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Based on interview and document review, the hospital failed to have a policy and procedure to be followed for patients initially declined for admission and then later admitted to the hospital by another provider for 1 of 7 patient records reviewed (Patient #1).

Failure to have a policy and procedure in place puts patients at risk of being admitted to the hospital when the hospital cannot safely meet the patient's needs.

Findings included:

1. Review of the hospital policy titled "Patient Admission Criteria and Intake and Inpatient", reviewed 09/20, showed the exclusion criteria for patient conditions the hospital could not accept for admission. The policy stated that some patients with medical conditions found during the pre-admission assessment to the hospital. The policy did not clearly state the steps to be taken to ensure the patient received an adequate medical review prior to acceptance for admission.

2. Review of Patient #1's medical record showed that:

a) Patient #1 was admitted to the hospital on 11/28/20. The patient was 440 lbs. The hospital policy stated that patients over 350 lbs were to be excluded for admission.

b) There was no information in the patient's medical record as to the process and the medical professionals involved in determining if the patient's needs could be met in the hospital.

3. On 12/02/20 at 9:30 AM, the investigator interviewed a Licensed Clinical Social Worker (LICSW) (Staff #2). Staff #2 stated that they were unsure of who was responsible for the more in-depth clinical reviews when there was a question about whether a patient was appropriate for admission to the hospital. Staff #2 stated that on several occasions a patient would be denied admission for medical reasons by one provider only to be admitted by another medical provider.

4. On 12/02/20 at 11:00 AM, the investigator interviewed a Physician Assistant (PA) (Staff #5). Staff #5 stated if a patient was denied admission by one medical provider the administration would ask another medical provider to review the patient information. Staff #5 stated that the reviewing medical provider did not always consult with the first provider as to why the patient was denied admission initially.

5. On 12/02/20 at 1:17 PM, the investigator interviewed the Chief Executive Officer (CEO) (Staff #10). Staff #10 stated that administration would review patients declined for admission with another medical provider to determine if the patient's needs could be met. The reviewing medical provider did not always consult with the provider that declined the admission originally.

6. On 12/03/20 at 12:30, the investigator interviewed the Director Of Quality (Staff #1). Staff #1 verified the above information.

Based on interview and document review the hospital failed to implement their policies and procedures to ensure patients received their admission history and physical within 24 hours of admission for 1 of 7 patient records reviewed (Patient #7).

Failure to complete the admission history and physical in a timely manner puts patients at risk for having unmet medical needs.

Findings included:

1. Review of the hospital policy titled "Rules and Regulations of the Medical Staff Bylaws", reviewed 03/19, showed that patients were to receive a history and physical examination within 24 hours of admission.

2. Review of Patient #7's medical record showed that:

a) Patient #1 was admitted to the hospital on 12/01/20. The patient's history and physical was still not completed as of 12/03/20.

3. On 12/03/20 at 12:30 PM, the investigator interviewed the Director of Quality (Staff #1). Staff #1 verified the above information.