HospitalInspections.org

Based on record review and interview, the facility failed to provide a medical record for the newborn fetus evaluated by the physician and nursing staff.

A review of records found no medical record for the newborn fetus or when the baby arrived at the hospital. No documentation of the baby being examined, except in the physician #7's history and physical and discharge summary of patient #1.

A record review revealed a consent form to release the baby to the Funeral Home, the record was in patient #1's medical record.

An interview with staff #3 on 4/4/2014 at approximately 1:30 PM confirmed staff #13 should have not documented in the patient #1's chart about the newborn fetus. She stated, the documentation should have been on a nurse's note and not in the delivery summary.