HospitalInspections.org

Based on review of medical record and policy and interview with staff this requirement was not met:

Findings:

a: Upon review of medical record of patient #1, 67 year old male admitted to Edinburg Regional Medical Center, 1102 West Trenton Rd, Edinburg, TX on August 14, 2015 it was obsercved that the history and physical on this patient was not completed and in the patient record within 24 hours. The history and physical was transcribed to the record on August 16, 2015 at 2:57am (31hrs and 39 minutes ) after the patient was admitted to the unit on August 14, 2015 at 7:18pm.

b. On review of South Texas Health System (STHS) Patient assessment and Reassement policy PC.1010 it states on page 11 of 42 under Nursing Medical-Surgical " The patients History and physical examination .........are completed within twenty-four (24) hours of admission....."

c. Interviewed staff #2, Director of Medical Surgical who also reviewed medical record at 1:50pm on September 18, 2015 in the administration conference room who also witnessed that the physician history and physical examination was dictated on August 15, 2015 at 9:01pm and transcribed on August 16, 2015 at 2:57am. The H&P was not placed in the patients record within 24 hours of admission.