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 their physician of the hospital admission and failed to document in the medical record if the patient requested or declined a family member or representative to be notified of the hospital admission including date, time and method of the requested notification in nine of nine medical records reviewed (MR2, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11).

Findings include:

1) On December 21, 2016, surveyor requested EMP2 to provide a policy for notification of patient's own physician and family member or representative to be notified promptly of the admission to the hospital. None was provided.

2) Review on December 22, 2016, of MR2, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 revealed these patients were admitted to the facility between October 18, 2016, and December 4, 2016.

Review of the "Face Sheet" for MR2, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 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.

Review of the "Facesheet" for MR2, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 revealed no documentation in the medical record if the facility asked each patient whether they requested or declined notification to his/her family member or representative of the hospital admission, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.

3) Interview with EMP2 on December 21, 2016, at 4 PM confirmed the facility did not have a policy for notification of patient's hospital admission to their Primary Care Providers or family member/representative. Continued interview with EMP2 confirmed there was no documentation in the medical record for MR2, MR4, MR5, MR6, MR7, MR8, MR9, MR10 and MR11 of whether the patient requested or declined notification to the patient's own physician, family member or representative, including the date, time and method of notification if the patient did request the family member or representative be notified of the hospital admission.