HospitalInspections.org

Based on interviews and documentation review, the Hospital failed to ensure that clinical information regarding observational status was documented in the medical record for 5 of 8 applicable patients (Patients #1, #6, #7, #10, and #11).

Findings included:

Review of the Hospital's policy/procedure related to observational status indicated the following: Observational status services are defined by the Centers for Medicare and Medicaid Services (CMS) as those services ordered by a physician and furnished to an outpatient on the hospital's premises including use of a bed and periodic monitoring by the facility's nursing staff which are reasonable and necessary to evaluate the outpatient's condition or to determine the need for possible inpatient admission. Any bed on any unit may be designated as an observation bed. Observational status is designated by the admitting practitioner. The rationale for such decisions must be clearly documented.

Review of the medical records for Patients #1, #6, #7, #10, and #11 indicated the patients were admitted to the Hospital under observational status however the Emergency Department and Admitting physicians did not clearly document the rationale for the decision to admit under observational status.