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Based on record review and interview, The facility failed to complete and document the required medical history and physical examination by the physician 24 hours after admission for 1 of 10 patients (Patient #4), in that, Patient #4's record did not evidence a physician's physical examination by 24 hours after admission.

Findings Included

Patient #4's record did not evidence a physician's physical examination by 24 hours after admission.

During interview on 11/16/2015 at 12:23 PM, Personnel #3 navigated the electronic record and was asked if the history and physical was completed within 24 hours from the patient's admission. Personnel #3 stated, "No."

The hospital's "2009 Hospital Medical Staff Rules and Regulations" required, "history and physical...24 hours..."

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the care for 3 of 10 patients (Patient #2, #3, and #4), in that, Patient #2, #3, and #4 were documented as incontinent during their stay and their documentation did not reflect daily incontinent care, linen changes, gown changes and/or bath/shower.

Findings Included

Patient #2's, #3's and #4's records did not reflect daily incontinent care, linen changes, gown changes and/or bath/shower.

During a record review and interview on 11/16/2015 beginning at 9:35 AM, Personnel #3 was asked if Patient #2, #3, and #4 were incontinent. Personnel #3 confirmed they were documented incontinent. Personnel #3 was asked if daily incontinent care, linen changes, gown changes and/or bath/shower were documented. Personnel #3 stated, "No. There are some documented but not enough to show the care we provide."