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Based on record review and interview, the hospital failed to use ensure the program data requirements were met by failing to implement a quality assurance and performance improvement plan with the data collected to address the high medical record delinquency rate.
Findings:
Review of the hospital's "Medical Staff Rules and Regulations" presented by S1Administrator as the current medical staff rules and regulations revealed, in part, "the attending practitioner shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnoses, and discharge summary."
Review of the delinquent chart report presented by S1Administrator, revealed "as of 03/20/13 at 8:20 a.m." there was a total of 463 charts that were delinquent greater than 120 days. Further review of the delinquent chart report revealed there was a delinquency rate of 30.16 percent.
In a face-to-face interview on 03/19/13 at 1:15 p.m., S10Medical Record indicated she sends the monthly delinquency reports for medical records to S1Administrator.
In a face-to-face interview on 03/19/13 at 1:30 p.m., S1Administrator indicated that the time frame for completion of the medical record by the physician was thirty days. He also indicated that if physicians were not compliant with completing the medical record, the physicians were forwarded a "series of letters" to complete the record(s), and the physicians, according to the medical staff bylaws, could have their admitting privileges suspended for noncompliance with completion of the medical record(s).
In an interview on 03/21/13 at 2:10 p.m., S11Medical Record indicated she informed S1Administrator in June, 2012, of the medical record delinquency rates. She also indicated she made a recommendation in October, 2012, that the medical record be "flagged" and be available to physicians on the units for needed documentation while the patient was still in the hospital. S11Medical Record indicated she thought this measure would expedite timely correction of deficient medical records. S11Medical Record further indicated that she was "not directed to do any QA (Quality Assurance)."
In a face-to-face interview on 03/22/13 at 10:40 a.m., S2DON indicated that S3Intake Coordinator was responsible for quality assurance and performance improvement activities.
In a face-to-face interview on 03/22/13 at 11:00 a.m., S1Administrator, S2DON, and S3Intake Coordinator indicated there were no quality assurance and performance improvement initiatives implemented by the hospital to address the high volume of medical record deficiencies. S1Administrator, S2DON, and S3Intake Coordinator confirmed that the medical record deficiencies have been a long-standing problem at the hospital.

Based on record review and interviews, the hospital failed to enforce its Medical Staff Bylaws by failing to address the medical staff regarding the medical record delinquency rates.
Findings:
Review of the hospital's "Medical Staff Rules and Regulations" presented by S1Administrator as the current medical staff rules and regulations revealed, in part, "the attending practitioner shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnoses, and discharge summary."
Review of the delinquent chart report presented by S1Administrator, revealed "as of 03/20/13 at 8:20 a.m." there was a total of 463 charts that were delinquent greater than 120 days. Further review of the delinquent chart report revealed there was a delinquency rate of 30.16 percent.
In a face-to-face interview on 03/19/13 at 1:15 p.m., S10Medical Record indicated she sends the monthly delinquency reports for medical records to S1Administrator.
In a face-to-face interview on 03/19/13 at 1:30 p.m., S1Administrator indicated that the time frame for completion of the medical record by the physician was thirty days. He also indicated that if physicians were not compliant with completing the medical record, the physicians were forwarded a "series of letters" to complete the record(s), and the physicians, according to the medical staff bylaws, could have their admitting privileges suspended for noncompliance with completion of the medical record(s).
In an interview on 03/21/13 at 2:10 p.m., S11Medical Record indicated she informed S1Administrator in June, 2012, of the medical record delinquency rates. She also indicated she made a recommendation in October, 2012, that the medical record be "flagged" and be available to physicians on the units for needed documentation while the patient was still in the hospital. S11Medical Record indicated she thought this measure would expedite timely correction of deficient medical records. S11Medical Record further indicated that she was "not directed to do any QA (Quality Assurance)."
Review of the documents provided by S1Administrator revealed, in part, the following:
A letter dated 01/03/11 from S1Administrator to S7Medical Director informing him of the suspension of his medical staff privileges as of 01/03/11 due to outstanding delinquent records.
In a face-to-face interview on 03/22/13 at 9:15 a.m., S1Administrator confirmed he had not sent any letters to medical staff suspending their privileges due to medical record deficiencies.
In a face-to-face interview on 03/22/13 at 11:00 a.m., S1Administrator, S2DON, and S3Intake Coordinator indicated there were no quality assurance and performance improvement initiatives implemented by the hospital to address the high volume of medical record deficiencies. S1Administrator, S2DON, and S3Intake Coordinator confirmed that medical record deficiencies have been a long-standing problem at the hospital.
Review of the minutes for the Governing Board revealed no documentation on discussion of delinquent medical records and enforcement of medical staff bylaws.
In an interview on 03/21/13 at 12:45 p.m., S1Administrator indicated that there have been no "formal" discussions with the Governing Board regarding medical record deficiencies and enforcement of medical staff bylaws.
In a face-to-face interview on 03/22/13 at 11:15 a.m., S1Administrator indicated he did not know why S7Medical Director was so far behind in correcting his medical record deficiencies. S1Administrator also indicated the Medical Staff Bylaws were not enforced to address the medical record delinquency rates, and he did not know why he hasn't enforced the bylaws suspension policy. S1Administrator further stated he just keeps sending letters to the physicians alerting them to their medical record deficiencies.

Based on interview and record review, the hospital failed to ensure the nursing staff developed, and kept current, a care plan for each patient as evidenced by all medical diagnosis not being included in the plans of care for 5 (#6, #7, #8, #15, #16) of 30 (#1- #30) patients sampled.
A review was made of the Policy and Procedure presented by the hospital as current titled Treatment Plans, Policy 1.37. Review of the policy revealed in part:
Each patient will have an individualized treatment plan that is based upon the assessments of the patient ' s clinical needs and is reviewed and revised if needed during the course of treatment.
3. The Master Treatment Plan shall be clearly linked to the assessment process. It shall:
o. Include any test results, medical conditions, medical treatment, rehabilitative service, diet limitations, significant lab findings, medications, fall risk and infection.

Patient #6
Review of the medical record for Patient #6 revealed he had been admitted to the hospital on 3/16/13 at 10:00 a.m. for having bizarre thoughts. Further review of the history and physical dated 3/18/13 at 12:30 p.m. revealed the following entry: Hard of hearing-pt. (patient) is very HOH (hard of hearing) but literate. Interview conducted by writing back and forth.
Review of the interdisciplinary treatment plan for Patient #6 revealed the problems Psychosis with Behavioral Impairment and Threat of Harm to Self. Further review revealed no care plans had been initiated for Patient #6 ' s hearing impairment.
Patient #7
Review of the medical record for Patient #7 revealed she was a 44 year old female that had been admitted to the hospital on 3/17/13 with diagnosis which included Depression with Suicidal Ideations. Review of the Psychiatric History dated 3/18/13 at 7:31 p.m. revealed an Axis I diagnosis of: Major Depressive Disorder, Recurrent, Severe. Further review revealed an Axis III diagnosis of: Medical factors contributory to Axis I: Chronic Pain.
Review of the interdisciplinary treatment plan for Patient #7 revealed care plans for the problems Depression and Substance abuse. Further review revealed no care plans had been initiated for chronic pain.
Patient #8
Review of the medical record for Patient #8 revealed he had been admitted to the hospital on 3/13/13 at 1615 with diagnosis which included Bipolar disorder and Polysubstance abuse. Review of the History and Physical for Patient #8 revealed an assessment of right hip pain.
Review of the Physician ' s Orders for Patient #8 revealed the following orders for pain medication:
3/12/13 at 1:00 p.m. - Skelaxin 800mg (milligrams) po tid prn (by mouth three times per day as needed) back pain.
3/19/13 - Lortab 5/500 po q 6 hours (every 6 hours) prn pain.
3/19/13- Percocet 5/325 1 po BID (twice per day) prn pain greater than 7/10 (pain scale 7 out of 10).

Review of the Plans of Care for Patient #8 revealed plans for the problems Psychosis with Behavioral Impairment, Substance Abuse, Altered Tissue Perfusion, Seizure Disorder, and unstable Mood. Further review revealed no care plans had been initiated for chronic pain.
Patient #16
Review of the medical record for Patient #16 revealed she had been admitted to the hospital on 3/16/13 with diagnosis which included Schizoaffective Disorder. Review of the History and Physical dated 3/18/13 at 7:45 a.m. revealed a medical diagnosis of COPD (Chronic Obstructive Pulmonary Disease).
Review of the Plans of Care for Patient #16 revealed care plans for the problems Alteration in Tissue Perfusion, Depression, and Pain. Further review revealed no care plans had been initiated for COPD.
In an interview on 3/20/13 at 1:20 p.m. with S1DON, she stated medical problems as well as psychiatric problems should be addressed in the care plans for the patients.


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Patient #15
Patient #15 was a 44-year-old female admitted to the hospital on 03/14/13 with diagnoses of schizoaffective disorder, gastroesophageal reflux disease (GERD), constipation, and multiple sclerosis (MS). Patient #15 was also identified as being wheelchair bound.
Review of the Interdisciplinary Plan of Care for Patient #15 revealed there were no care plans written for the diagnoses of multiple sclerosis, GERD, or fall prevention.
In a face-to-face interview on 03/20/13 at 2:00 pm, S2DON indicated there were no care plans written for the diagnoses of multiple sclerosis, GERD, or fall prevention for Patient #15. S2DON further indicated that the above mentioned care plans should have been completed for Patient #15.

Based on record review and interview, the hospital failed to ensure that medical record services were appropriate to the scope and complexity of the services performed by failing to ensure that medical record services was supervised by a qualified medical records practitioner.
Findings:
In a face-to-face interview on 03/19/13 at 1:10 p.m., S1Administrator indicated that S10Medical Record was not the director of medical record services, and S10Medical Record was not certified in health information services. S1Administrator further indicated S11Medical Record was a contract employee, and she was the person responsible for medical record services. He further indicated S11Medical Record was certified in heath information services.
In a face-to-face interview on 03/19/13 at 1:15 p.m., S10Medical Record indicated that she was trained by S11Medical Record, and she does not have any health information or medical record services certification. S10Medical Record also indicated she has been in this position since June, 2012, and she is a full-time employee. S10Medical Record also indicated she had 7 hours of on-site training with S11Medical Record.
In an interview on 03/21/13 at 2:10 p.m., S11Medical Record indicated that she was hired as a medical records consultant at the hospital on an as needed (PRN) basis. She indicated that her function was to be a consultant for the hospital in an advisory role, to train a new medical records employee, and to perform statistical calculations for raw data provided to her on a monthly basis. S11Medical Record also indicated that she does not consider herself responsible for the overall function of medical record services because "I'm not there enough to be responsible or to be a supervisor because I have another full-time job." S11Medical Record further indicated that S10Medical Record was responsible for the day-to-day operations of medical record services, and that S1Administrator was ultimately responsible for medical record services.
Review of S11Medical Record payroll statement revealed she was on site at the hospital for a total of 10.75 hours since June, 7, 2012 (date of hire).
In a face-to-face interview on 03/21/13 at 2:20 p.m., S1Administrator acknowledged that S11Medical Record indicated she was not responsible for the operations of medical record services at the hospital.

Based on record reviews and interviews the hospital failed to ensure patient medical records were promptly completed within 30 days from the patient's date of discharge as required by the hospital's Medical Staff Bylaws and Medical Staff Rules and Regulations.
Findings:
Review of the hospital's "Medical Staff Bylaws" presented by S1Administrator as the current medical staff bylaws revealed, in part, that the medical record of a discharged patient was to be completed within 30 days by the physician following the patient's discharge from the hospital.
Review of the hospital's "Medical Staff Rules and Regulations" presented by S1Administrator as the current medical staff rules and regulations revealed, in part, "the attending practitioner shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnoses, and discharge summary."
Review of the delinquent chart report presented by S1Administrator, revealed "as of 03/20/13 at 8:20 a.m." there was a total of 463 charts that were delinquent greater than 120 days. Further review of the delinquent chart report revealed there was a delinquency rate of 30.16 percent.
In a face-to-face interview on 03/19/13 at 1:15 p.m., S10Medical Record indicated she sends the monthly delinquency reports for medical records to S1Administrator.
In a face-to-face interview on 03/19/13 at 1:30 p.m., S1Administrator indicated the time frame for completion of the medical record by the physician was thirty days. He also indicated that if physicians were not compliant with completing the medical record, the physicians were forwarded a "series of letters" to complete the record(s), and the physicians, according to the medical staff bylaws, could have their admitting privileges suspended for noncompliance with completion of the medical record(s).

Based on interview, the hospital failed to have a system of coding and indexing medical records that allowed for timely retrieval by diagnoses and procedures.
Findings:
In a face-to-face interview on 03/6/13 at 1:05 p.m., S4Medical Record indicated the hospital did not have an electronic medical record system that enabled medical record information to be accessed by patients' diagnoses or procedures. S4Medical Record further indicated that the retrieval of this information had to be done manually.

Based on observation and interview, the hospital failed to ensure all entries in the medical records by the physicians and nurses were timed and/or dated for (#2, #9, #10, #4, #13, #15, #17, #27, #28) of 30 (#1- #30) patients sampled.
Findings:
Review of the Medical Staff Rules and Regulations revealed in part:
9. All clinical entries in the patient ' s medical record shall be accurately dated, timed, and authenticated.

Patient #9
Review of the medical record for Patient #9 revealed she had been admitted to the hospital on 3/14/13 at 6:45 a.m. with diagnosis which included Schizophrenia.
A review of the Physician ' s Orders for Patient #9 revealed the following order:
D/C (discontinue) Geodon. Geodon 120mg (milligrams) po q hs (by mouth every hour of sleep). Geodon 80mg po q a.m.
Further review revealed the order had been signed by S7Medical Director, but had not been dated or timed. This finding was verified by S3Intake Coordinator on 3/22/13 at 9:15 a.m.

A review of the History and Physical for Patient #9 revealed it had been signed by S13NP, but had not been dated or timed. This finding was verified by S3Intake Coordinator on 3/22/13 at 9:15 a.m.

Patient #17
Review of the medical record for Patient #17 revealed she had been admitted to the hospital on 3/16/13 at 10:30 a.m. with diagnosis which included Chronic Paranoid Schizophrenia.
A review was made of the document titled Patient Admission Consent for Treatment/Financial Responsibility/Authorizations, Rights and Assignments. The document had been signed by S6RN on 3/16/13, but the entry had not been timed.
Patient #27
Review of the medical record for Patient # 27 revealed she had been admitted to the hospital on 1/29/13 at 1445 with diagnosis which included Bipolar, Medication non-compliance, intrusive behavior and hypersexuality.
A review of the History and Physical revealed it had been signed by S5Physician and dated 1/30/13, but not timed.


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Patient #4

Review of the medical record for Patient #4 revealed he was admitted on 03/11/13. Patient # 4 had a Durable Healthcare Power of Attorney for medical and mental health. Further review of the medical record revealed Patient #4 was admitted under a PEC dated 3/11/13 at 1:15 p.m. for "Danger to others." Patient #4 was living in a group home and displayed agitation and aggressive and violent behavior. Patient #4 was intrusive, other residents were scared of him. Behavior was documented as erratic and impulsive - on the aggressive intrusive side. Medical History was documented as: Dementia, HTN, CAD, Polycythemia, CABG (coronary artery bypass graft). Current meds: Risperdal, Zyprexa, Depakote, Trazodone. Allergies: PCN . Admission Diagnosis. Axis I: Psychosis (Atypical). Problems: psychosis, agitation, paranoid, aggressive. anger, irritability, hostility.

Review of the History and Physical for Patient #4 revealed there was no time documented when the H&P was done.

In an interview on 03/19/13 at 2:02 p.m. with S2DON she confirmed the History and Physical had no documented time.


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Patient #2
Patient #2 was a 39 year-old male admitted to the hospital on 03/15/13 with diagnoses of major depressive disorder and hypertension.
Review of the medical record revealed that the consent form entitled "Patient Admission Consent for Treatment/Financial Responsibility/Authorizations Rights and Assignments" was signed and dated by the patient and the witness. Further review revealed the form did not have the time documented.
In a face-to-face interview on 03/19/13 at 2:15 p.m., S2DON indicated the above referenced form did not have a time documented, and there should have been a time documented on the form.
Patient # 10
Patient #10 was a 30 year-old male admitted to the hospital on 03/11/13 with a diagnosis of schizoaffective disorder.
Review of Patient #10's History and Physical (H&P) revealed there was no time documented on the history and physical examination form by S12Physician.
Review of Patient #10's "Admit/Discharge Medication Reconciliation and Order Sheet" revealed there was no time documented by S14RN with her signature dated 03/11/13.
In a face-to-face interview on 03/20/13 at 9:30 a.m., S2DON indicated there was no time documented on Patient #10's history and physical, and there should have been a time recorded on the history and physical. S2DON further indicated there was no time documented by S14RN with her signature dated 03/11/13, and there should have been a time documented.
Patient #13
Patient #13 was a 94 year-old female admitted to the hospital on 03/06/13 with a diagnosis of psychosis.
Review of the "Admit/Discharge Medication Reconciliation and Order Sheet" dated 03/06/13 for Patient #13 revealed there was no time documented by S7Medical Director.
In a face-to-face interview on 03/20/13 at 1:00 p.m., S6RN indicated there was no time documented on the above referenced form by S7Medical Director, and there should have been a time documented.
Patient #15
Patient #15 was a 44 year-old female admitted to the hospital on 03/14/13 with diagnoses of schizoaffective disorder, depression, anemia, gastroesophageal reflux disease (GERD), constipation, and multiple sclerosis (MS).
Review of the "Formal Voluntary Admission" form for Patient #15 revealed there was no date or time documented on the form by S7Medical Director.
In a face-to-face interview on 03/20/13 at 1:18 p.m., S6RN indicated there was no date and time documented by the S7Medical Director, and there should have been a date and time documented.
Review of the History and Physical for Patient #15, dated 03/15/13, revealed there was no time documented by S12Physician on the history and physical form.
In a face-to-face interview on 03/20/13 at 1:25 p.m., S2DON indicated there was no time documented by S12Physician, and there should have been a time documented.
Review of the physician order sheet for Patient #15 with dated entry of 03/20/13 revealed no time documented by S8Physician.
In a face-to-face interview on 03/20/13 at 1:55 p.m., S6RN indicated there was no time documented on the dated entry of 03/20/13 by S8Physician, and there should have been a time documented.
Patient #28
Patient #28 was a 52-year-old male admitted to the hospital on 01/30/13 with a diagnosis of schizophrenia, chronic paranoid, and psychosis.
Review of Patient #28's History and Physical revealed S5Physician signed and dated (01/31/13) the history and physical form. Further review revealed there was no time documented by S5Physician.
In a face-to-face interview on 03/21/13 at 10:20 a.m., S3Intake Coordinator indicated there was no time documented by S5Physician, and there should have been a time documented.

Based on interview and record review, the hospital failed to ensure a medical history and physical was completed and documented within 24 hours of admission for 3 (#6, #16, #17) of 19 (#1 - #19) current patients sampled.
Findings:
Review of the Medical Staff Bylaws presented as current by the hospital revealed in part:
b). A complete, legibly hand written or typed medical admission history and physical examination shall be recorded within twenty-four hours of admission.

Patient #6
Review of the medical record for Patient #6 revealed he had been admitted to the hospital on 3/16/13 with diagnosis which included Chronic Paranoid Schizophrenia. Further review revealed the history and physical had not been completed until 3/18/13 at 12:30 p.m. by S12Physician.
Patient #16
Review of the medical record for Patient #16 revealed she had been admitted to the hospital on 3/16/13 at 2:45 p.m. with diagnosis which included Schizoaffective Disorder. Further review revealed the History and Physical had not been completed until 3/18/13 at 07:45 a.m. by S13NP.
Patient # 17
Review of the medical record for Patient #17 revealed she had been admitted to the hospital on 3/16/13 at 10:30 a.m. with diagnosis which included Chronic Paranoid Schizophrenia. Further review revealed the History and Physical had not been completed until 3/18/13 at 07:30 a.m. by S13NP.
In an interview on 3/20/13 at 2:00 p.m. with S2DON, she verified the above mentioned Histories and Physicals for Patients #6, #16, and #17 had not been completed within the 24 hour time frame allowed by the Governing Body Bylaws and was a mistake.

Based on interview and record review, the hospital failed to ensure there was a director of respiratory care services who was a doctor of medicine with the knowledge, experience, and capabilities to supervise the service properly.
Findings:
Review of the Medical Executive Meeting minutes revealed no appointment of a physician to be director of respiratory services.
In an interview on 3/19/13 at 1:10 p.m. with S3RN, she stated S4RT was the director of respiratory services. S3RN also verified no physician was director of the service.
In an interview on 3/19/13 at 1:15 p.m. with S1Administrator, he verified no physician had been appointed by the governing body to be the director of respiratory services.
In an interview on 3/19/13 at 1:30 p.m. with S4RT, he stated he was the director of respiratory services at the hospital. S4RT stated there was no physician appointed as director of respiratory services.