HospitalInspections.org

Based on record review, staff interview and policy review, the hospital failed to conduct physical exams within 24 hours for 10 of 22 sampled patients, #2, 3, 9, 14, 15, 16, 18, 19, 20, and 22.

The findings:

A clinical record review was conducted for patients #2, 3, 9, 14, 15, 16, 18, 19, 20, and 22.

Patient #2 was admitted in 2015 and had a physical exam completed 5 days after admission.
Patient #3 was admitted in 2015 and had a physical exam completed 16 days after admission.
Patient #9 was admitted in 2015 and had a physical exam completed 4 days after admission.
Patient #14 was admitted in 2015 and had a physical exam completed 6 days after admission.
Patient #15 was admitted in 2015 and had a physical exam completed 4 days after admission.
Patient #16 was admitted in 2015 and had a physical exam completed 6 days after admission.
Patient #18 was admitted in 2015 and had a physical exam completed 4 days after admission.
Patient #19 was admitted in 2015 and had a physical exam completed 3 days after admission.
Patient #20 was admitted in 2014 and had a physical exam completed 7 days after admission.
Patient #22 was admitted in 2015 and had a physical exam completed 6 days after admission.

An interview was conducted with the Director of Nursing / Risk Manager (DON/RM) on 2/10/15 at approximately 1:00pm. The DON/RM stated that the hospital had withdrawn from the Medicare system and requested deactivation of their provider number. The hospital policy was that a physical exam would be conducted within 1 week of admission.

A record review of Policy Number 22-03, Analyzing an Incomplete Chart, undated, was conducted. Under the section for History and Physical the policy stated: " Every medical record requires a history and physical examination to be dictated within 7 days of admission and then signed, dated and timed when read by the attending physician. "

Based on record review, staff interview and policy review, the hospital failed to conduct a psychiatric evaluation within 60 hours of admission for 16 of 22 sampled patients, #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 18, 19, and 22.

The findings:

A clinical record review for the completion of the psychiatric evaluation was conducted for patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 18, 19, and 22.

Patient #1 was admitted in 2015 and had a psychiatric evaluation completed 8 days after admission.
Patient #2 was admitted in 2015 and had a psychiatric evaluation completed 14 days after admission.
Patient #3 was admitted in 2015 and had a psychiatric evaluation completed 5 days after admission.
Patient #5 was admitted in 2015 and had a psychiatric evaluation completed 13 days after admission.
Patient #6 was admitted in 2015 and had a psychiatric evaluation completed 14 days after admission.
Patient #7 was admitted in 2015 and had a psychiatric evaluation completed 18 days after admission.
Patient #8 was admitted in 2015 and had a psychiatric evaluation completed 8 days after admission.
Patient #9 was admitted in 2015 and had a psychiatric evaluation completed 7 days after admission.
Patient #10 was admitted in 2015 and had a psychiatric evaluation completed 7 days after admission.
Patient #11 was admitted in 2015 and had a psychiatric evaluation completed 5 days after admission.
Patient #14 was admitted in 2015 and had a psychiatric evaluation completed 8 days after admission.
Patient #15 was admitted in 2015 and had a psychiatric evaluation completed 10 days after admission.
Patient #16 was admitted in 2015 and had a psychiatric evaluation completed 5 days after admission.
Patient #18 was admitted in 2015 and had a psychiatric evaluation completed 14 days after admission.
Patient #19 was admitted in 2015 and had a psychiatric evaluation completed 6 days after admission.
Patient #22 was admitted in 2015 and had a psychiatric evaluation completed 6 days after admission.

An interview was conducted with the Director of Nursing / Risk Manager (DON/RM) on 2/10/15 at approximately 1:00pm. The DON/RM stated that the hospital had withdrawn from the Medicare system and requested deactivation of their provider number. The hospital policy was that a psychiatric evaluation would be conducted within 7 days of admission.

A record review of Policy Number 22-03, Analyzing an Incomplete Chart, undated, was conducted. Under the section for History and Physical the policy stated: " Every medical record requires a psychiatric admission evaluation dictated within 7 days of admission and then signed, dated and timed when read by the attending physician. "