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Based upon record review and interviews, the Medical Staff failed to enforce their By-Laws, Rules, Regulation, and policies and procedures related to medical record completion. This was evidenced by the failure of S6Physician to complete the patient's History and Physical and Discharge Summary leading to 51 delinquent medical records from 08/01/16 to 11/18/16.
Findings:

Review of the Medical Staff By-Laws, Rules, and Regulations, Article 8 - Corrective Action, Automatic Suspension 8.3.4, Medical Records (revised 08/25/01) revealed in part: An automatic suspension shall, after not less than three (3) days warning of delinquence, be imposed for failure of a professional to complete medical records in a timely fashion pursuant to and as required by hospital policies.

Review of the hospital policy titled Medical Record Requirements, #502, revised 05/2009 revealed in part: 1) The medical record should be completed at the time of discharge including progress notes, final diagnosis and dictated discharge summary. 2. A complete history and physical examination should be dictated or written within 24 hours of admission. 9. A discharge summary is to be dictated by the physician within (30) days of the patient's discharge.

In an interview on 11/17/16 at 11:20 a.m. with S5HIM (Health Information Management) Director, she revealed the hospital had only one physician with delinquent records and provided for review a document titled " Unresolved Chart Deficiencies for MD 01045 (S6Physician)". Review of this document revealed S6Physician had approximately 48 incomplete medical records that were missing a History and Physical from 08/01/16 to 11/16/16 and 6 medical records missing a Discharge Summary.

Interview on 11/18/16 at 11:20 a.m. with S4Physician/Chief of Medical Staff revealed the incomplete records for S6Physician had been addressed during Medical Staff Meetings; however, the former Hospital Administrator informed him that the missing History and Physicals for S6Physician would not be enforced.

Interview on 11/18/16 at 1:35 p.m. with S5HIM confirmed the former Hospital Administrator had met and talked with S6Physician about the delinquent records; however, the hospital's policy for delinquent records was not enforced and the records remained incomplete.

Based on record review and interview, the hospital failed to ensure medical records were completed promptly and properly stored. This was evidenced by: 1) The failure of S6Physician to complete a total of 51 medical records for the History and Physicals and the Discharge Summary, and 2) The failure to properly store medical records to ensure they were protected from fire and water damage.
Findings:
1) Review of the hospital's Bylaws of the Medical Staff, Article 8 - Corrective Action, 8.3 Automatic Suspension, 8.3.4. Medical Records (revised 08/25/11) revealed in part: An automatic suspension shall, after not less than three (3) days warning of delinquency, be imposed for failure of a professional to complete medical records in a timely fashion pursuant to and as required by hospital policies.
Review of the hospital policy titled, "Medical Record Requirements", #502, revised 05/2009 revealed in part: The medical record should be completed at the time of discharge including progress notes, final diagnosis and dictated discharge summary. 2. A complete history and physical examination should be dictated or written within 24 hours of admission. 9. A discharge summary is to be dictated by the physician within (30) days of the patient's discharge.
In an interview on 11/17/16 at 11:20 a.m. with S5HIM (Health Information Management) Director, she stated that the hospital had only one physician with delinquent records and provided for review a document titled " Unresolved Chart Deficiencies for MD 01045 ". Review of this documented revealed S6Physician had a total of 51 delinquent records from 08/01/16 to 11/16/16. 45 of the delinquent medical records had incomplete History and Physicals and 6 of the medical records were delinquent for completion of the Discharge Summary.
Interview on 11/18/16 at 1:35 p.m. with S5HIM confirmed that the former Hospital Administrator had met and talked with S6Physician about the delinquent records. S5HIM further stated that the hospital's policy for delinquent records was not enforced on S6Physician and the records remained incomplete.
2) Observation on 11/17/16 at 9:05 a.m. revealed room #1 had 5 open faced 5 tier shelving units lining the wall containing approximately 212 paper folders of medical records dated 2010 and approximately 157 paper folders containing medical records dated 2011. In room #2 there were 2 open metal rolling cabinets on a floor track which contained 36 shelves per unit and 2 wall mounted open metal shelf units which contained 18 shelf units. All of the medical records in rooms #1 and #2 were in paper form and a sprinkler system was present in the ceilings. Interview with S5HIM during the observation revealed she did not know how many medical records were filed in room #2 but they were dated from 2010 to 2014. S5HIM further stated that the hospital was in the progress of coping all records to electronic form and confirmed that all the medical records were not protected from the sprinkler system. She further stated that there was no specific hospital policy for protecting the medical records from water damage.

Based on observation, record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.


Review of the hospital policy titled Review of Medication Orders for Appropriateness, Policy Number: MM.4.10-1.00, revealed in part: When the pharmacy is closed, all medication orders will be reviewed for appropriateness. The pharmacist on call may be contacted for pharmacy review or two licensed healthcare providers will review orders for appropriateness.

On 11/16/16 at 11:00 a.m., observation in the nursing station revealed a large night cabinet. At that time, interview with S9RN revealed that if a new medication order is obtained after the pharmacy closes, the medication will be pulled from the night cabinet and administered to the patient. When asked if the pharmacist is contacted in order to perform a first dose review of the medication, she stated no.

On 11/16/16 at 11:30 a.m., interview with S8Pharmacist revealed that the hospital pharmacy is open from 7 a.m. to 3 p.m. on Monday thru Friday and from 7 a.m. until finished on Saturday and Sunday. He confirmed that he did not perform a first dose review on new (non-emergent) medications ordered after hours unless he had to come to the hospital due to the medication not being available in the night cabinet. He further stated that he performs a retrospective review of the medication the next morning.

Based on occurrence report reviews, record review and interview, the hospital failed to ensure drug administration errors were documented in the patients' medical records for 2 (Patient #9, 10) of 2 patients reviewed for medication errors.
Findings:

Review of the hospital's occurrence reports revealed medication errors, involving patient #9 (error on 03/08/16) and patient #10 (error on 04/06/16) had been identified. Review of their medical records revealed no documented evidence of an account of the medication errors referenced in the occurence reports.

In an interview on 11/17/16 at 11:40 a.m. with S3RN/Quality Improvement and S8Pharmacist, they confirmed that there was no documentation in the medical records of patients #9 and #10 of the medication errors referenced in the above occurence reports. S3RN further confirmed that she was aware that this information should be documented in the patients' medical records, but this is not something she checked when reviewing the occurence reports.