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NORTON-KING'S DAUGHTERS' HEALTH
MEDICAL STAFF RESPONSIBILITIES - H&P
Tag No.: A0358
Based on document review and staff interview, the medical staff failed to ensure a history and physical (H&P) exam was completed within 24 hours of admission for 3 of 5 patients (patients #1, 4 and 5).
Findings include:
1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted on 10/5/10.
(B) The history and physical (H&P) was not dictated until 11/22/10.
2. Review of patient #4 medical record indicated the following:
(A) The patient was admitted on 10/5/10.
(B) The H&P was not dictated until 10/15/10.
3. Review of patient #5 medical record indicated the following:
(A) The patient was admitted on 10/5/10.
(B) The H&P was not dictated until 10/10/10.
4. Staff member #2 verified the above medical record documentation in interview beginning at 2:25 p.m.
No Description Available
Tag No.: A0404
Based on document review and staff interview, nursing failed to administer medications according to physician orders for 1 of 5 patients (patient #1).
Findings include:
1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted on 10/5/10.
(B) The patient had orders written on 10/5/10 including, but not limited to, Haldol 2.5 mg IM every 6 hours prn and Dilaudid .5 mg IV every 2 hours prn.
(C) Per review of the medication administration record (MAR), the patient received 2.5 mg of Haldol at 10:15 a.m. on 10/6/10 and 2.5 mg again at 2:32 p.m. on the same date (only 4 hours and 17 minute lapse instead of 6 hours per order). The patient received .5 mg of Dilaudid at 1:55 a.m. on 10/7/10 and .5 mg again at 2:54 a.m. on the same date (only 59 minute lapse instead of every 2 hours per order).
2. Staff member #2 verified the above medical record information beginning at 2:25 p.m.
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
Based on document review and staff interview, the medical staff failed to complete the medical record within thirty (30) days of discharge for 1 of 5 patients (patient #1).
Findings include:
1. Patient #1 expired on 10/7/10. His/her discharge/death summary was not dictated until 11/22/10.
2. Staff member #2 verified the above medical record information beginning at 2:25 p.m.