HospitalInspections.org

Based on Interview, Policy and Procedure Review, Medical Staff Bylaws and Minutes, and Governing Body Bylaws and minutes, the facility failed to ensure completion of 587 medical records within 30 days following patient discharge.

Findings Include:

Interview with Medical Records Director on October 9, 3029, at 10:55 a.m., confirmed 587 Delinquent Discharge Summaries and History/Physicals for acute and/or swing bed patients. Medical Records Director also confirmed all delinquent records are greater than 30 days, the oldest being 4/14/16 through current date 10/9/19.

Interview with Chief Executive Officer on October 9, 2019, at 10:55 a.m. confirmed 587 Delinquent Discharge Summaries and History/Physicals for acute and/or swing bed patients.
Interview with Director of Nursing on October 9, 2019, at 10:55 a.m. confirmed 587 Delinquent Discharge Summaries and History/Physicals for acute and/or swing bed patients
Review of facility Policy and Procedure Manual Health Information on October 9, 2019, at 11:00 a.m. confirmed " I. Purpose - Health Information shall maintain complete and accurate records of care received by inpatients, outpatients ...III. General Policies and Procedures ...7. History and physical examination shall in all cases be completed within 24 hours of admission of the patient ...8. All medical records must be complete within 30 days of discharge from the hospital including progress notes, final diagnosis and discharge summary; over 15 days they are considered delinquent."

Review of Medical Staff Bylaws, Rules and Regulations ARTICLE XV ...RULES AND REGULATIONS on October 9, 2019, at 11:30 a.m., confirmed " ...14. The attending physician shall be held responsible for the preparation of a complete medical record for each patient ...24. ...At the time of discharge, the attending physician shall see that the record is complete, state his final diagnosis, and sign the record."

Review of Medical Staff Monthly Minutes on October 9, 2019, at 11:40 a.m., dated 8/29/19, 7/24/19, 6/26/19, 5/29/19, 3/27/19, 2/17/19, 1/23/19, 12/5/18, 10/24/18, and 9/26/18 confirmed discussion of chart delinquency reporting. No documentation of performance improvement plan for timely completion of medical records. No documentation of Medical Staff minutes for November 2018, or April 2019.

Review of Governing Body Bylaws Article VI Section 2. The Authorities and Duties of the Administrator on October 9, 2019, at 11:45 a.m. confirmed: " ...7. ...such reports will be made monthly and yearly ...The monthly report will. ...call attention to matters that are undesirable and suggest remedies ...".

Review of Governing Body Minutes on October 9, 2019, at 11:50 a.m., dated 7/18/19, 5/16/19, 4/25/19, 3/21/19, 2/21/19, 1/17/19, 12/20/18, and 10/25/18 confirmed discussion of medical record delinquency report. No documentation of development of performance improvement plan for timely completion of medical records. Governing Body minutes on 8/25/19 and 6/20/19 confirmed no discussion of medical record delinquency report.

Based on Interview, Policy and Procedure review, Medical Staff Bylaws and Minutes and Governing Body Bylaws and Minutes, and document review, 587 Medical Records had no complete Discharge Summary and/or History and Physical on each acute and/or swing bed patient.

Findings Include:

Cross Refer to C-0300 for the facility's failure to maintain complete Medical Records on each patient, acute and/or swing bed.