HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt. #2) OB (obstetric) patients, the Hospital failed to ensure an assessment of the patient was completed and documented in the clinical record.

Findings include:

1. The Hospital's policy titled, "Physician Documentation Expectation for OB Triage (no date)" was reviewed on 12/16/2020 and required, "Low acuity OB triage: Physician documentation should include a brief Summary Note of the interaction and plan of care."

2. The clinical record of Pt. #2 was reviewed on 12/14/2020. Pt. #2 presented to the OB department on 11/21/2019 at 10:43 AM. Pt. #2 was reporting constant mid and low abdominal cramping for about one hour.

- A nurse's note (E#3), dated 11/21/2019 at 11:17 AM, included, "Examined by Care Provider: [MD#1]"

- A Physician's order (MD#1), dated 11/21/2019 at 11:50 AM, included, "Discharge Order - Routine." The clinical record lacked a physician's assessment or plan.

3. The Obstetrician (MD#1) who treated Pt. #2 was interviewed, via telephone, on 12/15/2020 at 8:35 AM. MD#1 stated, "Everything was normal, and I did not identify any imminent signs of delivery. My assessment was the same as the nurses, so I didn't write a note in the chart. Looking back, I should have written a note of my assessment and discussion of the plan with the patient."