HospitalInspections.org

Based on patient record review and interview the hospital failed to ensure the completion and documentation of the medical history and physical exam (H & P) within 24 hours of admission for seven ( Patient # 16, 18, 19, 21, 22, 23, 24) of 30 patients.

This failed practice had the likelihood for patients to be placed at risk of incomplete documentation of records. Thereby, affecting the quality of patient care. As the patient record provides communication of patient care in a sequential manner to provide timely assessment and intervention.

Findings:

A review of Policy Number 8019 showed completion of a comprehensive medical history and physical examination (H & P) within 24 hours of admission.

A review of Medical Staff Bylaws showed a history and physical must be completed and documented twenty-four hours after hospital admission or registration.

A review of Patient Records Showed:
Patient #16 Admitted to the hospital on 02/21/19 the physician signature and date were not on the H&P.

Patient #18 Admitted to the hospital on 02/06/19 the physician signature for the H&P was dated on 02/27/19 (21 days after admission).

Patient #19 Admitted to the hospital on 03/13/19 the physician signature for the H&P was dated on 04/04/19 ( 21 days after admission).

Patient #21 Admitted to the hospital on 01/07/19 the physician signature and date were not on the H&P.

Patient #22 Admitted to the hospital on 07/30/19 the physician signature and date were not on the H&P.

Patient #23 Admitted to the hospital on 07/30/19 the physician signature and date were not on the H&P.

Patient #24 Admitted to the hospital on 07/29/19 the physician signature and date were not on the H&P.

On 07/31/19 at 11:00 am, Staff #D stated the history and physicals were not signed and dated.

Based on patient record review and interview the hospital failed to ensure documentation of the discharge summary containg outcome of hospitalization, disposition of care, and provisions for follow up care within 30 days following discharge on three (patient # 16, 19, and 21) of 30 patients.

This failed practice had the likelihood to place patients at risk of incomplete documentation of records. Thereby resulting in poor quality of care.


Findings:

A review of "Medical Staff Bylaws" Read in part "A medical record is considered delinquent when it has not been completed for any reason within thirty days after a patient's discharge."


A review of Patient Records Showed:

Patient #16 Discharged from the hospital on 02/25/19 the physician signature and date were not on the discharge summary (5 months and 3 days).

Patient #19 Discharged from the hospital on 03/15/19 the physician signature and date were not on the discharge summary (4 months and 16 days).

Patient #21 Discharged from the hospital on 01/24/19 the physician signature and date were not on the discharge summary (6 months and 7 days).

On 07/31/19 at 11:00 am, Staff #D stated the discharge summaries were not signed and dated.

Based upon observations and interview, the hospital failed to ensure a pharmacist reviewed all medication orders for appropriateness prior to dispensing the first medication dose. This was evidenced by interview with Staff M who reported that the pharmacist only visits the hospital once a week for medication reviews. Findings:

Observations of the drug storage area on 08/01/19 at 3:20 p.m. revealed the hospital utilized a drug storage room for all medications. Interview with Staff M during the observations revealed when asked how often the pharmacist conducted on-site visits, she replied the pharmacist visited the hospital weekly. When asked if the pharmacist reviewed the patient's medications orders prior to the administration of the first dose, Staff M replied "no" and added that the pharmacist only visited the hospital once a week.

Review of the pharmacy policies and procedures revealed there failed to be documented evidence a policy was developed related to reviewing all medication orders for appropriateness by a pharmacist prior to the administration of the first dose.

See Emergency Preparedness tag E0041 (NFPA 110 Emergency Power Supply System) and Life Safety Tag K918.

Based upon observations, record review, and interview, the hospital failed to ensure surgery personnel followed policies and procedures related to the covering of all head and facial hear while in the restricted areas of the surgical suites. Findings:

Observations on 07/31/19 at 8:38 a.m. of the remote in-patient hospital revealed in three of the six operating rooms, the surgical personnel were wearing skull caps which allowed the lower half of their hair to remain uncovered. During the observations interview with Staff N revealed it was the policy of the surgery department that all head and facial hair was to remain covered while in the operating rooms restricted areas.

Review of the policy and procedure titled "Attire in the Operating Room" Reference #4010 revealed: "All staff entering semi-restricted and restricted areas of the surgical suite shall be in operating room attire. All head and facial hair shall be covered while in the restricted areas of the surgical suite."