HospitalInspections.org

Based on record review and interview, the facility failed to include the patient/family in the development of the plan of care. 6 of 10 (#1, 2, 3, 4, 5, and 6) charts revealed no evidence the patient or family participated in the plan of care.

Findings include:

Review of patient records revealed no evidence patients or families participated in the development or implementation of the plan of care for 6 patients.

During an interview on 5/15/13 at 3:15pm in the conference room, staff #17 reviewed the charts and could not produce evidence of patient or family participation in the plan of care for these 6 patients.

Based on record review and interview, the facility failed to assure current patient history and physicals (H&P) were documented and on the chart within 24 hours. 4 of 10 (#4, 6, 8, and 10) charts had history and physicals that were not documented and on the chart within 24 hours.

Findings include:

Review of facility policy titled, " Medical Records Guidelines for Physicians, " revealed the following: " History and Physical Examinations shall be completed within 24 hours admission. "

Review of the Medical Staff Bylaws and Rules and Regulations revealed the following: " The H&P may be handwritten or transcribed, but, must always be placed within the patient ' s medical record within 24 hours of admission .... "

Review of patient records revealed the following H&Ps transcribed more than 24 hours after the patient was admitted, therefore not on the chart within 24 hours:
-Patient #4 was admitted on 4/2/13 with H&P transcribed on 4/4/13
-Patient #6 was admitted on 1/30/13 at 4:29pm with H&P handwritten on 1/31/13 at 6:35pm
-Patient #8 was admitted on 12/8/12 with H&P transcribed on 12/10/12
-Patient #10 was admitted on 1/6/13 at 3:56pm with H&P transcribed on 1/7/13 at 11:45pm

During an interview on 5/15/13 at 4:35pm in the conference room, staff #3 confirmed these findings.

Based on record review and interview, the facility failed to ensure verbal orders were authenticated within 48 hours in 9 of 10 charts (#1, 2, 3, 4, 6, 8, 8, 9, and 10).

Findings include:

Review of facility policy 3300.252, " Verbal/Telephone Orders, " revealed the following: " Verbal Order shall be authenticated and countersigned by the prescribing practitioner or other responsible practitioner within the time period specified by the medical staff rules and regulations. "

Review of Medical Staff Bylaws and Rules and Regulations revealed no time period specified for the authentication of verbal orders.

Review of medical records revealed 9 charts where verbal orders had not been authenticated within 48 hours. Findings were as follows (Chart# x number of verbal orders without authentication within 48 hours):
-Chart #1x 4
-Chart #2x 4
-Chart #3x 4
-Chart #4x 5
-Chart #6x 4
-Chart #7x 3
-Chart #8x 5
-Chart #9x 6
-Chart #10x 5

During an interview on 5/15/13 at 4:15pm in the conference room, staff #2 confirmed these findings.