HospitalInspections.org

Based on record review and interview, the hospital failed to ensure completion of History and Physical Examination (H&P) within 24 hours of patient admission for four (Patients #1, 2, 6, 7) of 17 patients.

This failed practice has the likelihood to place patients at risk of delayed recognition of medical conditions and delayed care planning.

A review of a document titled "Medical Staff Bylaws" read in part, "The attending physician or practitioner will be responsible for the completion of an admission history and physical examination no more than 30 days before or 24 hours after admission. The history and physical examination must be on a patient's chart within 24 hours of admission."

Patient #1

A review of a document titled "Admission H&P" showed the patient was admitted on 08/13/20 and the H&P was not signed by the physician until 08/18/20 (4 days late).

Patient #2

A review of a document titled "Admission H&P" showed the patient was admitted on 08/27/20 and the H&P was not signed by the physician until 09/04/20 (7 days late).

Patient #6

A review of a document titled "Admission H&P" showed the patient was admitted on 02/06/20 and the H&P was not signed by the physician until 02/13/20 (6 days late).

Patient #7

A review of a document titled "Admission H&P" showed the patient was admitted on 03/04/20 and the H&P was not signed by the physician until 03/06/20 (1 day late).

On 09/24/20 from 2:08 PM to approximately 2:35 PM, Staff A reviewed the medical records for Patients #1 and #2 and stated the physician should have signed the H&P within 24 hours of admission to prevent a delay in care.

On 09/24/20 from 3:25 PM to approximately 4:00 PM, Staff B reviewed the medical records for Patients #6 and #7 and stated the physician should have signed the H&P within 24 hours of admission and not doing so could have affected patient outcomes.

Based on record review and interview, the hospital failed to ensure assessment of pain after a pain medication was administered for one (Patient #6) of 17 patients.

This failed practice has the likelihood to result in patients having a perception of low quality of care.

A review of a document policy titled "Pain Control" read in part, "The nursing staff will...return to see how well the pain medication is working, whether it is helping the patient's pain or if they are having uncomfortable side effects."

Patient #6

A review of the medical record showed the patient reported a pain scale of 8 and was administered Norco 5mg on 02/19/20 at 6:09 PM. The medical record showed the next documented pain assessment occured on 02/20/20 at 7:17 AM and the patient reported a pain scale of 8.

On 09/24/20 from 3:25 PM to 3:50 PM, Staff B reviewed the medical record for Patient #6 and stated no post pain assessment was completed following the 2/19/20 6:09 PM administration of Norco to determine if pain was affected positively.

On 09/24/20 at 3:45 PM, Staff C stated staff were expected to reassess pain 30 minutes to one hour after administering a pain medication.