The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SCRIPPS MERCY HOSPITAL||4077 5TH AVE SAN DIEGO, CA 92103||Nov. 6, 2013|
|VIOLATION: MEDICAL STAFF RESPONSIBILITIES||Tag No: A0358|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the hospital failed to ensure that a History and Physical (a critical component of a patient encounter in which information relevant to a present complaint is obtained) was completed for 1 of 40 sampled patients (Patient 1) within 24 hours of her admission to Hospital A. The lack of a history and physical in a patient's medical record could hinder health practitioners in their treatment plan for the patient due to the lack of documentation of the patient's past medical history, allergies, comorbitities (existing medical diagnoses), and overall medical condition.
Patient 1 was admitted on [DATE] with a diagnosis of bilateral leg wounds, according to the Admission Facesheet. A review of Patient 1's medical record was conducted on 11/4/13 at 10:45 A.M. There was no evidence in Patient 1's medical record that her attending physician had either written or dictated a complete History and Physical.
A review of the hospital's Medical Staff Bylaws indicated that "Completion of a physical examination and medical history shall be done within twenty-four (24) hours after admission. This requirement may be satisfied by a complete history and physical that has been performed within 30 days prior to admission, so long as an examination for any changes in the patient's condition is completed and documented (interval note) in the medical record within twenty-four (24) hours after admission, but prior to surgery or a procedure requiring anesthesia services."
An interview was conducted with the Director of Patient Safety (DPS) on 11/4/13 at 11:25 A.M. The DPS stated that Patient 1's attending physician was currently in the process of dictating the History and Physical. That occurred seven days after Patient 1 was admitted to Hospital A. The DPS further explained that Patient 1's attending physician was not following the hospital's Medical Staff Bylaws regarding a History and Physical dictated or written for each patient within 24 hours of the patient's admission to the hospital.