HospitalInspections.org

Based on review of facility policy and procedures, review of medical records (MR) review of documents and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to their physician of the hospital admission for four of four medical records reviewed for physician notification (MR1, MR3, MR4, MR5).

Findings include:

Review on January 29, 2018, of facility policy and procedures "Patient Rights and Responsibilities," revised July 2017 revealed, " ... 1. Each patient upon admission to their assigned room, receives a copy of the Patient Rights and Responsibilities brochure in the inpatient folder."

Review on January 29, 2018, of facility document "Patient Rights and Responsibilities," brochure, dated 2011, revealed " ... You have the right to: Have a family member, another person that you choose, or your doctor notified when you are admitted to the hospital."

Review on January 29, 2018, of facility document "Primary Care Provider Notification Report," dated November 8, 2017, revealed documentation of Primary Care Provider (PCP) notification for twelve patients who were admitted to the facility between October 31, 2017, and November 8, 2017.

Review on January 30, 2018, of MR1, MR3, MR4, and MR5 revealed no documentation whether the patient requested or declined notification to the patient's own physician, including the date, time and method of notification if the patient did request the PCP to be notified.

Interview with EMP1 on January 29, 2018, at 1:30 PM confirmed the facility automatically generates notification to the patient's PCP of admission to the hospital without documenting in the medical record of whether the patient requested or declined notification to the patient's own physician, including the date, time and method of notification if the patient did request the PCP to be notified.

Interview with EMP2 on January 30, 2018, at 10:00 AM confirmed there was no documentation in MR1, MR3, MR4 and MR5 whether the patient requested or declined notification to the patient's own PCP.