HospitalInspections.org

The hospital Behavioral Health Unit (BHU) reported a census of ten patients. Based on medical record review, Medical Staff Bylaws review and staff interview the hospital failed to ensure a complete history and physical were in the patients chart as required by the hospital's Medical Staff Bylaws for three of five sampled patients requiring a history and physical (patient #'s 2, 3, and 4). This deficient practice had the potential to affect the patient's planned course of care.
Findings include:

- The hospital's Medical Staff Bylaws reviewed on 5/6/15 at 11:00am directed, "...a medical history and physical should be completed no more than 30 days before or 24 hours after admission..."

- Patient #2's medical record review on 5/5/15 revealed an admission date of 4/24/15 with diagnoses of increased confusion and no safety awareness. The medical record contained a history and physical transcribed on 4/27/15 (3 days after admission).

- Patient #3's medical record review on 5/5/15 revealed an admission date of 5/1/15 with diagnoses of agitation and combative behaviors. The medical record contained a history and physical transcribed on 5/3/15 (2 days after admission).

- Patient #4's medical record review on 5/5/15 revealed an admission date of 4/24/15 with diagnoses of wandering, delusions, and hallucinations. The medical record contained a history and physical transcribed on 4/27/15 (3 days after admission).

Administrative Nurse Staff A interviewed on 5/5/15 between 11:30am and 3:00pm during medical record review acknowledged the physician failed to complete the patient's history and physical within 24 hours of admission as directed by the hospital's Medical Staff Bylaws.