HospitalInspections.org
Bringing transparency to federal inspections
PEAK BEHAVIORAL HEALTH SERVICES, LLC
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on record review and interview, the facility failed to ensure staff members completed the medical records for 7 (P#4, P#5, P#6, P#13, P#15, P#16, P#18) of 19 medical records reviewed. This deficient practice could likely result in delayed medically necessary treatment for patients, medical errors or other adverse patient events. The findings are:
A. On 05-16-2017 during record review it was noted that 7 (R#4, R#5, R#6, R#13, R#15, R#16, R#18) of 19 charts reviewed were incomplete. The records included active and discharged patient charts. The missing documentation included but was not limited to unsigned admission forms, history and physicals, and discharge summaries by various practitioners. Also noted, were incomplete seclusion request forms and psychiatric evaluations. Most of the documentation reviewed was not dated and timed.
B. Record review of the Hospital MEDICAL STAFF RULES AND REGULATIONS item #26 indicated: "The physician shall complete the discharge summary within thirty (30) DAYS of the discharge of the patient."
C. Record review of the Hospital MEDICAL STAFF BYLAWS, RULES AND REGULATIONS, reviewed and signed by the Medical Director, Chief Executive Officer (CEO) and Governing Board Chairperson on 01-26-17, Article IV b. indicated: "abide by the medical staff bylaws, rules and regulations, and by all other hospital and service area standards, policies, rules and regulations. Article IV d. reads: prepare and complete in a timely manner medical records and all other required records of all patients he admits or in any way provides patient care services to in the hospital."
D. On 05-16-2017 at 2:40 pm during interview the CEO confirmed that a patient chart is not complete without the signature, date and time of the practitioner who documented. The CEO further stated, "The corporate compliance officer confirmed that all documentation by any practitioner must be signed, timed, and dated within 30 days of the patient's discharge. She [compliance officer] was referring to the medical staff by-laws as well."