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MILDRED MITCHELL-BATEMAN HOSPITAL
MEDICAL STAFF BYLAWS
Tag No.: A0353
Based on document review and staff interview it was determined the medical staff failed to follow their own medical staff by-laws, rules and regulations; by not ensuring a medical history and physical examination (H&P) was completed and documented in the medical record of one (1) (Patient#1) out of ten (10) medical records reviewed within twenty-four (24) hours of the patient's admission to the facility. This has the potential to negatively impact the care given to all patients who are admitted to the facility for treatment.
Findings include:
1. Review of Patient #1's medical record revealed the patient was admitted to the facility on 09/15/17 at 12:10 p.m. The nurse practioner conducted the admission H&P on 09/16/17 at 2:45 p.m. The H&P was conducted twenty-six
(26) hours and thirty-five (35) minutes after the patient's admission to the facility.
2. Review of the medical staff by-laws, "Medical Record Requirements for the Medical Staff" states, in part, "A complete medical H&P examination must be written and dictated by the Family Practice physician (or designee) within 24 hours after admission. The minimum requirement for content of the medical H&P examination is reflected in the most current template as approved by the medical staff ".
3. An interview was conducted with the Nurse Practioner on 10/31/17 at 11:00 a.m. She stated, "When a patient comes to the facility they are seen by the admission nurse who will put a referral in the computer for a H&P to be conducted by the physician. I see the consult on the computer or they will send it to me on the printer. I know the policy is for the admission H&P to be done within twenty-four (24) hours of the patient's admission to the facility. I know I was over the dead line for the H&P." She concurred with the findings.
4. An interview was conducted with the Family Practice Physician on 11/01/17 at 10:21 a.m. He stated, "My expectation is for the admission H&P to be completed within the twenty-four (24) hour time frame of the patient's admission. He concurred with the findings.