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Based on review of medical records and interview with staff the nursing staff initiates but does not keep current a nursing care plan for each patient which addresses the patient's need. This requirement was not met as follows:

Findings:

a. During a review of 24 open and closed medical records (MR) of inpatients (MR#1-24) it was observed that 12 of the 24 medical records reviewed (24%) (MR# 2,4,5,7,8,11,12,14,15,16,17 and MR#22) had nursing care plans that were initiated but were not ongoing and kept current for each patient addressing the patients needs during their stay and if the goals established were met or not met on discharge.

b. Interviewed staff #3, health information director at 2:30pm on June 9, 2010 in the administration conference room. The discrepancies that were found in 12 of the 24 medical records were also reviewed with staff #3, health information director. Staff #3, health information director agreed that the discrepancies reviewed did not meet the requirement and could not provide evidence that these discrepancies met this requirement.

Based on review of medical records and interview with staff. Medical record entries are not completed, dated, timed in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This requirement is not met as follows:

Findings:

a. During a review of 24 total medical records (MR#1-24) consisting of open and closed inpatient records it was observed that there were 19 out of 24 medical records (79%) (MR# 1,2,3,4,5,6,7,8,10,11,12,13,14,15,16,17,18,22 and MR# 23) that had incomplete entries or were not dated, timed in written or electronic form by the person responsible for providing or evaluating the services provided. Of the medical records reviewed 12 of the 24 (50%) (MR#1,2,3,7,8,10,11,13,14,15,22 and MR#23 had progress notes and other miscellaneous entries that were incomplete not being dated, timed and or authenticated. Of the medical records reviewed 12 of 24 medical records reviewed (50%) (MR# 2,4,5,7,8,11,12,14,15,16,17 and MR#22 had nursing care plans that were initiated but not kept current and ongoing. The nursing care plans did not address if the goals initiated were met or not met by discharge date. Of the 24 medical records reviewed 5 out of 24 (21%) (MR # 4,6,7,8 and MR # 18) had discharge summaries that were not completed, date, time and/or authenticated within 30 day of discharge of the patient.

b. Interviewed facility staff #3, health information manager at 2:30pm on June 9, 2010 in the administration conference room who also observed the discrepancies and could not provide evidence that these medical records reviewed met the requirements of this regulation.

Based on review of medical records and interview with staff. Medical record entries are not completed, dated, timed in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This requirement is not met as follows:

Findings:

a. During a review of 24 total medical records (MR#1-24) consisting of open and closed inpatient records it was observed that there were 19 out of 24 medical records (79%) (MR# 1,2,3,4,5,6,7,8,10,11,12,13,14,15,16,17,18,22 and MR# 23) that had incomplete entries or were not dated, timed in written or electronic form by the person responsible for providing or evaluating the services provided. Of the medical records reviewed 12 of the 24 (50%) (MR#1,2,3,7,8,10,11,13,14,15,22 and MR#23 had progress notes and other miscellaneous entries that were incomplete not being dated, timed and or authenticated. Of the medical records reviewed 12 of 24 medical records reviewed (50%) (MR# 2,4,5,7,8,11,12,14,15,16,17 and MR#22 had nursing care plans that were initiated but not kept current and ongoing. The nursing care plans did not address if the goals initiated were met or not met by discharge date. Of the 24 medical records reviewed 5 out of 24 (21%) (MR # 4,6,7,8 and MR # 18) had discharge summaries that were not completed, date, time and/or authenticated within 30 day of discharge of the patient.

b. Interviewed facility staff #3, health information manager at 2:30pm on June 9, 2010 in the administration conference room who also observed the discrepancies and could not provide evidence that these medical records reviewed met the requirements of this regulation.