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Based on record review, review of Medical Staff Bylaws, and staff interview, the facility failed to ensure that medical records were complete for 6 (#s 2, 3, 4, 5, 6, and 7) of 13 patient records reviewed. Findings include:

1. Patient #2 was admitted to the hospital on 3/17/10. During review of the patient's medical record on 3/30/10, it was noted there was no documentation of a history and physical, diagnosis, or physician visits/progress notes since admission.

2. Patient #3 was admitted to the hospital on 3/28/10. During review of the patient's medical record on 3/30/10, it was noted there was no documentation of a history and physical or physician visits/progress notes since admission.

3. Patient #4 was admitted to hospital on 11/17/09, and discharged on 11/20/09. During review of the patient's closed record on 3/31/10, it was noted there was no documentation of a patient care plan.

4. Patient #5 was admitted to the hospital on 1/6/10, and discharged on 1/11/10. During review of the patient's closed medical record on 3/31/10, it was noted there was no documentation of a history and physical and discharge summary.

5. Patient #6 was admitted to the hospital on 2/12/10, and discharged on 2/15/10. During review of the patient's closed medical record on 3/31/10, it was noted there was no documentation of a patient care plan, history and physical, and discharge summary.

6. Patient #7 was admitted to the hospital on 5/29/09, and discharged on 6/2/09. During review of the patient's closed medical record on 3/31/10, it was noted there was no documentation of a patient care plan, history and physical, and discharge summary.

7. There were no policy and procedures available for the completion of medical records. The facility's Medical Staff Bylaws were reviewed and the Bylaws state that records need to be completed in a timely manner. There were no specifics regarding time frames for record completion.

8. During an interview with the Director of Nursing on 3/31/10 at 3:30 p.m., she acknowledged the medical records were incomplete.

Based on staff interview and review of Medical Staff Bylaws, the facility failed to ensure that sixty-nine discharged patients' medical records had been promptly completed. Findings include:

1. During a review of the medical records department on 3/31/10 at 2:00 p.m., the medical records department manager revealed that there were incomplete discharged patient records. She provided the surveyor with a list of patient records that were incomplete for greater than 30 days. The list contained the following:

- Forty-two emergency room records.
- Fifteen inpatient records.
-2 observation records.

2. The facility's Medical Staff Bylaws, Article III 3.3, D, included the following statement: "Basic Responsibilities of Individual Staff Membership...Prepare and complete in timely fashion the medical and other required records for all patients he/she admits or in any way provides care to in the facility." There were no policy and procedures for completion of records, and the bylaws did not have specific time frames.