HospitalInspections.org

Based on record review, policy review and interviews, it was determined that for 1 of 3 sample patients (Patient C), the facility failed to perform and document a physical examination. Since the admitting physical exam, which would include a screening neurological examination, was not completed, it was not possible for the facility to determine if the patient required a more complete neurological evaluation. The absence of this patient information restricts clinicians' ability to accurately diagnose the patient's condition and to measure change in baseline function, thus affecting patient care.

Findings include:

A. Record Review

Patient C was admitted on 3/30/12. As of 4/2/12, there was no history and physical examination present in the medical record.

B. Policy Review

Bridgewell Hospital policy Admission Assessment Policy states that a physician is responsible for completing the medical history and physical examination within 24 hours of a patient's admission.

C. Staff Interviews

During an interview with the registered nurse on day shift on unit on 4/2/12 at 12p.m., the nurse stated, "It (referring to the History and Physical Exam) is not done. Usually it is done within 24 hours. The physician will do it today."

During an interview on 4/2/12 at 12:50p.m., the Medical Director stated, "It is not done. Our policy is to do it within 24 hours. Absolutely it is overdue. At least we did our part. We called the medical doctor to come in and complete the physical examination."