| 6400.141(c)(7) | Individual #1's, date of admission 11/14/17, initial physical examination completed 10/2/17, did not include a gynecological examination including a breast examination and a Pap test. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | In the future, no new admissions will be accepted without a complete and compliant physical exam. As for this individual, a pap and breast exam were scheduled for January 16, 2018 with her family doctor. The Breast exam was completed, but the individual became upset when the pap was attempted. A referral has been made to an OBGYN for January 31, 2018. [Individual #1 had a gynecological examination on 1/31/18. Immediately and upon completion, a designated staff person trained in the requirements of physical examination as per 6400.141(c)(1)-(15) shall audit all individuals' current physical examinations to ensure all required information is completed. Documentation of audits shall be kept. Immediately, missing information shall be obtained. Refusal of treatment, as per 6400.143 shall be implemented for Individuals who refuses medical and dental examinations. Documentation shall be kept as required. (AS 1/30/18)] |
01/31/2018
| Implemented |