HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure all practitioner's orders were contained in patients' medical records. This deficient practice was evidenced by failing to ensure admission orders were included in the medical record for 1 (#1) of 3 (#1, #2, #4) medical records reviewed.

Findings:

Review of the hospital's policy titled "Assessment Process Inpatient" revised 06/01/2024, revealed in part, Admitting Physician: 1.) If admission is necessary, will give approval and provide medical certification for admission. The admission order set will contain an admitting preliminary diagnosis, precautions, orders for treatment, legal status, preliminary plan of care, and diagnostic impression. 2.) Initiates initial treatment plan problem(s) to be followed up on by nursing, to include goals and interventions to meet patient transition/safety/discharge planning needs.

Review of Patient #1's medical record on 08/01/2024 at 12:50 p.m. revealed an admission date of 07/29/2024. Review of the physician orders failed to reveal admission orders.

Review of a blank admission order set revealed the following orders were included: admit to care of:, legal status, admitting diagnosis, diet, weigh patient, activity, medical consult, social services evaluation/treatment, recreational therapy evaluation/treatment, may attend exercise groups, education groups per schedule, anxiety test, depression scale, initial treatment plan problems, vital signs, precautions, observation/monitoring level, labs and diagnostics, medication levels, complete personal belonging inventory, and PRN admission medications.

In an interview on 08/01/2024 at 1:13 p.m. S1Adm and S2QD verified there was no documentation of admission orders in Patient #1's medical record.