HospitalInspections.org

Based on a review of hospital polices, medical staff bylaws, medical record review and staff and patient interview. It was determined that the Medical Staff failed to follow Rules and Regulations for the required time frames for documenting patient's history and physical examination information. This deficient practice poses a risk to patient health and safety in that the patient's assessments are not documented to ensure continuity of care as demonstrated by the failure of the medical staff to document patient's history and physical examination information within 24 hours of admission for 8 out of 13 medical records. Patient #5,6,7,8,9,10, 11, and 12.

Findings include:

Policy titled "Timeliness of Medical Record Completion" (PolicyStat ID: 9474113) revealed: "...2. History and Physical Exams, a. The patient's history and physical, including updates is completed no more than 30 days before or 24 hours after admission. The Physical examination will be performed by a qualified practitioner. If completed by a Nurse Practitioner, The Medical doctor will co-sign...."

Policy titled "Medical Consultation/Physical Examinations" (PolicyStat ID: 8808712) revealed: "...A medical consultation will be provided to the psychiatric patient within 24 hours after admission...."

A review of Medical staff Bylaws ( last Revised: 04/2021) revealed: "...11.4 1. A medical history and physical examination must be completed and documented by a licensed practitioner who is credentialed and privileged by the Medical Staff for each patient no more than seven (7) days before or twenty-four (24) hours after admission or registration...."

A review of medical records for Patient # 5 admitted on 05/11/2021; Patient #6 admitted on 05/12/2021; Patient #7 admitted on 05/13/2021; Patient #8 admitted on 05/13/2021; Patient #9 admitted on 05/13/2021; Patient #10 admitted on 05/13/2021; Patient #11 admitted on 05/15/2021; Patient #12 admitted on 05/17/2021 revealed no documented history and physical exams in the medical record on 05/18/2021 at 7:00 p.m.

Employee #1, Employee #4 and Employee #5 confirmed during separate interviews conducted on 05/18/2021 that the patients #5 through 12 did not have History and Physical exams because of change in medical providers.

Patient #5, Patient # 6, Patient #7, Patient #10, Patient #11, Patient #12 and Patient #13 confirmed during separate interviews they did not have a History and Physical examination and have not been seen by Provider #2 during their current hospitalization.