HospitalInspections.org

Based on record review, policy review and staff interviews it was revealed physician #1 failed to complete a daily assessment of patient #1 in two (2) out of seven (7) days following the facility's Medical Staff Bylaws rules and regulations. This failure was identified in one (1) out of ten (10) clinical record reviews. This failure has the potential to place all patients at risk for injury.

Findings include:

A review of patient #1's clinical record revealed there was not an attending physician's progress note by physician #1 for 6/27/21.

A review of patient #1's clinical record revealed there was not an attending physician's progress note by physician #1 for 6/29/21.

A review of the Medical Staff Bylaws rules and regulations dated 1/26/21 states in part: "No patient should be admitted to the hospital without being designated the responsibility of a specific admitting physician. That designated physician has the responsibility of providing quality medical care and treatment for the patient, as well as completing prompt (twenty-four (24) hours and accurate medical records and appropriate medical orders and progress notes."

The facility provided their investigation documentation initiated on 07/09/21 to the surveyor and it was reviewed along with the clinical record. The facility's investigation identified two (2) days where attending physician #1 did not document on the patient following the medical staff bylaws.

An interview was conducted on 8/24/21 at approximately 2:12 p.m. with physician #2. When asked how often the attending physician sees their patients, physician #2 stated in part, "If I am the attending, I or my partners sees the patient every day."

An interview was conducted on 08/24/21 at approximately 2:49 p.m. with physician #1. When discussing the dates lacking an attending progress note, the physician stated in part, "Physician #3 saw the patient on 06/27/21. I didn't see the patient on 06/29/21.

An interview was conducted on 08/24/21 at approximately 3:19 p.m. with Registered Nurse (RN) #1. When asked who covers physician #1's patients, the RN stated in part, "I couldn't tell you who covers for physician #1. ... Attending physicians are supposed to see patients every day."

An interview was conducted on 08/24/21 at approximately 4:01 p.m. with RN #2. When asked how often the attending physician sees their patients, the RN stated in part, "If you are the attending, you have to see patients every day."

An interview was conducted on 08/24/21 at approximately 4:22 p.m. with Clinical Nurse Manager (CNM) #1. When asked how often the attending physician sees their patients, the CNM stated in part, "The attending sees patients daily and documents daily."

An interview was conducted on 08/25/21 at approximately 7:50 a.m. with RN #4. When asked how often the attending physician sees their patients, the RN stated in part, "The attending sees them daily and if consulting, as needed, unless they sign off."

An interview was conducted on 08/25/21 at approximately 8:40 a.m. with the Chief Medical Officer (CMO). When asked about the attending physician documenting on the patient, the CMO stated in part, "The only thing we found was two (2) days the physician did not document. ... I agree physician #1 missed documenting two (2) days ... ."