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Based on interview and record review, the Governing Body failed to ensure that the hospital policies were administered regarding timely completion of discharged medical records.

Findings include:

During an interview with Staff D (Health Information Manager) on 5/23/13 it was revealed that the hospital had not taken any disciplinary action of medical staff members for failure to complete medical records according to the Professional Staff Bylaws for the previous year from the date of this interview. The compliance reports have been reported monthly with compliance rates to the Professional Staff at the monthly meetings. During an interview, Staff A (Risk Management) on 5/23/2013 confirmed the compliance reports have been on the agenda of the Professional Staff monthly meeting and reported to the Governing Body monthly. There was no documentation of the outcome of any remedial action as reported by Staff D. No remedial action has been taken for at least one year prior to 5/23/213.
(Cross Reference to C-307, C-342 & C-343)

Based on observation and interview the hospital failed to ensure that any/all expired medications are removed from the pharmacy.

Findings include:

Observation during tour of pharmacy on 5/21/13 at 1 p.m. with Staff C (Pharmacist) revealed the following medications located in the pharmacy were expired:

7 vials of Ampicillin expired 2/2013
5 vials of Valproic Acid expired 1/2012
4 vials of Multi Trace Concentrate expired 4/2013

Interview with Staff C on 5/21/13 at 1 p.m. confirmed the medications listed above were expired and should have been removed from the pharmacy and disposed of.

Based on interview and record review the hospital failed to ensure that physicians were compliant with the hospital established policy and procedure relating to completion of chart documentation within the required time frames based on hospital established Professional Staff Bylaws for discharged records.

Findings include:

Review of the facility generated "MEDICAL RECORD DELINQUENCY LIST" on 5/22/2013 for the months of January 2013 through May 22, 2013 revealed an overall compliance rate as follows:

January 2013 Overall Compliance Rate 37%
February 2013 Overall Compliance Rate 49%
March 2013 Overall Compliance Rate 51%
April 2013 Overall Compliance Rate 46%
May 1-22, 2013Overall Compliance Rate 35%

During an interview on 5/22/13 at approximately 2:45 p.m. with Staff D (Health Information Manager) and Staff E (Lead Coder) it was revealed that the Overall Compliance Rate report is generated monthly and reviewed as an agenda item at the Professional Staff monthly meeting. It was further explained that the report summarizes medical record delinquencies/deficiencies for the "total number of records for the month that do not meet facility established criteria for completion per Bylaws". During the interview Staff D confirmed the above listed compliance rates were accurate. Staff E further explained that the majority of the delinquencies are signatures, E-signatures (Electronic Signatures) and Emergency Department records.

Review of the "MEDICAL RECORD DELINQUENCY LIST" report revealed the established criteria identified and evaluated for compliance in the report are as follows:

Discharge summary completion 30 days after discharge
History and Physical completion within 24 hours after admission
Operative Reports completion within 24 hours after surgery
Signatures completion within 60 days after discharge
E-Sign completion within 60 days after discharge
Emergency Department record completion within 24 hours after visit

Based on interview and record review the hospital failed to take any remedial action to address medical record completion deficiencies that were identified through the quality assurance program.

Findings include:

Review of the facility generated "MEDICAL RECORD DELINQUENCY LIST" on 5/22/13 for the months of January 2013 through May 22, 2013 revealed an overall compliance rate as follows:

January 2013 Overall Compliance Rate 37%
February 2013 Overall Compliance Rate 49%
March 2013 Overall Compliance Rate 51%
April 2013 Overall Compliance Rate 46%
May 1-22, 2013Overall Compliance Rate 35%

During an interview on 5/22/13 at approximately 2:45 p.m. with Staff D (Health Information Manager) and Staff E (Lead Coder) it was revealed that the Overall Compliance Rate report is generated monthly and reviewed as an agenda item at the Professional Staff monthly meeting. It was further explained that the report summarizes medical record delinquencies/deficiencies for the "total number of records for the month that do not meet facility established criteria for completion per Bylaws". During the interview, Staff D confirmed the above listed compliance rates were accurate. Staff E further explained that the majority of the delinquencies are signatures, E-signatures (Electronic Signatures) and Emergency Department records.

Review of the "MEDICAL RECORD DELINQUENCY LIST" report revealed the established criteria identified and evaluated for compliance in the report are the following:

Discharge summary completion 30 days after discharge
History and Physical completion within 24 hours after admission
Operative Reports completion within 24 hours after surgery
Signatures completion within 60 days after discharge
E-Sign completion within 60 days after discharge
Emergency Department record completion within 24 hours after visit

Review of the Professional Staff Bylaws dated 12/09/10 Article VIII section C on page 17 revealed the following:

1. "Failure to complete medical records, after warning of delinquency for failure to complete medical records within thirty (30) days of patient's discharge" ... shall be grounds for automatic suspension of a Professional Staff Member's Clinical Privileges.

During an interview with Staff D on 5/23/13 it was revealed that the hospital had not taken any disciplinary action against medical staff members for delinquency in completing medical records according to the hospital established criteria per Professional Staff Bylaws for at least one year previous from the date of this interview, even though the compliance reports have been reported monthly with compliance rates to the Professional Staff at the monthly meetings.

Interview with Staff A (Risk Management) on 5/23/2013 confirmed the compliance reports have been on the agenda of the Professional Staff monthly meeting and reported to the Governing Body monthly.
(Cross Reference to C-037)

Based on interview and record review, the hospital failed to document the outcome of corrective actions of Medical Staff according the the Professional Staff Bylaws for medical record completion compliance.

Findings include:

Review of the facility generated "MEDICAL RECORD DELINQUENCY LIST" on 5/22/13 for the months of January 2013 through May 22, 2013 revealed an overall compliance rate as follows:

January 2013 Overall Compliance Rate 37%
February 2013 Overall Compliance Rate 49%
March 2013 Overall Compliance Rate 51%
April 2013 Overall Compliance Rate 46%
May 1-22, 2013Overall Compliance Rate 35%

During an interview on 5/22/2013 at approximately 2:45 p.m. with Staff D (Health Information Manager) and Staff E (Lead Coder) it was revealed that the Overall Compliance Rate report is generated monthly and reviewed as an agenda item at the Professional Staff monthly meeting. It was further explained that the report summarizes medical record delinquencies/deficiencies of the "total number of records for the month that do not meet facility established criteria for completion per Bylaws". During the interview Staff D confirmed the above listed compliance rates were accurate. Staff E further explained that the majority of the delinquencies are signatures, E-signatures (Electronic Signatures) and Emergency Department records.

Review of the "MEDICAL RECORD DELINQUENCY LIST" report revealed the established criteria identified and evaluated for compliance in the report are the following:

Discharge summary completion 30 days after discharge
History and Physical completion within 24 hours after admission
Operative Reports completion within 24 hours after surgery
Signatures completion within 60 days after discharge
E-Sign completion within 60 days after discharge
Emergency Department record completion within 24 hours after visit

Review of Professional Staff Bylaws dated 12/09/10 Article VIII section C on page 17 revealed the following:

1. "Failure to complete medical records, after warning of delinquency for failure to complete medical records within thirty (30) days of patient's discharge" ... shall be grounds for automatic suspension of a Professional Staff Member's Clinical Privileges.

During an interview with Staff D on 5/23/13 it was revealed that the hospital had not taken any disciplinary action of a medical staff member for delinquency to complete medical records according to the facility established criteria per Professional Staff Bylaws for at least one year previous to the date of this interview even though the compliance reports have been reported monthly with compliance rates to the Professional Staff at the monthly meetings

Interview with Staff A (Risk Management) on 5/23/13 confirmed the compliance reports have been on the agenda of the Professional Staff meetings and reported to the Governing Body monthly. There was no documentation of the outcome of any remedial action as reported by Staff E, no remedial action has been taken for at least one year prior to 5/23/13.
(Cross Reference to C-307 & C-342)