HospitalInspections.org

Based on staff interview, record review and policy and procedure review, the facility failed to ensure history and physicals were completed twenty-four (24) hours after admission or registration on two(2) out of 20 medical records reviewed; Patient # 13, and #16.


Findings Include:

Medical Record review for Patients #13 and #16 revealed no documented evidence that the history and physicals were completed within 24 hours of admission or registration. Patient #13 was admitted on 4/09/2021 and the history and physical was not completed until 4/11/2021. Patient #16 was admitted on 2/26/21 and the history and physical was not completed until 3/1/2021.


During an interview on 04/29/2021 at 12:15 PM, the Director of Nurses (DON) confirmed that the patients did not have history and physicals completed within 24 hours. DON reported that it was the weekend and sometimes they have problems getting all the information on the weekends. DON reported that the history and physical should have been completed within the appropriate time frame.


A review of the facility's policy and procedure, "Health Information Management, #HIM-102, Subject: History and Physical Report" revision date of 10/04/2016, review date 7/2020 revealed: " ...A medical history and physical examination shall be complete no more than (48) hours after admission or registration ...When the medical history and physical examination is completed within 30 days before admission or registration, the physician must complete the document an updated examination of the patient within 48 hours after admission or registration ..."


During Exit Conference on 04/29/2021 at 2:00 p.m. survey findings were discussed, and no further documentation was submitted for review.