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Based on record review and interview, the facility failed to ensure medical records were promptly completed thirty (30) days after a patients discharge; in accordance with the facility's policy for 7 of 18 discharged patients reviewed (#8, #9, #10, #11, #12, #13, and #14).

Patients #8, #9, #10, #11, #12, #13, and #14 had been discharged from the facility over 30 days; and up to 86 days, and the medical records were incomplete and delinquent requiring physician signatures on the following: verbal/telephone orders, admission physician orders, progress notes, discharge summaries, history and physicals (H&P)'s, consents, and other medical forms.


This deficient practice could affect the authenticity and integrity of Patients medical records; specifically those records requiring authentication by physician signature.


Findings included:


Review of the facility's Medical Staff By Laws and Medical Staff Rules and Regulations dated 02/11/14, revealed the following: "8. Medical records that incomplete thirty (30) days after patient discharge are considered delinquent. When a physician has a medical record thirty (30) days or greater from the date of discharge, the physician will be notified of delinquent medical records. The physician will be sent a letter requiring completion of the delinquent charts before sixty (60) days delinquent. If the physician has any medical records in a delinquent status at sixty (60) days post discharge then the physician's privileges may be suspended".


Patient #8

Record review on 02/24/15 of Patient #8 revealed she was discharged from the facility on 12/15/14 (70 days ago). The following Physician orders had not been signed or authenticated by a physician for Patient #8:
Physician B Verbal Order (VO) dated 11/21/14 for Vancomycin Protocol
Physician A VO dated 11/21/14 for Wound Care
Physician B VO dated 12/09/14 for Vancomycin Protocol
Physician B VO dated 12/11/14 for Nebulizer Treatments.

Further review of Patient #8's records revealed the following Progress Notes had not been signed by Physician A: 12/14/14, 12/13/14, 12/12/14, 12/07/14, 12/04/14, and 11/26/14.


Patient #9

Record review on 02/25/15 of Patient #9 revealed she was discharged from the facility on 01/21/15 (35 days ago). Patient #9's Discharge summary dated 01/21/15 had not been signed by Physician C. Patient #9's Routine Transfer Telephone Physician Orders dated 01/21/15 were not signed or authenticated by Physician C. Patient #9's Blood and Blood Product Administration Consent form dated 12/15/14 was not signed by a Physician.

The following physician verbal and/or telephone orders were not signed by a physician:
01/20/15 for laboratory (lab)
12/28/14 by Physician D for lab
12/26/14 by Physician D for lab
12/24/14 by Physician D for lab and medications ordered
12/19/14 for lab.

Patient #9's Medication Reconciliation and Physician Admission Orders dated 12/09/14 were not signed by Physician C.

Patient #9's Potassium Sliding scale Protocol Orders dated 12/09/14 were not signed by Physician C.

The following Progress Notes were not signed by Physician C for Patient #9:
01/21/15, 01/20/15, 01/19/15, 01/18/15, 01/17/15, 01/16/15, 01/14/15, 01/13/15, 01/12/15, 01/11/15, 01/10/15, 01/09/15, 01/08/15, 01/06/15, 01/05/15, 01/04/15, 01/03/15, 01/02/15, 01/01/15, 12/31/14, 12/30/14, 12/29/14, 12/21/14, 12/20/14, 12/19/14, 12/17/14, 12/16/14, 12/15/14, 12/14/14, 12/13/14, 12/12/14, 12/11/14, and 12/9/14.

The following Progress Notes were not signed by Physician D for Patient #9:
12/28/14, 12/27/14, 12/26/14, 12/25/14, 12/24/14, 12/23/14, and 12/22/14.


Patient #10

Record review of Patient #10 on 02/25/15 revealed he was discharged from the facility on 12/24/14 (61 days ago). Patient #10's Telephone and Verbal Orders dated 12/12/14, 12/22/14, and 12/23/14 by Physician E regarding medications had not been signed or authenticated.

The following Progress Notes were not signed by Physician E for Patient #10:
12/24/14, 12/23/14, 12/22/14, 12/19/14, 12/18/14, 12/17/14, 12/16/14, 12/15/14, 12/12/14, 12/11/14, 12/9/14, 12/8/14, 12/5/14, and 12/4/15

The following Progress Notes were not signed by Physician G for Patient #10:
12/23/14, 12/21/14, and 12/6/14.

Patient #11

Record review of Patient #11 on 02/25/15 revealed Patient #11 expired while at the facility with a discharge summary date of 12/17/14 (68 days ago). Patient #1 had a completed Do Not Resuscitate (DNR) signed by his daughter and a facility Licensed Vocational Nurse (LVN) dated 12/08/14 that was not signed by a Physician; and on 12/17/14 at 1720 Patient #11 was disconnected from the ventilator by Physician D with Patient #11 pronounced deceased at 1736.

Further review of Patient #11's medical record revealed the following Physician verbal and telephone orders that had not been signed or authenticated by the following Physicians:
Physician E: 12/5/14, 12/3/14, 12/1/14, 11/25/14, 11/21/14, 11/19/14, 11/14/14, 10/27/14, and 10/21/14.

Physician H: 12/11/4, 12/10/14, 12/09/14, 11/23/14, and 11/20/14. Further review revealed Physician H had not signed consents dated 12/8/14.

The following Progress Notes had not been signed for Patient #11 by the following Physician's:
Physician E: 12/17/14, 12/11/4, 12/10/14, 12/9/14, 12/5/14, 12/4/14, 12/3/14, 12/2/14, 12/1/14, 11/26/14, 11/25/14, 11/24/14, 11/23/14, 11/22/14, 11/21/14, 11/20/14, 11/19/14, 11/18/14, 11/17/14, 11/14/14, 11/12/14, 11/11/14, 11/10/14, 11/9/14, 11/8/14, 11/7/14, 11/6/14, 11/5/14, 11/4/14, 11/3/14, 10/31/14, 10/31/14, 10/29/14, 10/28/14, 10/27/14, 10/23/14, 10/22/14, 10/21/14, 10/17/14, and 10/16/14.

Physician H: 12/14/14, 12/13/14, 12/12/14, 12/11/14, 12/10/14, 12/8/14, 11/22/14, 11/21/14, 11/20/14, 11/19/14, 11/13/14, 11/12/14, 11/9/14, and 11/8/14


Patient #12

Record review on 02/25/15 of Patient #12 revealed she was discharged from the facility on 01/06/15 (50 days ago). Patient #12's Discharge Summary dated 01/06/15 had not been signed by Physician C. Patient #12's Routine Physician Admission Telephone Orders dated 12/18/14 had not been signed or authenticated by a Physician. Patient #12's Consent for Blood and Blood Product Administration Consent dated 12/21/14 had not been signed by Physician C. Patient #12's Memorandum of Transfer dated 12/18/14 had not been signed by a Physician. Patient #12's Admission Note dated 12/19/14 had not been signed by Physician C.

The following Telephone Physician Orders for Patient #12 had not been signed or authenticated by Physician D: 12/28/14 for labs and 12/24/14 for labs and medications.

The following Progress notes for Patient #12 had not been signed by the following Physician's:
Physician C: 01/06/15, 01/05/15, 01/04/15, 01/03/15, 01/02/15, 01/01/15, 12/31/14, 12/30/14, 12/29/14, 12/21/14, 12/2014.

Physician D: 12/28/14, 12/27/14, 12/26/14, 12/25/14, 12/24/14/12/23/14, and 12/22/14.

Patient #13

Record review on 02/25/15 of Patient #13 revealed she was discharged from the facility on 01/13/15 (43 days ago). Patient #13's Discharge summary dated 01/13/15 had not been signed by Physician C.

Patient #14

Record review on 02/25/15 of Patient #14 revealed she was discharged from the facility on 12/01/14 (86 days ago). Patient #14's Discharge summary dated 12/01/14 had not by signed by Physician C. Patient #14's Consents for Hemodialysis Treatments had not been signed by Physician I. Patient #14's H & P dated 10/23/14 had not been signed by Physician C.

The following Telephone/Verbal Physician Orders for Patient #14 had not been signed or authenticated by Physician C: 11/14/14, 11/6/14, 11/4/14, 11/3/14, and 10/30/14.

The following Progress notes for Patient #14 had not been signed by Physician C: 12/1/14, 11/30/14, 11/29/14, 11/28/14, 11/26/14, 11/25/14, 11/24/14, 11/23/14, 11/21/14, 11/19/14, 11/18/14, 11/17/14, 11/16/14, 11/15/14, 11/12/14, 11/10/14, 11/9/14, 11/8/14, 11/7/14, 11/5/14, 11/3/14, 11/2/14, 11/1/14, 10/31/14, 10/30/14, 10/29/14, 10/28/14, 10/27/14, 10/26/14, and 10/25/14.


Further review of the facility's Medical Staff By Laws and Rules and Regulations dated 02/11/14 revealed the following, "11. All orders, including telephone orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by Hospital policy. Telephone orders must be authenticated in accordance with state laws or regulations."



During an interview on 02/24/15 at 4:55 PM with the Medical Records Director (MRD), confirmed the Patients Discharged records were incomplete and delinquent for Patients #8, #9, #10, #11, #12, #13, and #14. The MRD stated the Medical Records department would tab all the records with each page for each Physician to sign; and that each Physician had their specific assigned color of tabbed sticky; to make it easier for them. The MRD indicated that Patients records were supposed to be completed and filed after 30 days of discharge and that a warning letter of notification was supposed to be sent to the Physicians if they were delinquent. The MRD confirmed a letter of warning had been sent to Physician C for delinquent medical records, but not to Physician A; that also had delinquent records beyond 60 days. The MRD stated that Physicians are usually given to the end of the month rather than the actual 30 days; so in fact they are given more than 30 or 60 days to complete a record. The MRD further stated that all verbal/telephone orders were supposed to be signed and authenticated by the Physician within 48 hours in accordance with the facility's policy and bylaws.


Record review of a letter sent to Physician C by the facility dated 02/13/15 revealed he had 9 delinquent medical records. The letter indicated that "Medical Records that are incomplete thirty (30) days after discharge, are considered delinquent, the CEO or designee shall notify the responsible staff member of any delinquent medical records."

Based on record review and interview, the facility failed to ensure all patient medical record entries were completed and authenticated in writing or electronic form by the person responsible for providing the information or services performed, consistent with hospital policies and procedures for 7 of 18 discharged patients (#8, #9, #10, #11, #12, #13, and #14) reviewed, and 1 of 14 current inpatient records reviewed (Patient #18).

Patients #8, #9, #10, #11, #12, #13, and #14 had been discharged from the facility over 30 days; and up to 86 days, and the medical records were incomplete and delinquent requiring physician signatures on the following: verbal/telephone orders, admission physician orders, progress notes, discharge summaries, history and physicals (H&P)'s, consents, and other medical forms. Patient #18's Admission Physician Orders had not been signed since his admission on 02/11/15.


This deficient practice could affect the authenticity and integrity of Patients medical records; specifically those records requiring authentication by physician signature.


Findings included:

Review of the facility's Medical Staff by Laws and Medical Staff Rules and Regulations dated 02/11/14, revealed the following: "8. Medical records that incomplete thirty (30) days after patient discharge are considered delinquent. When a physician has a medical record thirty (30) days or greater from the date of discharge, the physician will be notified of delinquent medical records. The physician will be sent a letter requiring completion of the delinquent charts before sixty (60) days delinquent. If the physician has any medical records in a delinquent status at sixty (60) days post discharge then the physician's privileges may be suspended".


Further review of the facility's Medical Staff by Laws and Rules and Regulations dated 02/11/14 revealed the following, "11. All orders, including telephone orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by Hospital policy. Telephone orders must be authenticated in accordance with state laws or regulations."


Patient #8

Record review on 02/24/15 of Patient #8 revealed she was discharged from the facility on 12/15/14 (70 days ago). The following Physician orders had not been signed or authenticated by a physician for Patient #8:
Physician B Verbal Order (VO) dated 11/21/14 for Vancomycin Protocol
Physician A VO dated 11/21/14 for Wound Care
Physician B VO dated 12/09/14 for Vancomycin Protocol
Physician B VO dated 12/11/14 for Nebulizer Treatments.

Further review of Patient #8's records revealed the following Progress Notes had not been signed by Physician A: 12/14/14, 12/13/14, 12/12/14, 12/07/14, 12/04/14, and 11/26/14.

Patient #9

Record review on 02/25/15 of Patient #9 revealed she was discharged from the facility on 01/21/15 (35 days ago). Patient #9's Discharge summary dated 01/21/15 had not been signed by Physician C. Patient #9's Routine Transfer Telephone Physician Orders dated 01/21/15 were not signed or authenticated by Physician C. Patient #9's Blood and Blood Product Administration Consent form dated 12/15/14 was not signed by a Physician.

The following physician verbal and/or telephone orders were not signed by a physician:
01/20/15 for laboratory (lab)
12/28/14 by Physician D for lab
12/26/14 by Physician D for lab
12/24/14 by Physician D for lab and medications ordered
12/19/14 for lab.

Patient #9's Medication Reconciliation and Physician Admission Orders dated 12/09/14 were not signed by Physician C.

Patient #9's Potassium Sliding scale Protocol Orders dated 12/09/14 were not signed by Physician C.

The following Progress Notes were not signed by Physician C for Patient #9:
01/21/15, 01/20/15, 01/19/15, 01/18/15, 01/17/15, 01/16/15, 01/14/15, 01/13/15, 01/12/15, 01/11/15, 01/10/15, 01/09/15, 01/08/15, 01/06/15, 01/05/15, 01/04/15, 01/03/15, 01/02/15, 01/01/15, 12/31/14, 12/30/14, 12/29/14, 12/21/14, 12/20/14, 12/19/14, 12/17/14, 12/16/14, 12/15/14, 12/14/14, 12/13/14, 12/12/14, 12/11/14, and 12/9/14.

The following Progress Notes were not signed by Physician D for Patient #9:
12/28/14, 12/27/14, 12/26/14, 12/25/14, 12/24/14, 12/23/14, and 12/22/14.


Patient #10

Record review of Patient #10 on 02/25/15 revealed he was discharged from the facility on 12/24/14 (61 days ago). Patient #10's Telephone and Verbal Orders dated 12/12/14, 12/22/14, and 12/23/14 by Physician E regarding medications had not been signed or authenticated.

The following Progress Notes were not signed by Physician E for Patient #10:
12/24/14, 12/23/14, 12/22/14, 12/19/14, 12/18/14, 12/17/14, 12/16/14, 12/15/14, 12/12/14, 12/11/14, 12/9/14, 12/8/14, 12/5/14, and 12/4/15

The following Progress Notes were not signed by Physician G for Patient #10:
12/23/14, 12/21/14, and 12/6/14.

Patient #11

Record review of Patient #11 on 02/25/15 revealed Patient #11 expired while at the facility with a discharge summary date of 12/17/14 (68 days ago). Patient #1 had a completed Do Not Resuscitate (DNR) signed by his daughter and a facility Licensed Vocational Nurse (LVN) dated 12/08/14 that was not signed by a Physician; and on 12/17/14 at 1720 Patient #11 was disconnected from the ventilator by Physician D with Patient #11 pronounced deceased at 1736.

Further review of Patient #11's medical record revealed the following Physician verbal and telephone orders that had not been signed or authenticated by the following Physicians:
Physician E: 12/5/14, 12/3/14, 12/1/14, 11/25/14, 11/21/14, 11/19/14, 11/14/14, 10/27/14, and 10/21/14.

Physician H: 12/11/4, 12/10/14, 12/09/14, 11/23/14, and 11/20/14. Further review revealed Physician H had not signed consents dated 12/8/14.

The following Progress Notes had not been signed for Patient #11 by the following Physician's:
Physician E: 12/17/14, 12/11/4, 12/10/14, 12/9/14, 12/5/14, 12/4/14, 12/3/14, 12/2/14, 12/1/14, 11/26/14, 11/25/14, 11/24/14, 11/23/14, 11/22/14, 11/21/14, 11/20/14, 11/19/14, 11/18/14, 11/17/14, 11/14/14, 11/12/14, 11/11/14, 11/10/14, 11/9/14, 11/8/14, 11/7/14, 11/6/14, 11/5/14, 11/4/14, 11/3/14, 10/31/14, 10/31/14, 10/29/14, 10/28/14, 10/27/14, 10/23/14, 10/22/14, 10/21/14, 10/17/14, and 10/16/14.

Physician H: 12/14/14, 12/13/14, 12/12/14, 12/11/14, 12/10/14, 12/8/14, 11/22/14, 11/21/14, 11/20/14, 11/19/14, 11/13/14, 11/12/14, 11/9/14, and 11/8/14


Patient #12

Record review on 02/25/15 of Patient #12 revealed she was discharged from the facility on 01/06/15 (50 days ago). Patient #12's Discharge Summary dated 01/06/15 had not been signed by Physician C. Patient #12's Routine Physician Admission Telephone Orders dated 12/18/14 had not been signed or authenticated by a Physician. Patient #12's Consent for Blood and Blood Product Administration Consent dated 12/21/14 had not been signed by Physician C. Patient #12's Memorandum of Transfer dated 12/18/14 had not been signed by a Physician. Patient #12's Admission Note dated 12/19/14 had not been signed by Physician C.

The following Telephone Physician Orders for Patient #12 had not been signed or authenticated by Physician D: 12/28/14 for labs and 12/24/14 for labs and medications.

The following Progress notes for Patient #12 had not been signed by the following Physician's:
Physician C: 01/06/15, 01/05/15, 01/04/15, 01/03/15, 01/02/15, 01/01/15, 12/31/14, 12/30/14, 12/29/14, 12/21/14, 12/2014.

Physician D: 12/28/14, 12/27/14, 12/26/14, 12/25/14, 12/24/14/12/23/14, and 12/22/14.

Patient #13

Record review on 02/25/15 of Patient #13 revealed she was discharged from the facility on 01/13/15 (43 days ago). Patient #13's Discharge summary dated 01/13/15 had not been signed by Physician C.

Patient #14

Record review on 02/25/15 of Patient #14 revealed she was discharged from the facility on 12/01/14 (86 days ago). Patient #14's Discharge summary dated 12/01/14 had not by signed by Physician C. Patient #14's Consents for Hemodialysis Treatments had not been signed by Physician I. Patient #14's H & P dated 10/23/14 had not been signed by Physician C.

The following Telephone/Verbal Physician Orders for Patient #14 had not been signed or authenticated by Physician C: 11/14/14, 11/6/14, 11/4/14, 11/3/14, and 10/30/14.

The following Progress notes for Patient #14 had not been signed by Physician C: 12/1/14, 11/30/14, 11/29/14, 11/28/14, 11/26/14, 11/25/14, 11/24/14, 11/23/14, 11/21/14, 11/19/14, 11/18/14, 11/17/14, 11/16/14, 11/15/14, 11/12/14, 11/10/14, 11/9/14, 11/8/14, 11/7/14, 11/5/14, 11/3/14, 11/2/14, 11/1/14, 10/31/14, 10/30/14, 10/29/14, 10/28/14, 10/27/14, 10/26/14, and 10/25/14.


Patient #18
Record review of patient #18's medical chart revealed he was admitted to the facility on 02/11/15 and remained as an inpatient in the facility as of 02/24/15. Record review of his Routine Admission Orders, dated 02/11/15 and taken over the phone by a registered nurse (RN) revealed that as of 02/24/15 (13 days later), these orders had not been signed by a Physician.


During an interview on 02/24/15 at 4:55 PM with the Medical Records Director (MRD), stated that all verbal/telephone orders were supposed to be signed and authenticated by the Physician within 48 hours in accordance with the facility's policy and bylaws. The MRD confirmed the Patients Discharged records were incomplete and delinquent for Patients #8, #9, #10, #11, #12, #13, and #14. The MRD stated the Medical Records department would tab all the records with each page for each Physician to sign; and that each Physician had their specific assigned color of tabbed sticky; to make it easier for them. The MRD indicated that Patients records were supposed to be completed and filed after 30 days of discharge and that a warning letter of notification was supposed to be sent to the Physicians if they were delinquent. The MRD confirmed a letter of warning had been sent to Physician C for delinquent medical records, but not to Physician A; that also had delinquent records beyond 60 days. The MRD stated that Physicians are usually given to the end of the month rather than the actual 30 days; so in fact they are given more than 30 or 60 days to complete a record.


Record review of a letter sent to Physician C by the facility dated 02/13/15 revealed he had 9 delinquent medical records. The letter indicated that "Medical Records that are incomplete thirty (30) days after discharge, are considered delinquent, the CEO or designee shall notify the responsible staff member of any delinquent medical records."

Based on record review and interview, the facility failed to ensure all orders, including verbal and telephone orders were authenticated promptly by the ordering practitioner or by another practitioner who was responsible for the care of the Patient in accordance with State law, Hospital policies, and medical staff by laws, rules, and regulations for 6 of 18 discharged patients (#8, #9, #10, #11, #12, and #14) reviewed, and 1 of 14 current inpatient records reviewed (Patient #18).


This deficient practice could affect the authenticity and accuracy of Patients verbal and telephone orders taken and transcribed by others that require authentication by physician signature.


Findings included:

Review of the facility's Medical Staff by Laws and Rules and Regulations dated 02/11/14 revealed the following, "11. All orders, including telephone orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by Hospital policy. Telephone orders must be authenticated in accordance with state laws or regulations."


Patient #8

Record review on 02/24/15 of Patient #8 revealed she was discharged from the facility on 12/15/14 (70 days ago). The following Physician orders had not been signed or authenticated by a Physician for Patient #8:
Physician B Verbal Order (VO) dated 11/21/14 for Vancomycin Protocol
Physician A VO dated 11/21/14 for Wound Care
Physician B VO dated 12/09/14 for Vancomycin Protocol
Physician B VO dated 12/11/14 for Nebulizer Treatments.

Patient #9

Record review on 02/25/15 of Patient #9 revealed she was discharged from the facility on 01/21/15 (35 days ago). Patient #9's Routine Transfer Telephone Physician Orders dated 01/21/15 were not signed or authenticated by Physician C.

The following Physician verbal and/or telephone orders were not signed by a Physician:
01/20/15 for laboratory (lab)
12/28/14 by Physician D for lab
12/26/14 by Physician D for lab
12/24/14 by Physician D for lab and medications ordered
12/19/14 for lab.

Patient #9's Medication Reconciliation and Physician Admission Orders dated 12/09/14 were not signed by Physician C.

Patient #9's Potassium Sliding scale Protocol Orders dated 12/09/14 were not signed by Physician C.


Patient #10

Record review of Patient #10 on 02/25/15 revealed he was discharged from the facility on 12/24/14 (61 days ago). Patient #10's Telephone and Verbal Orders dated 12/12/14, 12/22/14, and 12/23/14 by Physician E regarding medications had not been signed or authenticated.


Patient #11

Record review of Patient #11 on 02/25/15 revealed Patient #11 expired while at the facility with a discharge summary date of 12/17/14 (68 days ago).

Patient #11's medical record revealed the following Physician verbal and telephone orders that had not been signed or authenticated by the following Physician's:
Physician E: 12/5/14, 12/3/14, 12/1/14, 11/25/14, 11/21/14, 11/19/14, 11/14/14, 10/27/14, and 10/21/14.

Physician H: 12/11/4, 12/10/14, 12/09/14, 11/23/14, and 11/20/14.


Patient #12

Record review on 02/25/15 of Patient #12 revealed she was discharged from the facility on 01/06/15 (50 days ago). Patient #12's Routine Physician Admission Telephone Orders dated 12/18/14 had not been signed or authenticated by a Physician.

Patient #12's Memorandum of Transfer dated 12/18/14 had not been signed by a Physician.

The following Telephone Physician Orders for Patient #12 had not been signed or authenticated by Physician D: 12/28/14 for labs and 12/24/14 for labs and medications.

Patient #14

Record review on 02/25/15 of Patient #14 revealed she was discharged from the facility on 12/01/14 (86 days ago).

The following Telephone/Verbal Physician Orders for Patient #14 had not been signed or authenticated by Physician C: 11/14/14, 11/6/14, 11/4/14, 11/3/14, and 10/30/14.

Patient #18
Record review of patient #18's medical chart revealed he was admitted to the facility on 02/11/15 and remained as an inpatient in the facility as of 02/24/15. Record review of his Routine Admission Orders, dated 02/11/15 and taken over the phone by a registered nurse (RN) revealed that as of 02/24/15 (13 days later), these orders had not been signed by a Physician.

During an interview on 02/24/15 at 4:55 PM with the Medical Records Director (MRD), stated that all verbal/telephone orders were supposed to be signed and authenticated by the Physician within 48 hours in accordance with the facility's policy and bylaws. The MRD confirmed the Patients Discharged records were incomplete and delinquent for Patients #8, #9, #10, #11, #12, and #14. The MRD stated the Medical Records department would tab all the records with each page for each Physician to sign; and that each Physician had their specific assigned color of tabbed sticky; to make it easier for them. The MRD indicated that Patients records were supposed to be completed and filed after 30 days of discharge and that a warning letter of notification was supposed to be sent to the Physicians if they were delinquent.


Further review of the facility's Medical Staff by Laws and Medical Staff Rules and Regulations dated 02/11/14, revealed the following: "8. Medical records that incomplete thirty (30) days after patient discharge are considered delinquent. When a physician has a medical record thirty (30) days or greater from the date of discharge, the physician will be notified of delinquent medical records.

Based on record reviews and interview, the facility failed to ensure that a medical history and physical (H & P) examination was completed by the Physician within 24 hours of admission in accordance with the facility's policy for 2 of 7 active Patient records reviewed (#16 and #19) that were currently hospitalized at facility A.

This deficient practice could lead to a possible delay in the detection of health and safety issues.

Findings included:

Record review on 02/24/15 of Patient #16's medical chart revealed he was admitted to the facility on 02/20/15 and his H & P was completed by the Physician on 02/23/15 (3 days later).

Record review on 02/24/15 of Patient #19's medical chart revealed she was admitted to the facility on 02/21/15 and her H & P was completed by the Physician on 02/23/15 (2 days later).

Record review of Medical Staff Rules and Regulations, dated February 11, 2014, revealed but was not limited to the following: " A physician shall be responsible for a complete admission history and physical examination, which shall be recorded within twenty-four (24) hours after admission."

Interview on 02/24/15 at PM with the facility Chief Executive Officer confirmed that the history and physical was to be completed by the physician within the first 24 hours of admission and should be placed in the medical chart during this time.

Based on observation, interview, and record review, the facility failed ensure that food and dietetic services organization requirements were met and; in accordance with the facility's polices. Specifically, The Director of Dietary Services failed to ensure:

1.) Food intended for patient use was properly stored, labeled, and dated.
2.) Expired food was discarded and not available for use.
3.) The automatic warewashing machine was working properly including the temperature gauge and electronic rinse manager.
4.) Sanitizer test strips were available for use that were not expired for testing the sanitization of dishes.
5.) Drain board area of the warewashing machine was clean and free from contamination.
This deficient practice could place the Patients and employees at risk of obtaining food borne illnesses and/or infections.

Findings included:

Observations conducted on 02/24/15 at 12:05 PM of facility A's Kitchen, with the Director of Dietary Services present and the Director of Quality Management (QM) revealed the following:

* The facility's automatic warewashing machine temperature gauge for the wash cycle did not work during the wash cycles (x 2) and the needle remained at zero; despite the temperature logs located on the machine documented normal temperatures.

* The stainless steel drain board area of the warewashing machine; specific for the final drying area following the dish washing, was dirty and contaminated with debris and trash.

*The warewashing machine's electronic rinse additive manager was not working.

* The clean dishes on the racks were heavily spotted with residue which may have been as a result of a needed rinse aid, sanitization, or dishwasher failure.

* The available sanitization test strips p Hydrion QT-40 expired 12/15/11 and provided all different readings on the same test strip when attempted a test 0-150-200-400 parts per million.

*The flour in the plastic bin had expired on 12/05/14 and remained available for use.

*The baking powder in the plastic bin had expired 01/27/14 and remained available for use.

*There was coconut in a large plastic bag in a bin labeled, "sugar and brown sugar" that was not labeled as coconut or dated. The QM had to smell the outside of the plastic bag to determine what the food product actually was and stated the date may have been erased off from the plastic.

*The open paper bag of sugar did not contain an open date or expiration date.

*There was a plastic bag of hot dog buns and a plastic bag of hamburger buns that were not labeled, or dated.

*In the refrigerator were 28 prepared individualized applesauce containers in cups that were not identified with a label or date. In the same refrigerator was prepared cups of lemonade and tea that were not labeled or dated.

*The holding temperature of the potato salad being served on the serving line of the kitchen was at 42.8 degrees Fahrenheit.

During an interview on 02/24/15 at 12:15 PM with the Director of Dietary Services (DS) confirmed the above observations. The Director of DS stated he would need to call out the company to service and/or repair the automatic warewashing machine. The Director of DS indicated that the rinse additive manager for the warewashing machine had been broken and fixed before, but that he would have to call another company for that repair. The Director of DS confirmed that expired foods should have been discarded and not available for use. The Director of DS stated the potato salad should be held at 40 degrees of below and that 42.8 was too warm. The Director of DS confirmed that all food was supposed to be labeled and dated.

During an interview on 02/24/15 at 02:00 PM with the Director of QM stated that company was out to repair the facility's A warewashing machine.


Further observations on 02/25/15 at 3:34 PM of facility B's kitchen with the Director of DS and the Director of QM present revealed the following:

* The available sanitization test strips p Hydrion QT-40 expired 09/15/11.

*The food warmer contained the following food that was not being served and was labeled or dated:
1.) a container of green beans
2.) a container of "chili mac"
3.) a container of gravy
4.) a container of "rice casserole."

During an interview on 02/25/15 at 3:40 PM with the Director of DS confirmed the above findings during observation on 02/25/15.

Review of the facility's policies revealed the following:

Dietary Food Handling Techniques, Revised 03/01/13, revealed the administrative and technical personnel shall confirm to food handling techniques in accordance with paragraph (2) E (Viii) of this subsection (ensuring compliance with 229.161-229.171of this title (relating to Texas Food Establishments).

Storage and Use of Chemicals, Revised 01/13, revealed "8. Use the appropriate chemical test kit to measure the concentration of sanitizer each time a new batch of sanitizer is mixed."

Cleaning and Sanitizing Food Contact Surfaces, Revised 01/13, "3. If a dish machine is used: Refer to the information on the data plate for determining wash, rinse, and sanitization (final) rinse temperatures; sanitizing solution concentrations; and water pressures, if applicable." Further review revealed food contact surfaces of sinks, tables, equipment, utensils, thermometer, carts, and equipment will be washed, rinsed, and sanitized.

Food Production, Service and Distribution Standards, Revised 01/13 revealed in the area of Food Temperature that, "Keep all foods, received, stored, prepped and served below 40 degrees [Fahrenheit] or above 140 degrees."

Food and Nutrition Service Scope of Services and Standards, Revised 01/13 revealed in the area of Storage; in part, that foods will be inspected for proper packaging and sanitary conditions. Food that is soiled, in broken or disrupted packages, will not be accepted.