HospitalInspections.org

Based on review of a medical record, staff interview and review of pertinent facility documentation provided by facility staff, it was determined that the facility failed to ensure compliance with all facility policies and procedures.

Findings include:

Reference #1: Facility Policy #E-12, Event Reporting, states: "... Documentation: 1. Physician Documentation Responsibility: If the event involves a patient, he/she must be examined by either and [sic] attending physician or a resident physician as soon as possible. a. The physician must document his/her findings in the patient's medical record in Progress Notes. ... 2. Nurses' documentation responsibility: Patient related events should also be documented in the Nurses' notes in the Medical Record.
a. Factual information including the patient's condition at the time of the event, therapeutic interventions taken in response to the event and the patient's response to the interventions should be recorded.
b. The nurse will record any notification to the attending or resident physician as well as subsequent orders. ..."

1. Per the document completed by Staff #12, titled "Monmouth Medical Center Response," during the evening shift on 5/25/11, Patient #7 reported to nursing staff that he/she had sexual contact with a male employee.

a. There was no evidence in the medical record that a physician examined the patient and/or documented in the Progress Notes of Medical Record #7, after the above allegation was made.

b. There was no evidence that the nurse documented in the Nurses' Notes of Medical Record #7 after the above allegation was made.

c. There was no evidence in Medical Record #7 that the nurse notified a physician regarding the above allegation.

d. These findings were confirmed by Staff #11.