HospitalInspections.org

Based on review of the medical record, staff interview and review of the medical staff rules and regulations it was determined the facility failed to ensure an updated examination was completed and documented prior to a surgical procedure for one (#3) of ten patient's sampled.

Findings include:

Patient #3 was admitted on 10/14/2013 for a surgical procedure. Review of the record revealed a pre-operative H&P (History & Physical) was performed on 10/3/2013 (within 30 days of the procedure). On the date of admission, 10/14/2013, review of the record revealed no evidence an updated examination was completed and documented prior to the procedure.

Review of the medical staff rules and regulations stated if the H&P is performed within 30 days of the surgical procedure that the physician will examine the patient for any changes to the patient since the H&P was performed.

Interview with the Manager of Risk Management on 10/8/2014 at approximately 4:15 p.m. confirmed the findings.