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Based on review of medical records, medical staff bylaws, rules and regulations, patient and staff interviews, it was determined the hospital failed to comply with the provisions of Medical Staff Services, as evidenced by:

A0358: failure of the medical staff to enforce its bylaws, rules and regulations by:

1. failing to ensure Pt #1 had a physical exam completed and documented; and

2. failing to ensure physical examinations were completed, documented and dictated for 10 of 11 patients, who had an internal medicine consultation with Provider #2; (Pt #'s 4, 5, 6, 8, 11, 12, 16, 17, 18, and 22).

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Medical Staff.

Based on review of medical records, medical staff bylaws, rules and regulations, patient and staff interviews, it was determined the hospital failed to enforce its bylaws, rules and regulations as evidenced by:

1. failing to ensure Pt #1 had a physical exam completed and documented; and

2. failing to ensure physical examinations were completed, documented and dictated for 10 of 11 patients, who had an internal medicine consultation with Provider #2; (Pt #'s 4, 5, 6, 8, 11, 12, 16, 17, 18, and 22).

Findings include:

The Medical Staff Bylaws, Rules and Regulations revised 08/30/12, required: "...Admission...The physical examination shall be performed and documented and dictated within 24 hours of admission by either the admitting physician and/or A.H.P. or his/her designee...b. A complete neurological screening will be performed on each patient, which addresses all twelve cranial nerves and the method of testing...."

1. Patient #1 was admitted on 01/08/14 and was emergently transferred to an acute care hospital on 01/16/14. The medical record contained the following order: "...01/08/14 at 2355...H & P (history and physical): Consult with Internal Medicine to evaluate Medical Status and follow up as needed, or to rule out medical reasons for psychiatric illness...."

Physician #2 evaluated Pt #1 on 01/09/14 at 12 noon. The medical record contained a form titled History and Physical Consultation, documented by Physician #2. The area titled "Examination" contained "Difficult to arouse for complete exam." The examination parameters were left blank. The area titled "Neurologic" contained "Unable to complete." The Neurologic parameters were left blank.

Patient #1's medical record did not contain a documented complete physical or Neurologic examination. On 01/17/14 at 1530 hours personnel #2 confirmed the medical record did not contain a documented physical and Neurologic examination by Provider #2.

2. The following patient medical records (Pt #'s 4, 5, 6, 8, 11, 12, 16, 17, 18, and 22) contained forms titled History and Physical Consultation documented by Provider #2.

The forms contained areas titled "Examination" and "Neurologic." The "Examination" area required the following information to be documented: "...General Appearance; Vital Signs; Eyes; Ears; Nose Mouth; Throat; Neck; Respiratory; Cardiovascular; Chest (breasts); Gastrointestinal (Abdomen); Genitourinary (Male/Female); Lymphatic; Musculoskeletal; Skin; Psychiatric...." The area titled "Neurologic" area required the following information to be documented: "...Neurologic...CN (cranial nerve) I; CN II Able to read a printed page; CN III Able to move eyes upward and outward; CN IV Able to move eyes medially (downward at nose); CN V Able to clench teeth and feels touch on front of head; CN VI Able to move eyes to either side; CN VII Able to lift both eyebrows; CN VIII Able to hear finger rubs in both ears; CN IX Gag reflex tested and present; CN X Able to lift palate when saying "Ah"; CN XI Able to shrug shoulders equally; CN XII Able to stick tongue out straight.

Review of the History and Physical Consultation forms for Pt #'s 4, 5, 6, 8, 11, 12, 16, 17, 18, and 22 revealed the Examination and Neurologic areas contained dashes "--" .

All forms contained vitals signs and the following documentation was included for all the Neurologic documentation for "Motor Strength and Coordination: "...5/5 intact...(coordination) intact (reflexes) intact N (normal) DTR (deep tendon reflex)...."

Interviews were conducted with Patient #'s 4, 5, and 6. The interviews took place on 01/23/14 at 1030 hours. The patients were interviewed individually. All of the patients (4, 5, and 6) were asked about the physical examination conducted by Provider #2. All remembered and offered that Provider #2 used a stethoscope on the chest or upper back area.

All patients (4, 5, and 6) denied Provider #2 looked in their ears, mouth, palpated the abdomen, checked eyes with a light, tested arm or leg strength, or tested reflexes (They were asked if the Provider used something on their knee to make their leg jerk).

The H & P Consultation Forms for Pt #'s 4,5, 6, 8, 11, 12, 16, 17, 18, and 22 were hand written and these patients did not have dictated H & P's. Personnel #2 confirmed on 01/23/14, that these patients did not have dictated H & P reports.

Provider #2 was interviewed on 01/23/14 around 1330 hours. She was asked what the "--" (dashes) meant on the History and Physical Consultation form. She explained that meant the exam was normal and that's how she documents normal. The Surveyors explained that 3 of 3 patients interviewed could remember her listening to the chest or back and none of the patients remembered any other exam conducted by Provider #2. None could remember testing or arm or leg strength, or testing of reflexes.
Provider #2 confirmed that she doesn't always dictate the H & P's.