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TYLER HOLMES MEMORIAL HOSPITAL CAH
No Description Available
Tag No.: C0305
Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all medical records contained a history and physical examination.
Findings include:
1. Twenty (20) discharged medical records were selected at random from a list of discharges from January 1, 2012, through May 31, 2012, and reviewed along with two (2) inpatient medical records and the last seven (7) patients discharged from the Crirical Access Hospital (CAH), for a total of 29 medical records.
2. The Medical Staff Rules and Regulations require a history and physical examination to be documented within 24 hours of admission.
3. On two (2) of the seven (7) recently discharged patient medical records reviewed, the history and physical examination was absent.
No Description Available
Tag No.: C0307
Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all verbal orders are signed by the physician within 24 hours.
Findings include:
1. Twenty (20) discharged medical records were selected at random from a list of discharges from January 1, 2012, through May 31, 2012, and reviewed along with two (2) inpatient medical records and the last seven (7) patients discharged from the Crirical Access Hospital (CAH), for a total of 29 medical records.
2. The Medical Staff Rules and Regulations require verbal orders to be signed by the physician within 24 hours.
3. On four (4) of the nine (9) records reviewed that belonged to inpatients and recently discharged patients, the physician had not countersigned his verbal orders within 24 hours.
PERIODIC EVALUATION
Tag No.: C0334
Based on review of the facility's policies and procedures and review of the annual evaluation from July, 2011, the facility failed to ensure that a review of the Critical Access Hospital's (CAH's) policies and procedures were done in conjunction with an annual evaluation.
Findings include:
There was no documented evidence that the CAH had evaluated, reviewed and/or revised the health care policies as part of the annual program evaluation.