HospitalInspections.org

In a review of 19 open medical records and 2 closed records, 1 out of 6 Medicare recipients did not have evidence that an Important Message had been given.

Patient #15 was admitted to the ICU on 10/3/2014. Medical record review done on 10/9/2014, revealed no Important Message. This was confirmed by the charge nurse of the ICU.

Based on the review of 19 open medical records, along with the medical staff bylaws, it was determined that 1 patient did not have a history and physical as required by regulation and policy.

Patient #16 was admitted to the Behavioral Health Unit on 10/7/2014. A review of her medical record on 10/9/2014 revealed no history and physical. There were notations that she refused to see the medical doctor, but she had signed a release of information upon admission allowing staff to contact her mother for information. No history or physical exam was present on the record.

Based on review of 4 medical records from the emergency department, it was determined that 2/2 patients that were transferred to other hospitals contained transfer consents that did not include the risks and benefits.

Patients #6 and 7 had signed consents for transfer to other hospitals. Both were transferred because they needed a higher level of care. Neither consent contained the risk and benefits of transfer. Both consents were complete in all other aspects and were signed by the patient and the appropriate people.

In a review of 19 open medical records, it was determined that 1 elderly patient who was admitted on 10/3/2014, had not had a discharge planning evaluation 10/9/2014.

Patient #15 was an 89 year old patient admitted to the ICU on 10/3/2014. Her care and medical record were reviewed on 10/9/2014 and no discharge planning evaluation was found. This was confirmed by the discharge planning RN in an interview on 10/10/2014. The patient was subsequently evaluated for discharge needs. According to the discharge planning RN the patient met criteria based on her age and diagnosis, and should have had a discharge planning evaluation soon after admission.

Based on a review of 4 patients who underwent surgical procedures on 10/8/2014 and 10/9/2014, it was determined that 1 of the anesthesia consents was not dated and timed by the anesthesiologist.

Patient #1 had a surgical procedure on 10/9/2014. The surgical consent was signed by the patient and the physician on 10/9/2014. The anesthesia consent lacked a date and time for the anesthesiologist signature.
The consent was signed and dated by the patient.