HospitalInspections.org

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Based on Medical Record review, document review and interview, in two (2) six (6) Medical Records, the facility did not ensure that History and Physicals (H&P) were completed as per Medical Staff Rules and Regulations.

This places all residents at potential risk for harm.

Findings:

The Medical Staff Rules and Regulations, dated 09/17/13, stated, "Members of the Graduate Medical Staff must be supervised by the Medical Staff member of record or designee. The Medical Staff member is responsible for countersigning the H&P written by a member of the Graduate Medical Staff within twenty-four (24) hours ... Merely countersigning the notes written by a member of the Graduate Medical Staff is not sufficient documentation of the Medical Staff member's involvement and supervision."

Review of Patient #13's Medical Record identified that a History and Physical was completed on 07/01/18 at 4:25AM by Staff D (Medical Resident). Staff J (Attending Physician) did not sign the patient's History and Physical until 07/02/18 at 1:15PM, thirty-five (35) hours and ten (10) minutes after completion of the document.

Staff J did not document his involvement and supervision in the patient's Medical Record.

The same lack of documentation of an Attending involvement and supervision for a Resident Physician's History and Physical was noted for Patient #5.

During an interview with Staff B (Assistant Vice President of Clinical Performance Improvement) on 07/09/18 at 2:35PM, Staff B acknowledged these findings.