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Based on document review, Medical Staff Bylaw review, Medical Staff Rules and Regulations review, policy and procedure review, observation and staff interview, the facility failed to ensure all medical records are promptly completed following discharge.


Findings include:


On 12/17/12 at 2:10 p.m. tour of the medical records department with the Medical Records Director revealed two (2) boxes which were labeled "Jan - Dec loose paper that need to be filed." When asked why so many loose documents were not filed, Medical Records File Clerk #1 stated, "They (loose documents) just need to be filed." This was confirmed by the Medical Records Director.


Review of the facility document "Delinquent Record Report" revealed the facility had a total of 660 delinquent records with a delinquency rate of 62%. These records were acute care records. Further review revealed a total of 42 physicians and one (1) Nurse Practitioner were included in the delinquent rate. This document was submitted and confirmed by the Medical Records Director.


On 12/17/12 at 2:20 p.m. observation of the delinquent medical record count in the physicians dictation room, performed by the Medical Records Director, confirmed the 660 delinquent records. These records were dated from June of 2011 to present. The Medical Records Director stated, "I have not been able to provide a delinquent list to the physicians according to our policy because with the current system. It is hard to tell what is complete or incomplete. I have sent some emails to physicians. I may or may not have a copy and no physician is currently off staff due to delinquent records."


Review of the facility's "Medical Staff Rules and Regulations" revealed, "Article II Medical Records ...2.13 Permanently Filed Medical Records: A medical record shall not be permanently filed until it is completed by the responsible practitioner(s) or is ordered filed by the Medical Executive Committee (MEC), the Chief of Staff or Chief Executive Officer (CEO) with an explanation of why it was not completed by the responsible practitioner(s) ....2.15 Completion of Medical Records: The patient's medical record shall be complete at the time of discharge, including progress notes and final diagnosis. The written or dictated discharge summary shall be completed within thirty (30) days of discharge ....2.16 Delinquent Medical Records: patient medical records are required to be completed within thirty (30) days of discharge. The Health Information Management Department will provide each physician with a list of his/her incomplete medical records every seven (7) days. At the twenty-first (21st) day for any incomplete medical records, the letter will include a warning that the record(s) will be delinquent at thirty (30) days and the physician's privileges will be suspended if any records become delinquent."


Review of the facility's "Medical Staff Bylaws" revealed, "Article III: Medical Staff Membership ...3.3 Basic Responsibilities of Staff Membership: Each member of the Medical Staff shall: ...3.3(f) Adequately prepare and complete in a timely fashion the medical and other required records for all patients he/she admits or, in any way provides care to, in the Hospital; ...Article V: Allied Health Professionals (AHP) ...5.5 Responsibilities: 5.5(e) Adequately prepare and complete in a timely fashion the medical ...Article VIII: Corrective Action ...8.1(d) Medical Executive Committee Action ...(3) Issuing a warning or a reprimand ...(5) Recommend reduction, suspension or revocation of clinical privileges; ...8.3 Automatic Suspension: ...8.3(c) Medical Records: (1) Automatic suspension of a practitioner's privileges shall be imposed for failure to complete medical records as required by the Medical Staff Bylaws and Rules and Regulations. The suspension shall continue until such records are completed unless the practitioner satisfies the Chief of Staff that he/she has a justifiable excuse for such omissions. (2) Medical Records - Expulsion: ...any staff member who accumulates forty-five (45) or more consecutive days of automatic suspension ...shall automatically be expelled from the medical Staff. Such expulsion shall be effective as of the first day after the forty-fifth (45th) consecutive day of such automatic suspension."


Review of facility's "Purpose and Objectives" policy revealed, "2.The contents of the medical records shall be in accordance with ...Mississippi State Regulation and ...Medical Center Rules and Regulations ....Responsibility: 2 ...A. The patient's medical record shall include all significant clinical information pertaining to the patient ...".

Based on document review, Medical Staff Bylaw review, Medical Staff Rules and Regulations review, policy and procedure review, observation and staff interview, the facility failed to ensure all medical records are promptly completed following discharge.


Findings include:


Cross Refer to A-0431 for the facility's failure to ensure all medical records are promptly completed following discharge.

Based on document review, Medical Staff Bylaw review, Medical Staff Rules and Regulations review, policy and procedure review, observation and staff interview, the facility failed to ensure all medical records are promptly completed following discharge.


Findings include:


Cross Refer to A-0431 for the facility's failure to ensure all medical records are promptly completed following discharge.

Based on document review, contract review, Medical Staff Rules and Regulations review, policy and procedure review and staff interview, the facility failed to ensure deaths are reported in a timely manner.


Findings include:


Review of the of the facility contract "Organ and Tissue Procurement Agreement between organ procurement designee #1" dated 06/15/09 revealed, " ...Timely Notification for Organ Donation: For individuals who are on a ventilator, a referral is timely if it is made as soon as possible (ideally within one (1) hour) after the patient meets the definition of imminent death ....Timely Notification for Tissue Donation: For individuals who have died a cardiac death, notification is timely if the referral is made within one (1) hour of the cardiac death"

Review of the facility's "Death Notification Report" for June, August and September 2012 revealed: for June ...Total Untimely Referrals were two (2); for August ...Total Not Referred were two (2); and for September ...Total Untimely Referrals were two (2).

On 12/17/12 at 3:45 p.m. an interview with the Director of Nursing (DON) revealed, "This (late reporting) was due to changes in our policy and procedures." She stated that the coroner had been reporting 100% in the past and now the staff is reporting. "I have done in-services on the policy and procedures."

Review of the medical staff rules and regulations revealed, "4.10 Organ and Tissue Donations: The hospital shall refer all inpatient deaths, emergency room deaths and dead on arrival cases (term birth to age 75) to the designated organ procurement agency and/or tissue and eye donor agency in order to determine donor suitability, and shall comply with all CMS conditions of participation for organ, tissue and eye procurement."

Review of the facility policy "Organ and Tissue Donation" (effective 06/01/12) revealed, "Procedure: ...(2) Nursing Service will immediately report every death to the 24-hour referral number."

On 12/18/12 at 8:45 a.m. the DON submitted copies of an in-service dated June 26, 2012 titles "Topic: Death and Main Points of Discussion/Conclusions: call organ donation; with staff signatures."

Based on Based on document review, contract review, Medical Staff Rules and Regulations review, policy and procedure review and staff interview, the facility failed to ensure implementation of written protocols.


Findings include:


Cross Refer to A-0884 for the facility's failure to ensure implementation of written protocols.

Based on document review, contract review, Medical Staff Rules and Regulations review, policy and procedure review and staff interview, the facility failed to report deaths in a timely manner.


Findings include:


Cross Refer to A-0884 for the facility's failure to notify Organ Procurement Designee #1 in a timely manner of an individuals imminent death or of who had died in the hospital.