HospitalInspections.org

Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure the right to have family and physician notified promptly of admission for 1 of 13 sample patients (#11). The findings were:

Review of the history and physical (H&P) dated 10/11/19 at 9:28 PM showed patient #11 was admitted to the hospital related to atrial fibrillation with rapid ventricular rate. Review of the admission adult patient history showed the patient had an advanced directive that was not on file at the hospital. In addition, the patient answered yes to needing the facility to contact family and physician, and the names and phone numbers were listed. Further, the section related to education and communication showed the patient had no barriers to learning, and verbalized understanding of all areas reviewed including his/her condition, rights/responsibilities, and advanced directives. The following concerns were identified:
a. Review of the admission history showed the section to document the date and time of family and physician notification remained blank. Review of the record failed to show documentation the patient's daughter was notified. A later entry showed the patient's primary care physician was notified on 10/15/19 at 9:30 AM (the date of discharge).
b. Interview with registered nurse (RN) #1 revealed she was the manager of the unit the patient was on during his/her stay. The RN recalled communications were had with the patient's daughter during the stay; however, there was no documentation and she could not recall dates or details.
c. Review of the policy and procedure "Notification of Patient Family/Representative and/or Physician" with an effective date of 11/2018 showed promptly was defined as "As soon as possible after the physician's order to admit the patient has been given." The procedure/guideline showed "...2. Nursing will take responsibility for contacting the family, and will document the means and time contact occurred in the patient's EMR [electronic medical record]. 3. The nursing documentation will send a task to the Patient Experience Representatives to contact the patients' physician..."