HospitalInspections.org

Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to his/her own physician of the hospital admission including date, time and method of the requested notification in 14 of 14 inpatient medical records reviewed (MR1, MR5, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20).

Findings include:

1) On October 31, 2018, surveyor requested EMP1 to provide a policy that included if the patient requested or declined notification to his/her own physician of the admission to the hospital. None was provided.

2) Review on October 31, 2018, of MR1, MR5, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20 revealed these patients were admitted to the facility between June 22, 2017, and October 9, 2018.

Further review of MR1, MR5, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20 revealed no documentation in the medical record whether the facility asked each patient if they requested or declined notification to his/her own physician of the hospital admission including date, time and method of the requested notification.

3) Interview with EMP1 on October 31, 2018, at 11:45 AM confirmed the facility did not have a policy for notification of patient's hospital admission to his/her own physician and there was no documentation in MR1, MR5, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20 of whether the patient requested or declined notification to his/her own physician, including the date, time and method of notification if the patient did request notification.