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Based on record review and interview, Patient #1's medical record failed to have a consultative Cardiologist physical evaluation assessment documented in the patient's electronic medical record that was completed on 10/4/17. Patient #1 then alleged an allegation against the Cardiologist following his physical assessment.

Findings included:

Review of Patient #1's allegation made on 10/4/17 to the facility's nurse house supervisor stated that she was touched inappropriately by a man that came and told her that nothing was wrong with her heart, grabbed her breast, and grabbed her intimate areas. The man was described as a white, tall, older man with blue eyes, dressed in a white lab coat. This description potentially met the description of Cardiologist A and B (except that neither Cardiologist had blue eyes according to their credentialing records); but who both assessed Patient #1 on 10/4/17 according to review of the facility's video surveillance and interviews.

Observation and review of the facility's video surveillance for 10/4/17 revealed at 08:55 AM Cardiologist-B went in to Patient #1's room and left at 09:01 AM.

Review of Patient #1's electronic medical record (EMR) revealed there was no documentation of Cardiologist B's physical assessment dated 10/4/17.

During an interview with Cardiologist B on 10/18/17 at 09:22 AM stated that he remembered Patient #1 due to her explicit history; and on 10/4/17 he completed a consultative cardiology assessment. Cardiologist B stated during his assessment on 10/4/17 Patient #1 requested an order for a mammogram because she further specified that she had "bumps on her upper left side breast." Cardiologist B stated that he assessed her based on her concerns expressed and that he; "touched that area with fingers and did not feel anything there." Cardiologist B stated he then told Patient #1 that at her age, she should have a mammogram and would need to talk to her Primary Care Physician for additional follow-up and orders. Cardiologist B confirmed he did not document in Patient #1's EMR his consultative cardiology assessment or the physical breast examination completed.