HospitalInspections.org

Base on review of medical records the governing body failed to ensure that histories and physicals were completed by the providers within 24 hours of the patients ' admission. 6 of 10 medical records contained histories and physicals that were not authenticated by the providers.
Findings were:
Review of Basic Obligations Accompanying Staff Appointment and/or the granting of clinical privileges. 4.5.3. A history and physical examination (H&P) must be completed and documented in accordance with Medical Staff Bylaws, Rules and regulations, and Hospital Policy within 24 hours after a patient is admitted to the hospital.
In an interview at the facility on the afternoon of 9/15/15 staff # 10 agreed with the findings.

Base on observation, review of facility policy and interviews with the facility staff, the facility failed to maintain legible medical records. 3 of 10 medical records reviewed contained blanks and a nursing assessment was not legible.
Findings were:
Patient # 3, 1, and 8 medical records reviewed contained blanks in the documentation that were not completed by the author
Review of Basic Obligations Accompanying Staff Appointment and/or the granting of clinical privileges. 4.5.3. Accurately and legibly prepare and complete in timely fashion, the medical records for all patients he/she admits or in any way provides care to in the Hospital in accordance with the rules and regulations.
Review of nursing assessment patient # 1 was not legible. Staff # 2 returned to the facility and translated the nursing assessment.
In an interview at the facility on 9/15/2015 staff # 2 and # 10, both staff agreed with the findings.