HospitalInspections.org

Based on review of medical staff bylaws, medical record review, and staff interview, the hospital failed to ensure medical record entries were complete by failing to ensure care provided by a physician was documented in 1 of 3 Labor and Delivery patients (Patient #11).

The findings include:

Review of Medical Staff Bylaws, Revised March 19, 2013, revealed, "...DUTIES AND RESPONSIBILITIES A. Each appointee to the Medical Staff, regardless of category, shall:... 4. prepare and complete as defined by policy the medical and other required records for all patients he/she admits or in any way provides care to in the Hospital, including but not limited to: ... iii The history and physical examination and the updated examination, must be completed and documented by a physician (MD/DO) or other qualified licensed individual in accordance with state and federal laws and Medical Staff Policies and Procedures..."

Medical record review of a Nursing Note written on Patient #11, by Registered Nurse (RN) #1 on 03/11/2016 at 1826, revealed, "1716- pt (patient) received to labor and delivery via rescue squad pt presents stating that she has had foul smelling brown discharge for two weeks. Pt assisted to room 301. pt assisted into gown and onto bed monitors applied to abd (abdomen) and FHR (Fetal Heart Rate) obtained. Plan of care discussed with the pt... 1733- (MD #1) into the pt room perineal exam done swabs done and pt refused speculum exam at this time. SVE (Sterile Vaginal Exam) per (MD #1) pt is closed thick and long. (MD #1) discussed plan of care with the pt. Pt voices no further needs or questions at this time." Review could reveal no evidence of any documentation of patient examination by MD #1.

Staff interview with Administrative Staff #1, conducted on 07/21/2016 at 1139, revealed the expectation for practitioner is to document assessments performed, and hospital policy was not followed. NC00118337