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.
|KAISER FOUNDATION HOSPITAL - SAN DIEGO||4647 ZION AVE SAN DIEGO, CA 92120||Jan. 18, 2017|
|VIOLATION: HISTORY AND PHYSICAL||Tag No: A0952|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the hospital failed to ensure an interval updated History and Physical (H&P) exam was completed within 24 hours of admission prior to a surgical procedure per the hospital's policy, for 1 of 32 sampled patients (31).
As a result, there was potential for Patient 31's medical information to be inaccurate.
1. Patient 31 was admitted on [DATE] for cesarean section (surgery to deliver a baby) and sterilization procedure, per the Face Sheet.
On 1/18/17 at 14:05 P.M., a review of Patient 31's electronic medical record was conducted with the Director of Peri-Operative Services (LN 1). The H&P was dated 11/30/16. The Operative Report (a detailed account of the cesarean section surgery) was dated 12/2/16, two days after the H&P. There was no interval admission note in Patient 31's electronic medical record.
In a subsequent interview with LN 1, she confirmed an interval admission note was not included in Patient 31's medical record and added, "The pre-operative nurse was responsible for confirming an interval admission note was included when the H&P was older than 24 hours."
According to the hospital's policy and procedure, History and Physical Examination & Discharge Summary Documentation, dated 7/03, "I. Timing and Expiration of the History and Physical Exam, B. ...If the H&P is over 24 hours old, an interval admission note is required and must be completed within 24 hours of admission or before the planned procedure."