HospitalInspections.org

Based on the hospital's policy, "Admission Process Quick and Dirty" and interview with the Medical Director on April 12, 2011, it was determined that the facility failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients.

The findings are as follows.

1. The hospital policy "Admission Process Quick and Dirty" specifies the following: "Adequate clinical information must be obtained for the MD and NS to make a decision regarding admission. The on call MD must be involved as clinical information about the referral is gathered. Often, after receiving the referral, more information must be requested from the referral party. If the patient is not being referred from an ED, there may be no H & P and the on call MD must decide if this is okay or if we require that the patient be medically cleared prior to admission."

2. A patient referral was made requesting a transfer for an involuntary admission for psychiatric care. The transferring hospital had three and possibly four communications with Mid Level practitioners regarding the status of the transfer. There was no documentation found in the clinical record that the on-call physician was called prior to the patient admission.

3. An interview conducted with the on-call physician on 4-12,2011 substantiated that she was not informed of all the necessary medical information regarding the patient or informed of the patient's admission prior to the transfer.