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Based on medical record review, review of the facility's Medical Staff Rules and Regulations and staff interview, the facility failed to ensure medical staff enforced bylaws for one of 11 medical records reviewed (Patient #6). The facility's active census was 55.

Findings include:

The Rules and Regulations of the Medical Staff (Approved 03/16/22) stated:
11. The attending physician is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant. He or she will provide a written request authorizing another practitioner to attend and/or consult on his/her patient, except in an emergency. Consultants shall dictate or enter their recommendations and all pertinent findings in the medical record within seventy-two (72) hours of the consultation being ordered or within the timeframe set forth within the Physician Order for consultation. Any qualified practitioner with Clinical Privileges in this Hospital can be called for consultation within his area of expertise, or as otherwise required by State Law.

Review of Patient #6's medical record revealed an order was placed for a pulmonology consult for Patient #6 on 03/20/23 at 4:07 PM. A pulmonologist conducted the consult on 03/24/23 at 4:15 PM.

The findings were reviewed with Staff Q on 06/15/23 at 7:52 AM and confirmed.

This deficiency represents non-compliance investigated under Substantial Allegation OH00142715.