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Based on clinical record review and staff interview the admitting physician failed to complete and document a medical history and physical examination on 1 of 3 sampled patients (#1), in accordance with state law and hospital policy as specified in the facility's governing Bylaws.

The Findings Include:

Review of the clinical record for patient #1 revealed he/she presented in the Emergency Room (ER) on 04/28/10 at 3:22 PM with chief complaints of chest pains. The patient has a pertinent history of Hypertension and Diastolic Heart failure. An evaluation of the patient was performed by nursing staff and the medical screening examination was performed by the ER physician.

Review of the ER Physician's medical screening note dated 04/28/10 documented by Dr P---------- revealed the patient was alert and oriented. The patient's vital signs were normal: Temperature (T) - 98 degrees Farenheit (F), Pulse (P) - 69, Respirations - 14, Blood Pressure (BP) - 109/65, Oxygen Saturation (O2 Sat) - 96% on room air. The patient complained of chest pains which was assessed at the level of 7 on a scale of 1 -10 (zero being the lowest and 10 being the highest). The patient's Electrocardiogram (ECG) was abnormal but found to be no different when compared to a prior ECG. A chest Xray and multiple blood tests were performed to evaluate the patient's cardiac status. The facility's chest pain protocol (MONA) was implemented. This meant the patient was given Morphine Sulfate for pain, Oxygen to maintain respiratory status, Nitroglycerine to relieve the chest pains and Aspirin to keep the blood thin.

Further review of the ER physician's medical screening note revealed at 4:33 PM doctor (Dr) P---------- reassessed the patient and at 4:47 PM documented he discussed the patient's condition and reviewed tests results with Dr S-------- (the admitting physician). Dr P------wrote that the treatment plan for the patient was agreed upon and that Dr S------------- will see the patient in the facility. The patient was diagnosed with precordial chest pains characterized as discomfort and pressure.

The patient remained in the ER until a bed was available. While in the ER he/she was continuously monitored and treated with Morphine Sulfate (MSO4) as ordered for complaints of chest pains. At 11:31 PM the patient was reassessed and noted to be calm, resting quietly and pain free. At 6:17 AM on 04/29/10 the patient was officially admitted to the facility and transferred to the Telemetry unit.

Per nurses note dated 04/29/10 at 11:45 AM the patient was transported to the stress test lab for a nuclear stress test procedure.

Review of the Cardio Pulmonary Arrest Record dated 04/29/10 revealed that the patient became unresponsive during the stress test procedure at 1:26 PM. A resuscitation code was called. Attempts to resuscitate the patient were unsuccessful. The patient was pronounced dead at 2:04 PM by Dr P--------.

Consultation Record dated 04/29/10 documented by Dr P----- revealed the patient complained to the nuclear technologist of ringing in the ears prior to becoming unresponsive.

Review of the stress test final result dated 04/29/10 at 12:00 Noon, revealed the patient exercised for 1 minute 53 seconds on the standard Bruce protocol. The patients' maximum heart rate was 134 (normal = 60 to 100), and the maximum BP was 128/92 (normal = 120/80). The maximum workload obtained was 3.9 METS. The exercise was terminated due to complaints of chest pains and shortness of breath. Review of the interpretation of the stress test result by the Cardiologist revealed the patient had extremely poor exercise tolerance, exercise induced chest discomfort and shortness of breath.

Review of the clinical record revealed a Short Stay Summary and Progress note dated 04/29/10 was completed by Dr S------- at 2:01 PM (3 minutes before the patient was pronounced dead). Dr S-------- documented the following: "Admitted for observation overnight with cp (chest pains). Troponins (cardiac enzyme) normal. Went to stress lab for stress testing for risk stratification this am. Developed arrhythmias (abnormal heart rhythm) and code called per house staff. Please refer to separate documentation."

The clinical record review revealed no documentation to substantiate that Dr S--------- or any other physician had seen and performed a medical history and physical (H & P) examination on the patient prior to his/her death.

The facility policy: "Rules and Regulations of the Medical Staff, "specifies at #2 (A) and (C): "A complete H & P examination or a short stay form shall in all cases be recorded on the day of admission. All patients must be seen by a physician or designee within the following time frames: Telemetry (8) hours."
The patient was admitted to Telemetry on 04/29/10 at 6:17 AM and experienced cardio-pulmonary arrest on 04/29/10 at 1:26 PM (within the 7 hour and 9 minutes period the History & Physical (H&P) was not done. The H&P / Short Stay Summary was not done until 7 hours and 44 minutes of the patient's Telemetry admission, at 3 minutes before the patient's death and during the cardio-pulmonary resuscitation event.

During a phone interview with the Chief Medical Officer (CMO) on 05/14/10 at 10:00 AM, the CMO stated that it is the admitting physician who needs to see the patient within 24 hours of admission to the facility.

Upon review of the policy, as noted in the above paragraph, the time frame for Dr S------- to have seen patient #1 was within (8) hours of admission to the Telemetry unit.

During an interview conducted with the supervisor of the stress test lab on 05/14/10 at 12:05 PM, the supervisor confirmed that Dr S--------- had not visited the patient while in the stress test lab. The supervisor stated he was aware that the patient was not feeling well and that the technologist had notified Dr S--------, who authorized continuation of the test.

During an interview conducted with the nuclear technologist, who attended the patient, on 05/14/10 at 12:30 PM, the technologist stated that she visited the patient at approximately 8:30 AM on the morning of the test. The patient complained of nausea and looked "sweaty." The technologist stated that she notified Dr S--------- and asked whether the stress test should be continued. The technologist stated that Dr S---------authorized continuation of the test.
The technologist further stated that before starting the test, she again observed the patient was "sweaty."

During an interview conducted with the Registered Nurse (RN) on 05/14/10 at 12:30 PM, who cared for the patient before he/she left the unit for the stress test, the RN stated that she did not observe Dr S----------visit the patient before the patient left the unit for the stress test. The RN confirmed that she treated the patient with MSO4 for complaints of chest pains which were resolved prior to him/her leaving the Telemetry unit.
The RN also stated that she was not aware that the nuclear technologist had notified the physician of the patients' complaints.

During an interview conducted with the risk manager on 05/14/10 at 4:20 PM, the risk manager reviewed patient #1's clinical record and agreed the admitting physician had not completed the H & P assessment on the patient prior to the patient's death.