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Based on record review and interview, the facility failed to insure the medical staff enforced the rules and regulations of the facility for 3 of 10 sampled patient records (#2, 8 & 9).

Finding:

Review of patients #2, #8 and #9's records failed to document consultations were provided to patients when ordered within 24 hours as required by hospital policies.

1. Patient #2's record reflected an order for a Neurologist consultation on 06/01/2011 at 11:30 a.m. The review failed to document that a Neurologist consultation occurred or that the neurologist saw the patient.

2. Patient #8's record reflected an order for a Psychiatric consultation on 06/19/2011 at 10:40 a.m. The review failed to document that a Psychiatric consultation occurred or that the psychiatrist saw the patient.

3. Patient #9's record reflected an order for a Psychiatric consultation on 06/19/2011 at 10:40 a.m. The review failed to document that a Psychiatric consultation occurred or that the psychiatrist saw the patient.

Interview on 06/21/2011 at 3:30 p.m. with Risk Manager confirmed the records were complete at the time of review.