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INDEPENDENCE HEALTH SYSTEM WESTMORELAND HOSPITAL
MEDICAL STAFF - BYLAWS
Tag No.: A0047
Based on a review of facility policies, and medical records and staff interview, it was determined that the facility failed to ensure that medical staff rules and regulations were followed for three of 11 medical records reviewed (MR1, MR6, and MR7).
Findings include:
"Medical Staff Bylaws, Policies and Rules and Regulations of Excela Health, reviewed March 2013. ... .3.3. (C) All medical records will document the information outlined in this paragraph, as relevant and appropriate to patient care. This document shall be joint responsibility of the attending physician and the Hospital: ... . Content of Record. (6) Admitting history and physical examination and conclusions or impressions drawn from the history and physical examinations. ... . (19) Discharge summary with outcome of hospitalization, final diagnoses, ... ."
1) Review of MR1 on July 3, 2013 at approximately 11:00 AM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR1 revealed the Discharge Summary, which failed to include the diagnosis of decubitus ulcers
2) Review of MR6 on July 3, 2013 at approximately 1:00 PM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR6 revealed the History and Physical and Discharge Summary, which failed to include the diagnosis of decubitus ulcers.
3) Review of MR7 on July 3, 2013 at approximately 1:30 PM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR7 revealed the History and Physical and Discharge Summary, which failed to include the diagnosis of decubitus ulcers.
During an interview with EMP2 on July 3, 2013, at approximately 2:00 PM, EMP2 confirmed the above findings.
MEDICAL STAFF - BYLAWS
Tag No.: A0047
Based on a review of facility policies, and medical records and staff interview, it was determined that the facility failed to ensure that medical staff rules and regulations were followed for three of 11 medical records reviewed (MR1, MR6, and MR7).
Findings include:
"Medical Staff Bylaws, Policies and Rules and Regulations of Excela Health, reviewed March 2013. ... .3.3. (C) All medical records will document the information outlined in this paragraph, as relevant and appropriate to patient care. This document shall be joint responsibility of the attending physician and the Hospital: ... . Content of Record. (6) Admitting history and physical examination and conclusions or impressions drawn from the history and physical examinations. ... . (19) Discharge summary with outcome of hospitalization, final diagnoses, ... ."
1) Review of MR1 on July 3, 2013 at approximately 11:00 AM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR1 revealed the Discharge Summary, which failed to include the diagnosis of decubitus ulcers
2) Review of MR6 on July 3, 2013 at approximately 1:00 PM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR6 revealed the History and Physical and Discharge Summary, which failed to include the diagnosis of decubitus ulcers.
3) Review of MR7 on July 3, 2013 at approximately 1:30 PM, revealed a patient with documented decubitus ulcers assessments and treatments. Further review of MR7 revealed the History and Physical and Discharge Summary, which failed to include the diagnosis of decubitus ulcers.
During an interview with EMP2 on July 3, 2013, at approximately 2:00 PM, EMP2 confirmed the above findings.