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22930

Based on interview and record review, the hospital failed to ensure that Registered Nurses (RNs) consistently implemented the "Fall Prevention and Post Fall Management" policy and procedure, related to fall prevention monitoring, strategies, assessments and documentation, for 2 of 48 sampled patients (23, 24). Patient 23 was identified as a high fall risk patient, there was no documented evidence to show that a reassessment was performed and that fall prevention monitoring and strategies were implemented in accordance with the hospital's policy. Fall risk assessment scores for Patient 24 were not consistently documented nor were they accurately assessed to reflect the patients' fall risk status. In addition, the hospital failed to ensure that Neuraxial (epidural or spinal) Analgesia (injection of an anesthetic into the space outside the dura mater enveloping the spinal cord; sensation is lost in the abdominal, genital and pelvic areas; used in childbirth).

Orders were not followed when RNs in the birth unit did not obtain respiratory rates every hour times 12 hours, then every 2 hours times 6 hours post cesarean section for, 3 of 48 sampled patients (26, 27, 28).

The hospital failed to ensure that Emergency Department (ED) Intake Assessments were completed to include height, weight and fall risk assessment scores in accordance with their "Patient Care Process: Assessment, Planning, Intervention and Evaluation" policy and procedure for, 2 of 48 sampled patients (21, 22).

Lastly, the hospital failed to ensure that pain assessments and reassessments were performed when PRN (as needed) pain medications were not administered in accordance with the hospital's policy, for 2 of 48 sampled patients (25, 29).

Findings:

1. A review of Patient 21's medical record was conducted on 4/23/12 at 1:05 P.M. Patient 21 was admitted to Hospital A's ED with a diagnosis that included abdominal pain, per the Facesheet. According to an ED Intake Assessment Report dated 4/23/12, there was no documented evidence to show that a fall risk assessment was performed nor was the height or weight obtained. Per the same Report, the weight section, height section and the Morse falls risk score sections were "blank."

An interview and joint record review with RN 22 was conducted on 4/23/12 at 1:30 P.M. RN 22 stated that as the Intake RN, it was her responsibility to perform and complete the ED Intake Assessment. She acknowledged that Patient 21's ED Intake Assessment Report was incomplete. She stated that the weight, height and fall risk score should have been documented when the assessment was performed.

An interview with the Administrative Director of the ED (ADED) was conducted on 4/23/12 at 2:55 P.M. The ADED stated that the ED nursing staff were expected to ensure that ED patient records contained complete documentation of assessment findings in accordance with the hospital's policy.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation" with an effective date of 4/12 was conducted on 4/24/12. The policy stipulated that RNs performed focused assessments to assess the immediate needs and safety of the patient which included documentation of orientation of patient to environment, immediate safety needs, allergy, height and weight.

According to the hospital's policy entitled "Assessment and Reassessment Requirements for the Emergency Department," effective date of 5/10, was conducted on 4/24/12. The policy indicated that, "All assessment data will be documented on the intake screen and nursing flowsheet."


2. A review of Patient 22's medical record was conducted on 4/23/12 at 2:22 P.M. Patient 22 was admitted to Hospital A's ED on 4/23/12, with a diagnosis that included chest pain, per the Facesheet. According to an ED Intake Assessment Report dated 4/23/12, there was no documented evidence to show that a fall risk assessment was performed nor was the height or weight obtained. Per the same Report, the weight section, height section and the Morse falls risk score section were "blank."

An interview and joint record review with RN 22 was conducted on 4/23/12 at 2:45 P.M. RN 22 stated that as the Intake RN, it was her responsibility to perform and complete the ED Intake Assessment Report. She acknowledged that Patient 22's ED Intake Assessment Report was incomplete. She stated that the weight, height and fall risk score should have been documented when the assessment was performed.

An interview with the Administrative Director of the ED (ADED) was conducted on 4/23/12 at 2:55 P.M. The ADED stated that the ED nursing staff were expected to ensure that ED patient records contained complete documentation of assessment findings in accordance with the hospital's policy.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation" with an effective date of 4/12 was conducted on 4/24/12. The policy stipulated that RNs performed focused assessments to assess the immediate needs and safety of the patient which included documentation of orientation of patient to environment, immediate safety needs, allergy, height and weight.

According to the hospital's policy entitled "Assessment and Reassessment Requirements for the Emergency Department" effective date of 5/10 was conducted on 4/24/12. The policy indicated that "All assessment data will be documented on the intake screen and nursing flowsheet."

3. A review of Patient 23's medical record was conducted on 4/23/12 at 3:00 P.M. Patient 23 was admitted to Hospital A's ED with a diagnosis that included anasarca (generalized edema with accumulation of serum in subcutaneous connective tissue), per the Facesheet. According to the ED Intake Summary Report dated 4/23/12, Patient 23 had a fall risk score of 25. Per the ED Nursing Flowsheet dated 4/23/12 at 12:30 P.M., the documentation indicated that Patient 23 was a high fall risk but there was no documented evidence to show that fall prevention monitoring or strategies were implemented.

An interview and joint record review with RN 23 was conducted on 4/23/12 at 3:15 P.M. RN 23 stated that during her initial assessment of Patient 23, she assessed the patient as a low risk for falls. However, she stated that during a reassessment of Patient 23, she identified the patient as being a high risk for falls. She acknowledged that she did not document her reassessment findings, fall prevention monitoring and strategies that had been implemented for the patient.

A review of the hospital's policy entitled "Assessment and Reassessment Requirements for the Emergency Department," effective date of 5/10, was conducted. The policy stipulated that reassessments will be documented in the ED record.

An interview with the Administrative Director of the ED (ADED) was conducted on 4/23/12 at 3:25 P.M. The ADED stated that RN 23's documentation should have reflected her reassessment findings regarding Patient 23's change in fall status from low to high. She further stated that Patient 23's medical record should have had documentation to reflect the fall prevention monitoring and strategies that were implemented in accordance with the hospital's policy.

A review of the hospital's "Fall Prevention and Post Fall Management," effective 6/11, was conducted. The policy indicated that RN assessments will include assessing each patient for potential fall risk by using the Morse Fall Risk Scale on admission, every shift, when transferred, a change in condition occurs and following any patient fall. Per the same policy, it instructed the nursing staff to document all assessments, plans and interventions in the patient's medical record.

4. A review of Patient 24's medical record was conducted on 4/25/12 at 8:50 A.M. Patient 24 admitted to Hospital A on 4/23/12, with a diagnosis that included abdominal pain per the Facesheet. According to the History and Physical (H&P) dated 4/23/12, Patient 24's chief complaint was total body spasticity for 3 months. Per the H&P, Patient 24 had a chronic issue with weakness of his left lower extremity and primarily relies on his wheelchair for mobility purposes.

Patient 24's medical record entitled "Medical Surgical View," showed a Morse fall risk score of 85, with no documented evidence to show that fall prevention monitoring and strategies had been implemented.

A review of the hospital's policy entitled, "Fall Prevention and Post Fall Management," effective date of 6/11, was conducted. The policy indicated that when patients were identified as "high-risk" for falls, a Morse Fall Score of greater than 45, additional interventions were implemented on top of the hospital's Universal Fall Prevention Interventions. The Fall Prevention interventions included the following: orient patient to environment, educate patient/family on fall risks and fall reduction/prevention strategies, apply non-skid footwear for all "out of bed" activities, place call light within reach, ensure the signage for "Call, Don't Fall," was posted in the patient room, place the bed in the lowest position and any additional interventions appropriate to the patient's assessments.

An interview and joint record review with RN 24 was conducted on 4/25/12 at 9:18 A.M. RN 24 stated that when a patient was identified as a high fall risk, fall prevention monitoring and strategies were implemented in accordance with the hospital's policy. She acknowledged that Patient 24 was identified as high risk for falls but there was no documented evidence to show that interventions were implemented.

An interview with the surgical acute manager (SAM) was conducted on 4/25/12 at 3:25 P.M. The SAM acknowledged that Patient 24's medical record did not contain documented evidence to show that fall prevention monitoring and strategies were implemented when the patient was identified as a high risk for falls.

5. A review of Patient 25's medical record was conducted on 4/25/12 at 9:38 A.M. Patient 25 was admitted to Hospital A on 3/30/12 with a diagnosis that included a fall, per the Facesheet. According to the History and Physical dated 3/30/12, Patient 25 had a left hip fracture.

Patient 25's Physician's Orders dated 3/30/12 at 1:00 P.M., indicated to administer Dilaudid (a narcotic analgesic also known as hydromorphone hydrochloride used to treat moderate to severe pain), 0.5 mg (milligrams) IV (intravenous) every 2 hours PRN (as needed) for severe pain.

A review of the Medication Administration Record (MAR) dated 4/18/12, indicated that Patient 25 was given 0.5 mg of Hydromorphone hydrochloride intravenously at 11:44 A.M. There was no documented evidence in the medical record to show that a complete pain assessment and reassessment were performed prior to and after the PRN pain medication was administered.

A review of the hospital's policy entitled "Pain Management," effective date of 4/12, was conducted on 4/25/12. The policy stipulated that pain assessments were performed as determined by individual patient status/needs. Per the same policy, it indicated that assessment components may include (for patients able to provide self-report): location, characteristics, frequency, pain level and comfort-function goal. When pain management interventions were implemented such as the administration of PRN medications, reassessments of pain to evaluate the effectiveness of the intervention were on going and documented in the medical record.

An interview with the surgical acute manager (SAM) was conducted on 4/25/12 at 3:25 P.M. The SAM acknowledged that Patient 25's medical record did not contain documented evidence to show that pain assessments and reassessments were performed prior to and after the administration of PRN pain medication. She acknowledged that the nursing staff did not follow the hospital's policy.

6. A review of Patient 26's medical record was conducted on 4/24/12 at 1:05 P.M. Patient 26 was admitted to Hospital A on 4/23/12 with a diagnosis that included "Pregnancy EDC" (estimated date of confinement, the estimated calendar date when the baby will be born), per the Inpatient Facesheet. Per the same Facesheet, a cesarean section (a surgical operation for delivering a child by cutting through the wall of the mother's abdomen) was performed.

Patient 26's Neuraxial Analgesia Orders- Post PACU (post anesthesia care unit) dated 4/23/12, indicated that "Pain and narcotic symptom management per anesthesiologist for 24 hours after neuraxial injection. Then initiate surgeon's orders for pain and narcotic symptom management." Per the same order under monitoring, it instructed the nursing staff to obtain respiratory rates every hour times 12 hours, then every 2 hours times 6 hours post operatively. According to the hospital's Navicare WatchChild Rounding Report, it contained Patient 26's hourly respiratory rates post cesarean section. There was no documented evidence to show that respiratory rates were obtained in accordance with the Neuraxial Analgesia Orders by the RN on 4/23/12 at 9:00 P.M. and 11:00 P.M.

An interview and joint record review with RN 25 was conducted on 4/24/12 at 1:25 P.M. RN 25 stated that the nursing staff obtained respiratory rates in accordance with the patient's neuraxial analgesia orders post cesarian section. She stated that the respiratory rates were obtained hourly times 12 hours, then every 2 hours times 6 hours. She acknowledged that Patient 26's respiratory rates that should have been obtained every 2 hours were missed.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation," effective date of 4/12, was conducted on 4/24/12. The policy indicated that reassessments were performed by the RN each shift, "As patient condition required evaluating response to care, treatment, or services, e.g. post procedure, per physician order, previous abnormal findings, untoward event or change in condition."

An interview with the Director of Maternal Child (DMC) was conducted on 4/24/12 at 2:35 P.M. The DMC stated that respiratory rates should have been obtained hourly or every 2 hours in accordance with the physician's orders.

7. A review of Patient 27's medical record was conducted on 4/24/12 at 1:40 P.M. Patient 27 was admitted to Hospital A on 4/23/12 with a diagnosis that included "Pregnancy EDC" (estimated date of confinement, the estimated calendar date when the baby will be born), per the Inpatient Facesheet. According to an Initial Postpartum Assessment dated 4/23/12, Patient 27 had a cesarean section (a surgical operation for delivering a child by cutting through the wall of the mother's abdomen).

Patient 27's Neuraxial Analgesia Orders - Post PACU (post anesthesia care unit) dated 4/23/12, indicated that "Pain and narcotic symptom management per anesthesiologist for 24 hours after neuraxial injection. Then initiate surgeon's orders for pain and narcotic symptom management." Per the same order under monitoring, it instructed the nursing staff to obtain respiratory rates every hour times 12 hours, then every 2 hours times 6 hours post operatively. According to the hospital's Navicare WatchChild Rounding Report, it contained Patient 27's hourly respiratory rates post cesarean section. There was no documented evidence to show that respiratory rates were obtained in accordance with the Neuraxial Analgesia Orders by the RN on 4/24/12 at 10:00 A.M.

An interview and joint record review with RN 25 was conducted on 4/24/12 at 1:50 P.M. RN 25 stated that the nursing staff obtained respiratory rates in accordance with the patients' neuraxial analgesia orders post cesarian section. She stated that the respiratory rates were obtained hourly times 12 hours, then every 2 hours times 6 hours. She acknowledged that Patient 27's respiratory rate that should have been obtained every 2 hours was missed.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation," effective date of 4/12, was conducted on 4/24/12. The policy indicated that reassessments were performed by the RN each shift, "As patient condition required evaluating response to care, treatment, or services, e.g. post procedure, per physician order, previous abnormal findings, untoward event or change in condition."

An interview with the Director of Maternal Child (DMC) was conducted on 4/24/12 at 2:35 P.M. The DMC stated that respiratory rates should have been obtained hourly or every 2 hours in accordance with the physician's orders.

8. A review of Patient 28's medical record was conducted on 4/24/12 at 1:40 P.M. Patient 28 was admitted to Hospital A on 4/23/12 with a diagnosis that included "Pregnancy EDC" (estimated date of confinement, the estimated calendar date when the baby will be born), per the Inpatient Facesheet. According to an Initial Postpartum Assessment dated 4/23/12, Patient 28 had a cesarean section (a surgical operation for delivering a child by cutting through the wall of the mother's abdomen).

Patient 28's Neuraxial Analgesia Orders- Post PACU (post anesthesia care unit) dated 4/23/12, indicated that "Pain and narcotic symptom management per anesthesiologist for 24 hours after neuraxial injection. Then initiate surgeon's orders for pain and narcotic symptom management." Per the same order under monitoring, it instructed the nursing staff to obtain respiratory rates every hour times 12 hours, then every 2 hours times 6 hours post operatively. According to the hospital's Navicare WatchChild Rounding Report, it contained Patient 28's hourly respiratory rates post cesarean section. There was no documented evidence to show that respiratory rates were obtained in accordance with the Neuraxial Analgesia Orders by the RN on 4/24/12 at 4:00 A.M. and 6:00 A.M.

An interview and joint record review with RN 25 was conducted on 4/24/12 at 2:10 P.M. RN 25 stated that the nursing staff obtained respiratory rates in accordance with the patients' neuraxial analgesia orders post cesarian section. She stated that the respiratory rates were obtained hourly times 12 hours, then every 2 hours times 6 hours. She acknowledged that there was no documented evidence to show that Patient 28's hourly respiratory rates were obtained.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation", effective date of 4/12, was conducted on 4/24/12. The policy indicated that reassessments were performed by the RN each shift, "As patient condition required evaluating response to care, treatment, or services, e.g. post procedure, per physician order, previous abnormal findings, untoward event or change in condition."

An interview with the Director of Maternal Child (DMC) was conducted on 4/24/12 at 2:35 P.M. The DMC stated that respiratory rates should have been obtained hourly or every 2 hours in accordance with the physician's orders.

9. A review of Patient 29's medical record was conducted on 4/25/12 at 1:11 P.M. Patient 29 was admitted to Hospital A with a diagnosis that included left hip fracture status post fall, per the Inpatient Facesheet.

Patient 29's Physician's Orders dated 4/18/12, indicated to administer Oxycodone (a narcotic pain reliever, used to treat severe pain) 5 mg (milligrams) PO (by mouth) every 4 hours PRN (as needed).

A review of the Medication Administration Record (MAR) dated 4/21/12, indicated that Patient 29 was given 5 mg of Oxycodone PO tablet at 7:18 A.M. There was no documented evidence in the medical record to show that a reassessment was performed after the PRN pain medication was administered to Patient 29.

A review of the hospital's policy entitled "Pain Management," effective date of 4/12, was conducted on 4/25/12. The policy stipulated that pain assessments were performed as determined by individual patient status/need. Per the same policy, it indicated that assessment components may include (for patients able to provide self-report): location, characteristics, frequency, pain level and comfort-function goal. When pain management interventions were implemented such as the administration of PRN medications, reassessments of pain to evaluate the effectiveness of the intervention were on going and documented in the medical record.

An interview with the surgical acute manager (SAM) was conducted on 4/25/12 at 3:25 P.M. The SAM acknowledged that Patient 25's medical record did not contain documented evidence to show a pain reassessment was performed after the administration of PRN pain medication. She acknowledged that the nursing staff did not follow the hospital's policy.

Based on interview and document review, the hospital failed to ensure the safe administration of medications at Hospital A, when 2 of 10 patients (21, 31) were administered medications in a manner contrary to the manufacturer's recommendations and Physicians Orders:

RN 21 administered Zofran (an anti-emetic) to Patient 21 in the presence of a contraindication to its use specified by the manufacturer. Patient 21 had documentation of a previous allergic reaction during which she experienced shortness of breath. The hospital's failure placed the patient at risk for fatal allergic reaction as a result of re-exposure.

RN 32 administered Tylenol (an analgesic used to treat mild pain) to Patient 31 during an episode of severe pain. RN 34 administered Vicodin
(a Schedule III opiate analgesic) to Patient 31 during an episode of severe pain. These were preventable medication errors as Patient 31 had Physicians Orders for intravenous Morphine (a Schedule II opiate analgesic reserved for severe pain). The hospital's failure placed Patient 31 at risk for harm from pain as a result of under-treatment with prescribed medications.

Findings:

1. A review of Patient 21's medical record was conducted on 4/23/12 at 1:05 P.M. Patient 21 was admitted to the hospital's ED (Emergency Department) on 4/23/12, with diagnoses that included abdominal pain, per the Facesheet. According to Patient 21's ED Intake Assessment Report dated 4/23/12, a list of allergies and reactions were documented. The Report indicated that Patient 21 was allergic to Zofran and her reaction to the medication was "Shortness of Breath."

Patient 21's ED Physician Record dated 4/23/12 at 10:50 A.M., indicated that the patient had an allergy to Zofran and on the same record it read, "Zofran 4 mg (milligrams) ODT (orally disintegrating tablet)."

According to the ED Nursing Flowsheet, Patient 21 was given Zofran 4 mg ODT on 4/23/12 at 11:20 A.M.

An interview and joint record review with RN 21 was conducted on 4/23/12 at 1:50 P.M. RN 21 stated that prior to the administration of medications, she did not review Patient 21's ED Intake Assessment which contained the patient's allergy status. She stated that when she reviewed the physician's orders for medications, the allergies section of the form was "blank." She stated that Physician 21's handwriting was difficult to read and she did not see that the physician had documented an allergy to Zofran. She further explained that prior to the administration of Zofran, she asked Patient 21 if she had any allergies to medications and the patient did not verbalize any allergies.

An interview and joint record review with the Physician (MD 32) was conducted on 4/23/12 at 2:00 P.M. MD 32 stated that Patient 21 verbalized to him that she had an allergy to Zofran. He acknowledged that he made a mistake when he wrote the order for Zofran 4 mg ODT to be administered to Patient 21.

A review of the hospital's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation", dated 4/12, was conducted. The policy indicated that "Interventions are identified and carried out in a collaborative manner based on assessed patient needs." Per the same policy, under intervention it indicated the safe and effective use of medications.

An interview with the Director of the ED (DED) was conducted on 4/23/12 at 2:10 P.M. The DED stated that the handoff report that occurred between the ED Intake RN and the ED Treatment RN (RN 21) included the review of the ED Intake Assessment. She stated that the ED nurses used a format called APIE (assessment, planning, intervention and evaluation) to communicate patients' care plans. She acknowledged that RN 21 should have reviewed Patient 21's Intake Assessment findings to verify the patient's allergies prior to the administration of medications.


25447

2. Record review was conducted on 4/25/12, and found that Patient 31 was admitted to Hospital A on 4/19/12, with a diagnosis of chest pain.

On 4/25/12, a review of Patient 31's record showed she had a Physicians Order, dated 4/20/12 at 3:45 P.M., for Morphine Sulfate 2 milligrams IV (intravenously) every three hours as needed for severe pain. Morphine Sulfate is a Schedule II opiate analgesic reserved for severe pain.

On 4/25/12, during an interview and policy review, the MSOP (Medication Safety Officer, Pharmacist) demonstrated in the hospital's Pain Management policy, dated 4/12, where pain levels were defined. According to the facility's policy, pain levels described as being between "7 and 10" were considered to be "severe pain."

A review of Patient 31's pain summary report, dated 4/21/12 at 12:00 P.M., showed Patient 31 had a Numerical Rating Scale (pain level) of "7" on a scale of 1 to 10, with 10 being the "the worst pain imaginable." The nurse gave Patient 31 two Tylenol (a mild pain reliever and a fever reducer) tablets, instead of morphine sulfate IV, on 4/21/12 at 11:21 A.M.

On 4/25/12 at 2:50 P.M. in an interview, RN 31 said that the hospital had done an investigation into the apparent medication error discovered by the surveyor. RN 31 said she spoke to RN 32, the night nurse who administered the Tylenol and she said, "Yes, this is a medication error." RN 31 explained that RN 32 said that the patient refused the tylenol, but there was no documentation in the patient record, and RN 32 did not clarify the pain order with the doctor. RN 31 elaborated that the Tylenol was not ordered for pain and for the nurse to give it under the circumstances was outside of RN 32's scope of practice.


22479

3. Patient 31 was admitted to Hospital A on 4/19/12, with a diagnosis of chest pain according to the Admission Facesheet. A review of Patient 31's medical record was conducted on 4/23/12 at 2:40 P.M. According to Patient 31's History and Physical, she was admitted with sub-sternal pressure type chest pain ranging in intensity from a pain scale of 5 to 7 out of 10 (10 being most severe).

A review of the hospital's policy and procedure entitled "Pain Management," dated 4/12, under "Attachment F: Pain Tools for Patients Able to Provide a Self-Report," the self-report tool Numeric Rating Scale (NRS) is described as a "Scale, using numbers from 0-10, in which each number refers to a different Pain Level, such that "0" represents "No Pain" to a rating of "10" which represents "the worst possible pain." The policy further indicated that the Verbal Descriptor Scale (VDS) for the Self-Report Pain Tool was as follows:

Severe Pain (Pain Level 7-10)
Moderate Pain (Pain Level 4-6)
Mild Pain (Pain Level 1-3)
No Pain (Pain Level 0)

According to Patient 31's Pain Assessment in her Electronic Medical record (EMR) on 4/22/12 at 8:01 P.M., Patient 31 reported to her nurse (RN 37) that she was experiencing pain at a scale of 8/10. The Physician's Order Sheet indicated that Morphine Sulfate (an opium derivative for the relief of pain) 2 mg (milligrams) IV (intravenous) was to be administered Q3 (every three hours) prn (as required) for severe pain. Hydrocodone/acetaminophen (a semi-synthetic opioid pain reliever brand name of Vicodin) 5-500 1 TAB (tablet) PO (by mouth) Q4 (every 4 hours) prn (as required) was to be administered for moderate pain.

It was documented on the Medication Administration Record that RN 37 administered one tablet of Hydrocodone/acetaminophen 5-500 to Patient 31 at 8:01 P.M. even though Patient 31 had reported her pain intensity to be an 8 (severe).

An interview was conducted with the Registered Nurse Manager (RN 31) on 4/26/12 at 3:00 P.M. RN 31 acknowledged that, according to the physician's orders, RN 37 should have administered the Morphine 2 mg. IV instead of the Vicodin tablet by mouth. RN 31 further acknowledged that RN 37 was not following the physician's medication orders. RN 37 did not administer the proper medication when Patient 31 was experiencing severe pain.

Based on interview, document and record review Hospital A failed to ensure that 1 of 48 sampled patient's (Patient 20) medical record contained an adequate and complete History and Physical.

Findings:

Patient 20 was admitted to Hospital A on 4/24/12 with a diagnosis of recurrent syncope (temporary loss of consciousness caused by a fall in blood pressure) according to the Admission Facesheet. A review of Patient 20's medical record was conducted on 4/25/12 at 9:30 A.M. According to an Operative Report, dated 4/24/12, Patient 20 underwent a cardiac catheterization and implantation of a loop recorder (an implantable patient activated heart monitoring system).

A review of the hospital's policy and procedure entitled "Physician Documentation Requirements", dated 1/12, indicated that "A medical history and physical should consist of, however is not limited to : the patient's chief complaint, History of Present Illness, Past Medical History, any prior surgeries, OB/GYN history. Allergies, Current Medications, ETOH/Smoking History, Exercise/Functional level, Occupational and Environmental History, Social History, Family History, Review of Systems, Physical Examination, Lab results, Assessment and Plan...There must be a complete medical history and physical performed no more than 30 days before or 24 hours after admission for each patient by a physician..."

On 4/25/12 at 10:10 A.M. a concurrent interview and review of Patient 20's History and Physical was conducted with the Medical Director of Quality (MDQ 1). After review of the patient's History and Physical, dated 4/23/12, MDQ 1 acknowledged that Patient 20's History and Physical was not adequate for a patient having a procedure with anesthesia. MDQ 1 stated that the History and Physical was incomplete because it did not contain an examination of the patient's heart and lungs or documentation of the condition of the patient's airway. Also, there was no mention of the patient's allergies or functional level. There was no review of systems and the physical examination was lacking completion and was not consistent with what was documented regarding Patient 20 elsewhere in the chart such as no mention of the patient's previous cerebral vascular accident (stroke) or her severe expressive aphasia (expression by speech or writing is severely impaired).