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.
|MOUNT SINAI SOUTH NASSAU||ONE HEALTHY WAY OCEANSIDE, NY 11572||July 11, 2018|
|VIOLATION: MEDICAL STAFF RESPONSIBILITIES||Tag No: A0358|
Based on Medical Record review, document review and interview, in two (2) six (6) Medical Records, the facility did not ensure that History and Physicals (H&P) were completed as per Medical Staff Rules and Regulations.
This places all residents at potential risk for harm.
The Medical Staff Rules and Regulations, dated 09/17/13, stated, "Members of the Graduate Medical Staff must be supervised by the Medical Staff member of record or designee. The Medical Staff member is responsible for countersigning the H&P written by a member of the Graduate Medical Staff within twenty-four (24) hours ... Merely countersigning the notes written by a member of the Graduate Medical Staff is not sufficient documentation of the Medical Staff member's involvement and supervision."
Review of Patient #13's Medical Record identified that a History and Physical was completed on 07/01/18 at 4:25AM by Staff D (Medical Resident). Staff J (Attending Physician) did not sign the patient's History and Physical until 07/02/18 at 1:15PM, thirty-five (35) hours and ten (10) minutes after completion of the document.
Staff J did not document his involvement and supervision in the patient's Medical Record.
The same lack of documentation of an Attending involvement and supervision for a Resident Physician's History and Physical was noted for Patient #5.
During an interview with Staff B (Assistant Vice President of Clinical Performance Improvement) on 07/09/18 at 2:35PM, Staff B acknowledged these findings.