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Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure there was a process in place for staff to follow to promptly notify the patient's family member or representative of choice and their own physician when admitted to the hospital for 10 of 17 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review on April 14, 2016, of the facility policy "Patients' Rights and Responsibilities," revision date September 15, 2015, revealed "Policy: Hospital Administration will introduce and make available to patients and parents/guardians of neonatal, child, and adolescent patients the statement 'Patients' Rights and Responsibilities'. The hospital's goal is to support and protect the rights of patients and parents/guardians of patients who are minors. ... Patient's Rights ... The right to be informed of rights as a patient at the earliest possible moment in the course of a patient's hospitalization and to have a family member and/or physician of choice notified of your hospitalization. ..."

The facility policy did not provide for prompt notification of the family member or representative of choice and physician when the patient was admitted to the hospital.

Review of medical records on April 14, 2016, revealed the following:

MR1 was admitted on April 10, 2016, for fever. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR2 was admitted on April 13, 2016, for diarrhea. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR3 was admitted on March 9, 2016, for a cerebrovascular accident. The patient was discharged on March 10, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR4 was admitted on March 8, 2016, for fever. The patient was discharged on March 10, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR5 was admitted on February 27, 2016, for seizure activity, epilepsy. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR7 was admitted on April 6, 2016, for shortness of breath and respiratory failure. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR8 was admitted on April 4, 2016, for weakness and lung disease. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR9 was admitted on April 4, 2016, for neck swelling-cellulitis. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR10 was admitted on March 29, 2016, for heart failure and shortness of breath. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR11 was admitted on March 13, 2016, for heart failure. The patient was discharged on March 15, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

An interview on April 14, 2016, at 12:30 PM with EMP1 confirmed there was not a defined field in the electronic medical record to document the notification of the family member or representative and primary care physician. EMP1 confirmed there was no policy for staff to follow to ensure prompt notification of the family member or representative and primary care physician. EMP1 confirmed there was no documentation in MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR9, MR10, and MR11 the family member or representative and primary care physician were notified.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure a physician order was obtained prior to the delivery of services for one of one occurrence.

Findings include:

Review on April 13, 2016, of the facility policy "Plan for Provision of Care," last revision date September 25, 2015, revealed "Abington Hospital Plan for the Provision of Patient Care Services 2015 - 2016 Preamble Abington Hospital is committed to the provision of patient care services that provide for the prevention of illness, maintenance of wellness, and treatment of the ill, injured and disabled. ... Standards of Patient Care Within Abington Hospital, the standards of patient care exist to ensure patients receive the right procedures, treatments, and care performed correctly and with competence under the order of physician or advance practice providers. ... "

Review on April 13, 2016, of facility documents revealed EMP3 performed a test on February 16, 2016, on a child in the Emergency Trauma Center (ETC) without an order from a physician or advance practice provider.

Interview conducted on April 13, 2016, at 1:07 PM with EMP3 confirmed EMP3 performed a test on February 16, 2016, on a child in the ETC without an order from a physician or advance practice provider.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure there was a medical record for each patient evaluated and treated in Abington Memorial Emergency Trauma Center (ETC) for one of one occurrence.

Findings include:

Review on April 13, 2016, of the facility policy "Medical Record Content," last revision date August 2015 revealed "Purpose: To ensure that the medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately and facilitate continuity of care among health care providers. Policy: Each inpatient Medical Record shall contain information in accordance with JCAHO [the Joint Commission] standards. Each outpatient record shall contain similar items as appropriate. ... Procedure: Each patient medical record shall contain at least the following: 1. The patient's name, address, date of birth and the name of any legally authorized representative. 2. The patient's legal status, for patient receiving mental health services. 3. Emergency care provided to the patient prior to arrival, if any; 4. The record and findings of the patient's assessment. 5. A statement of the conclusions or impressions drawn from the medical history and physical examination. 6. The diagnosis or diagnostic impression. 7. The reason(s) for admission or treatment. 8. The goals of treatment and the treatment plan. 9. Evidence of known advance directives. 10. Evidence of informed consent for procedures and treatments for which informed consent is required by organization policy. 11. Diagnostic and therapeutic orders, if any. 12. All diagnostic and therapeutic procedures and test performed and the results. ... 21. Every medication dispensed to or prescribed for an ambulatory patient or an inpatient on discharge. ... "

Review on April 13, 2016, of the facility documents revealed an employee requested a professional courtesy examination on February 16, 2016, for their child and a prescription for their child. The child was not registered in the ETC. A medical record was never established.

Interview conducted on April 13, 2016, at 11:11 AM with EMP2 revealed an employee's child was treated in the ETC. A medical record was not completed for the care and services provided to the child.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure there was a process in place for staff to follow to promptly notify the patient's family member or representative of choice and their own physician when admitted to the hospital for 10 of 17 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review on April 14, 2016, of the facility policy "Patients' Rights and Responsibilities," revision date September 15, 2015, revealed "Policy: Hospital Administration will introduce and make available to patients and parents/guardians of neonatal, child, and adolescent patients the statement 'Patients' Rights and Responsibilities'. The hospital's goal is to support and protect the rights of patients and parents/guardians of patients who are minors. ... Patient's Rights ... The right to be informed of rights as a patient at the earliest possible moment in the course of a patient's hospitalization and to have a family member and/or physician of choice notified of your hospitalization. ..."

The facility policy did not provide for prompt notification of the family member or representative of choice and physician when the patient was admitted to the hospital.

Review of medical records on April 14, 2016, revealed the following:

MR1 was admitted on April 10, 2016, for fever. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR2 was admitted on April 13, 2016, for diarrhea. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR3 was admitted on March 9, 2016, for a cerebrovascular accident. The patient was discharged on March 10, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR4 was admitted on March 8, 2016, for fever. The patient was discharged on March 10, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR5 was admitted on February 27, 2016, for seizure activity, epilepsy. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR7 was admitted on April 6, 2016, for shortness of breath and respiratory failure. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR8 was admitted on April 4, 2016, for weakness and lung disease. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR9 was admitted on April 4, 2016, for neck swelling-cellulitis. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR10 was admitted on March 29, 2016, for heart failure and shortness of breath. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

MR11 was admitted on March 13, 2016, for heart failure. The patient was discharged on March 15, 2016. There was no documentation a family member or representative of choice and the primary care physician were notified promptly of the patient's admission.

An interview on April 14, 2016, at 12:30 PM with EMP1 confirmed there was not a defined field in the electronic medical record to document the notification of the family member or representative and primary care physician. EMP1 confirmed there was no policy for staff to follow to ensure prompt notification of the family member or representative and primary care physician. EMP1 confirmed there was no documentation in MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR9, MR10, and MR11 the family member or representative and primary care physician were notified.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure a physician order was obtained prior to the delivery of services for one of one occurrence.

Findings include:

Review on April 13, 2016, of the facility policy "Plan for Provision of Care," last revision date September 25, 2015, revealed "Abington Hospital Plan for the Provision of Patient Care Services 2015 - 2016 Preamble Abington Hospital is committed to the provision of patient care services that provide for the prevention of illness, maintenance of wellness, and treatment of the ill, injured and disabled. ... Standards of Patient Care Within Abington Hospital, the standards of patient care exist to ensure patients receive the right procedures, treatments, and care performed correctly and with competence under the order of physician or advance practice providers. ... "

Review on April 13, 2016, of facility documents revealed EMP3 performed a test on February 16, 2016, on a child in the Emergency Trauma Center (ETC) without an order from a physician or advance practice provider.

Interview conducted on April 13, 2016, at 1:07 PM with EMP3 confirmed EMP3 performed a test on February 16, 2016, on a child in the ETC without an order from a physician or advance practice provider.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure there was a medical record for each patient evaluated and treated in Abington Memorial Emergency Trauma Center (ETC) for one of one occurrence.

Findings include:

Review on April 13, 2016, of the facility policy "Medical Record Content," last revision date August 2015 revealed "Purpose: To ensure that the medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately and facilitate continuity of care among health care providers. Policy: Each inpatient Medical Record shall contain information in accordance with JCAHO [the Joint Commission] standards. Each outpatient record shall contain similar items as appropriate. ... Procedure: Each patient medical record shall contain at least the following: 1. The patient's name, address, date of birth and the name of any legally authorized representative. 2. The patient's legal status, for patient receiving mental health services. 3. Emergency care provided to the patient prior to arrival, if any; 4. The record and findings of the patient's assessment. 5. A statement of the conclusions or impressions drawn from the medical history and physical examination. 6. The diagnosis or diagnostic impression. 7. The reason(s) for admission or treatment. 8. The goals of treatment and the treatment plan. 9. Evidence of known advance directives. 10. Evidence of informed consent for procedures and treatments for which informed consent is required by organization policy. 11. Diagnostic and therapeutic orders, if any. 12. All diagnostic and therapeutic procedures and test performed and the results. ... 21. Every medication dispensed to or prescribed for an ambulatory patient or an inpatient on discharge. ... "

Review on April 13, 2016, of the facility documents revealed an employee requested a professional courtesy examination on February 16, 2016, for their child and a prescription for their child. The child was not registered in the ETC. A medical record was never established.

Interview conducted on April 13, 2016, at 11:11 AM with EMP2 revealed an employee's child was treated in the ETC. A medical record was not completed for the care and services provided to the child.