HospitalInspections.org

Based on record review and interview, the Medical Staff failed to enforce their bylaws to carry out it's responsibilities for 9 of 9 paracentesis procedures (Dates of 11/21/2014, 12/05/2014, 12/19/2014, 12/31/2014, 01/22/2015, 02/06/2015, 02/20/2015, 03/06/2015, and 03/20/2015) performed for Patient #1, in that, Patient #1's records did not include a History & Physical (H&P), a Post procedure physician note, a Discharge Summary, or a Discharge Order for the paracentesis procedures performed between 11/21/2014 and 03/20/2015.

Findings Included

Patient #1's record for the 11/21/2014 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 12/05/2014 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.


Patient #1's record for the 12/19/2014 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 12/31/2014 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 01/22/2015 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 02/06/2015 paracentesis did not reflect a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 02/20/2015 paracentesis did not reflect procedure orders, a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

Patient #1's record for the 03/06/2015 paracentesis did not reflect procedure orders, a History & Physical (H&P), a Discharge Summary, or a Discharge Order. The procedure note was completed by a scribe and there was no indication of the physician's review or signature.

Patient #1's record for the 03/20/2015 paracentesis did not reflect procedure orders, a History & Physical (H&P), a Discharge Summary, or a Discharge Order.

During an interview in the board room on 04/13/2015 ending at 12:10 PM, Personnel #14 was informed the H &P, Discharge Summary and Discharge Orders for the procedure dates listed in this citation were missing. Personnel #14 stated, "I realized, after I started printing the records (for the survey).Wednesday, letters are sent out (to the physicians about delinquencies)."

The 09/08/2008 Glen Rose "Rules and Regulations of the Medical Staff" required, "member of the medical staff shall be responsible for the medical care and treatment of each patient...for the prompt completeness and accuracy of the medical record for necessary special instructions...he must write specific orders on the patient's chart...A medical history shall be dictated or written for each patient...practitioner shall document and have available for the medical record a current and thorough physical examination and other required reports prior to the performance of surgery...a short form may be used for outpatient surgical procedures...Postoperative documentation...patient will be discharged...by the order of a...practitioner in accordance with discharge criteria approved by the Medical Staff...discharge summary shall be written or dictated...as soon after discharge as reasonably possible but no later than thirty (30) calendar days..."