HospitalInspections.org

Based on document review and interview, the governing board failed to ensure that the medical staff followed the facility policy related to the completion of a psychiatric evaluation within 60 hours of admission for 1 of 5 closed medical records reviewed, Patient #10.

Findings Include:
1. The policy Timeliness of Medical Record Completion, policy number III - A.9, last approved/issued 5/2015 indicated the psychiatric evaluation was to be completed within 60 hours of admission.

2. Review of the medical record for patient #10 indicated the patient was admitted on 11/30/15 and the psychiatric evaluation was done and dictated on 12/11/15.

3. At 1:00 PM on 9/28/16 interview with staff member #52, the regional quality/risk staff member, confirmed that the psychiatric evaluation for patient #10 was not done until 12/11/15 which was not per facility policy and that it was unknown why there was such a delay in providing this service to the patient.