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Based on record review and interview, the facility failed to ensure 4 patients (Patients #4, #6, #8, #27) out of 30 patients had a history and physical (H&P) examination within 24 hours of admission.

Finding Included:

1) Record review of Face Sheet and Patient Progress Notes (nursing) dated 04/10/2025 reflected Patient #4 (current patient) was a 58 year old female, with history multiple knee surgeries and allergies to tape, plastic, penicillin, iodine, and betadine. Patient records reflected she was transfer from outside facility to swing bed on 04/07/2025 at 12:28 pm for post knee surgery. Last H&P provided was dated 03/31/2025 and 04/03/2025 operative report from Medical City Dallas. As of 04/10/2025 at 10:15 am, no H&P or physician progress notes were found in patient's record.

2) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, and ER Visit Note dated 04/06/2025 reflected patient #6 (current patient), a 70 year-old male with history of cancer of the liver, cirrhosis of liver, paralysis of diaphragm, sleep apnea, hypertension, and pulmonary edema. Patient records reflected admission to medical inpatient from emergency department on 04/08/2025 at 1:15 pm for cellulitis of lower extremities, antibiotics started. Last physician note was ER Visit Note dated 04/06/2025 at 10:05 am. As of 04/10/2025 at 10:30 am, no H&P or physician progress notes were found in patient's record. Per interview with staff #B on 04/10/2025 at 3:35 pm, patient has left the facility.

3) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, and ER Visit Note dated 04/05/2025 reflected patient #8 (current patient), a 54 year-old female with history of lung cancer. Patient records reflected admission to medical inpatient from emergency department on 04/05/2025 at 11:26 pm for pneumonia. Last physician note was from ER Visit Note on 04/05/2025 at 11:37 pm. As of 04/10/2025 at 10:50 am, no H&P or physician progress notes were found in patient's record.

4) Record review of Face Sheet, Patient Progress Notes (nursing) dated 04/10/2025, United Regional Hospitalist Discharge Summary dated 03/31/2025 and ER Visit Note dated 04/01/2025 reflected patient #27 (discharged patient), a 70 year-old male with history of chronic heart failure, urinary tract infection, paroxysmal atrial fibrillation, and COPD. Patient records reflected admission from outside facility to swing bed on 03/31/2025 at 2:07 pm for congestive heart failure exacerbation. Last physician note was ER Visit Note dated 04/01/2025 at 6:09 pm. As of 04/10/2025 at 11:57 am, no H&P or physician progress notes were found in patient's record. Patient was discharged on 04/07/2025 at 11:55 am. Per interview with staff #B, staff #T saw patient on 04/01/2025 at 6:09 pm, which is greater than 24 hours after admission. The H&P provided was started but not completed (per interview with staff #B) and was signed on 04/10/2025 at 3:30 pm by staff #T.

Review of Policy and Procedure titled "History and Physical", Reference Number: 6129, dated April 2025 reflected the Outcome Standard to provide "A guideline to ensure the compliance of History and Physicals being on the medical record within 24 hours and/or prior to operative and other invasive procedures."

Record review of the the Hospital's Medical Bylaws, Article III 3.1 noted the Medical Staff Membership requirement to abide by " ...any department rules, policies and procedures ..."

In an interview on 04/10/2025 at 10:55 am, Staff #B confirmed the hospital expectation that patients were to be physician evaluated for a history and physical examination within 24 hours of admission and seen daily during their inpatient hospitalization. The documented admission history and physical examination (H&P) was to be in the patients' medical chart within 24 hours.