HospitalInspections.org

Base on review of medical record and staff interview, it was determined the hospital failed to ensure the medical record contained history and physical exam within 24 hours of admission.
Findings:
a. During review of patient #1 medical record it was found that a history & physical exam was not done within the 24 hours of admission. MD documented unable to perform history and physical exam due to patient being sedated. Facility failed to have a process in place when history and physical exams are not able to be completed within the 24 hour time frame.
b. Facility ' s Root Cause Analysis, Action for Improvement established a target date of 03/18/13 for development of policy for pending history and physical exam. As of April 4, 2013 facility has not develop a policy.
c. In an interview with personnel #1 on 04/03/13 at approximately 1:30 pm, personnel #1 (Director of Behavioral Health Services) confirmed that the facility did not completed a history and physical within the 24 hours after admission and had not developed a policy for pending history and physical exams.