HospitalInspections.org

Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to his/her own physician of the hospital admission including date, time and method of the requested notification in 2 of 2 inpatient medical records reviewed (MR28 and MR29 ).

Findings include:

1) On December 6, 2018, surveyor requested EMP10 and EMP17 to provide a policy that included if the patient requested or declined notification to his/her own physician of the admission to the hospital. None was provided.

2) Review on December 6, 2018, of MR28 and MR29 revealed these patients were admitted to the facility between August 29, 2018 and September 1, 2018

Further review of MR28 and MR29 revealed no documentation in the medical record whether the facility asked each patient if they requested or declined notification to his/her own physician of the hospital admission including date, time and method of the requested notification.

3) Interview with EMP10 and EMP17 on December 6, 2018 at approximately 1:45 PM confirmed the facility did not have a policy for notification of patient's hospital admission to his/her own physician and there was no documentation in MR28 and MR29 of whether the patient requested or declined notification to his/her own physician, including the date, time and method of notification if the patient did request notification.