HospitalInspections.org

Based on record review and interview the facility failed to document a complete medical record for 1 (P [patient] 7) out of 10 (P1-P10) patients reviewed for medical screening examinations. This deficient practice could possibly lead to incomplete records that do not adequately support the patient's diagnoses and condition.

The findings are:

A. Record review of P7's medical record revealed the following:

a. The face sheet revealed P7 presented to the emergency department on 10/15/24 for Hematemesis (Vomiting blood)

b. Provider's note revealed a physical examination was not documented. The note did not contain any review of systems (ROS, method of collecting history and full assessment from patients) for P7. Under "Physical Exam" there were only vital signs charted, no further documentation of an assessment was documented.

c. Section "ED [Emergency Department] course and impression [explanate of care that was provided in the ED]" stated "He [name of P7] was discharged home with a prescription for Zofran [medication for nausea] as well as Carafate [medication for stomach ulcers]. Referral to GI [gastroenterology] made."

C. During an interview on 11/12/24 at 2:00 PM with S2, Clinical staff member, S2 confirmed that there was nothing documented under "Review of Systems" (ROS) and there was no further assessment documented.

D. During an interview on 11/13/24 at 8:55 AM, with S (staff) 5, clinical staff member, S5 confirmed that a physical examination was not documented. S5 also confirmed that a physical examination should be documented on all patients.