HospitalInspections.org

Based on document review and staff interview, medical staff failed to ensure appropriate findings of consultative evaluations related to diagnostic testing reflected the practitioner's order for 1 of 10 (#1) patient medical records (MRs) reviewed.

Findings:

1. Rules and Regulations of the Medical Staff, revised/reapproved 2/2015, were reviewed on 9/14/15 at approximately 1504 hours, and indicated on pg. 9, under Medical Records section, point d. Reports of Tests and Results, "All diagnostic and therapeutic procedures shall be recorded and authenticated in the medical record.

2. Review of patient MRs, confirmed patient 1 was admitted to the facility on 8/8/15 at 0110 hours for major depressive disorder with psychosis and:
a. Fall precautions were ordered and implemented and no falls noted during patient's length of stay.
b. On 8/11/15 at 0850 hours, patient complained of pain 10/10 in the rib area on 0-10 pain scale with 10 being the worst.
c. A PA (posterior/anterior) and lateral x-ray of chest was ordered on 8/11/15 at 1100 hours due to clinical indication of "left anterior rib pain and cough."
d. Radiology Report dated 8/11/5 at 1240 hours, confirmed "heart is in the upper limits of normal...remainder of the lung fields are otherwise essentially clear...accuentuation of the pulmonary vasculature with no active infiltrates." The report does not mention the ribs and is not authenticated by the ordering practitioner.
e. Discharge Summary dated 8/17/15 confirmed physically doing well, no complaints and discharged home to family in stable condition.

3. Medical staff P7 (Family Nurse Practitioner) was interviewed on 8/28/15 at approximately ¿¿1624 hours, and confirmed diagnostic testing should reflect the practitioner's order. For patient 1 date of service 8-11-15 for "x-ray chest PA & lateral left anterior rib pain and cough" the radiology report did not address ribs. The radiology report also was not authenticated by P7 (ordering practitioner) after receiving the report.