HospitalInspections.org

Based on record review, facility document review and staff interview, it was determined the facility failed to ensure a History and Physical was documented in the medical record, no more than 30 days before or 24 hours after admission, for 1 (#12) of 12 sampled patients. This practice does not ensure vital patient information is available to all members of the health care team (CCR# 2012008954).

Findings include:

During review of the medical record of patient #12 on 9/28/12 at approximately 1:30 p.m., it was noted that there was no History and Physical in the record. The patient had been admitted to the facility on 9/24/12 with pneumonia, hypertension and diabetes. Review of the facility's Medical Staff Rules and Regulations, last reviewed on 3/12 revealed that a History and Physical be entered into the medical record within 24 hours of admission. The unit manager was present during the record review. She confirmed there was no History and Physical in the medical record and none had been dictated.

Based on clinical record review, staff interview and policy review it was determined the staff did not verify and document the allergies for 1 (#3) of 10 sample patients, resulting in the patient receiving a prescription for medication they were allergic to. The continued use of this practice could result in patients receiving medications they are allergic to and lead to negative outcomes (CCR# 2012008826).

Findings include:


A review of patient #3's clinical record revealed she presented to the emergency department on 6/20/12 at 9:30 a.m. The patients allergies were listed as no known allergies (NKA) on the triage documentation. A review of the emergency medical services (EMS) report revealed allergies to codeine sulfate. Further review of the patients clinical record revealed the patients clinical record had been merged with another patients record. The patients true allergy was to ultram. There was no documentation of the patients allergies being confirmed by the nursing staff and the patient was discharged with a prescription for ultram. This was confirmed with the Director of Quality and Patient safety during record review on 9/27/12 at approximately 9:30 a.m.

Based on clinical record review, facility document review and staff interview it was determined the facility did not ensure that a History and Physical was placed in 1 (#12) of 10 sample patient's medical record within 24 hours after admission. The continued use of this practice could result in inaccurate patient information and treatment (CCR# 2012008952).

Findings include:

During review of the medical record of patient #12 on 9/28/12 at approximately 1:30 p.m., it was noted that there was no History and Physical in the record. The patient had been admitted to the facility on 9/24/12 with pneumonia, hypertension and diabetes. Review of the facility's Medical Staff Rules and Regulations, last reviewed on 3/12 requires that a History and Physical be entered into the medical record within 24 hours of admission. The unit manager was present during the record review. She confirmed there was no History and Physical in the medical record and none had been dictated.

Based on review of facility documents, clinical record and staff interview it was determined the facility did not ensure a discharge note or summary was completed for 1 (#3) of 10 sample patients. The continued use of this practice does not ensure an accurate and complete medical record is maintained for the patient (CCR# 2012008826).

Findings include:

During review of the medical record of patient #3 on 9/26/12 at approximately 2:00 p.m., it was noted that there was no discharge note or discharge summary in the record. This was also reviewed by the Director of Patient Safety and Quality. The patient had been admitted to the facility on 6/20/12 with pleural effusion, anemia in neoplastic disease, abdominal swelling,ascites and peritoneal carcinomatosis.

Review of the facility's Medical Staff Rules and Regulations, last reviewed on 3/12 revealed all discharge summaries shall be authenticated by the attending physician and completed within 15 days of discharge.

An interview was conducted on 9/28/12 at 11:20 a.m., with the attending physician. The attending physician confirmed he had not dictated a discharge summary or a final disposition note.