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.

SUMNER COMMUNITY HOSPITAL 1323 NORTH A STREET WELLINGTON, KS 67152 May 6, 2015
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital Behavioral Health Unit (BHU) reported a census of ten patients. Based on medical record review, Medical Staff Bylaws review and staff interview the hospital failed to ensure a complete history and physical were in the patients chart as required by the hospital's Medical Staff Bylaws for three of five sampled patients requiring a history and physical (patient #'s 2, 3, and 4). This deficient practice had the potential to affect the patient's planned course of care.
Findings include:

- The hospital's Medical Staff Bylaws reviewed on 5/6/15 at 11:00am directed, "...a medical history and physical should be completed no more than 30 days before or 24 hours after admission..."

- Patient #2's medical record review on 5/5/15 revealed an admission date of [DATE] with diagnoses of increased confusion and no safety awareness. The medical record contained a history and physical transcribed on 4/27/15 (3 days after admission).

- Patient #3's medical record review on 5/5/15 revealed an admission date of [DATE] with diagnoses of agitation and combative behaviors. The medical record contained a history and physical transcribed on 5/3/15 (2 days after admission).

- Patient #4's medical record review on 5/5/15 revealed an admission date of [DATE] with diagnoses of wandering, delusions, and hallucinations. The medical record contained a history and physical transcribed on 4/27/15 (3 days after admission).

Administrative Nurse Staff A interviewed on 5/5/15 between 11:30am and 3:00pm during medical record review acknowledged the physician failed to complete the patient's history and physical within 24 hours of admission as directed by the hospital's Medical Staff Bylaws.