. The following were observed during this tour and/or identified through the review of inspection reports:

The facility failed to ensure nine patient rooms doors failed to resist the passage of smoke. Exit directional signs were not readily visible in two locations. Three exit discharges lacked the required lighting. Dirty sprinkler heads were observed in the kitchen. The generator logs were silent to weekly inspections for three weeks between January 2013 and May 2013. The fire watch plan for the fire alarm and sprinkler systems did not included required information. Refer to A 0710.

Based on observations, staff interviews, and review of the generator log, and fire watch plan, the hospital failed to ensure life safety from fire requirements were met. This was in regard to patient room doors not resisting the passage of smoke, exit directional signs, exit discharge lighting, dirty sprinkler heads, generator inspections, and the fire watch plan for the fire alarm and sprinkler systems. This could potentially affect all patients, staff, and visitors. The census on the first survey day was 39 patients.

Findings include:

During this visit, on 05/28/13 and 05/29/13, tour was conducted in the hospital facility with Staff A, K, and L. The following were observed during this tour and inspection report reviews:

Nine patient rooms doors failed to resist the passage of smoke. Refer to K18.

The facility failed to ensure exit directional signs were readily visible in two locations. Refer to K22.

Three exit discharges lacked the required lighting. Refer to K47.

Dirty sprinkler heads were observed in the kitchen. Refer to K62.

The generator logs were silent to weekly inspections for three weeks between January 2013 and May 2013. Refer to K144.

The fire watch plan for the fire alarm and sprinkler systems did not included required information. Refer to K154 and K155.