HospitalInspections.org

Based on record review and interview, it was determined that for 15 of 15 patients (A1, A2, A3, A4, A5, B1, B2, B3, B4, B5, C1, C2, C3, C4 and C5), the physical examinations failed to include any information about physical findings that were more than a non-descriptive statement "WNL" (Within Normal Limits) and/or "intact". Also, for one (1) patient (A2), information within the examination was contradictory. These failures resulted in no clarification or description of actual physical status at the time of the examination.

Findings include:

I Record Review

For 15 of 15 active sample patients (dates of H&P in parenthesis) A1 (5/23/18), A2 (5/2/18), A3 (7/31/18), A4 (7/20/18). A5 (6/1/18), B1 (7/22/18), B2 (11/28/17), B3 (8/31/17), B4 (9/6/17), B5 (11/30/17), C1 (7/6/18), C2 (6/21/18), C3 (8/16/17), C4 (3/25/18), C5 (3/27/18) the History and Physicals stated "WNL" for head, eyes, ears, mouth, throat, teeth, chest, lung, cardiovascular, breast, abdomen, etc. No recording of findings such as "pupils equal, reactive to light and accommodation" was present. Additionally, for patient A2, who was blind in the left eye, a review of systems stated "eyes - normal," and the general appearance was described as "Healthy - Left eye blind." The examination for eyes states "WNL."

II Staff Interviews

1. On 8/21/18 at 10:25 a.m., the supervisory nurse practitioner for the physical examinations performed by the nurse practitioners and/or physicians was interviewed. She was shown the physical examinations of patients C1 and C5. She agreed with the findings described in section I above and stated, "the use of Avatar (the electronic medical record system) only allows two responses to any examination or review of systems, either "normal or abnormal." The system does not enable the examiner to describe specific tests u