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Based on record review and interview, the designated professional staff for maintaining medical records (Personnel #22) did not ensure the following:

1) that the emergency department's (ED) medical records contained accurate dispositions, citing 4 of 26 patients (Patient #16, #20, #21, and #24);

2) that 2 of 26 patients (Patient #15 and #21) discharge summaries were completed; and

3) that assessments of 1 of 2 Allied Health Professionals (Personnel #15-Advanced Nurse Practitioner) for Patient #18, #19, and #22 were co-signed by physicians.

Findings:

1) Patient #16 presented in the ED on 7/25/14 for shortness of breath. The physician did not document Patient #16's disposition. Subsequently, Patient #16 was admitted as an inpatient.

Patient #20 presented to the ED on 10/7/14 at 4:15 PM for respiratory distress symptoms. The physician documented Patient #20's disposition was "discharged to home." Review of Patient #20's medical record indicated the patient was admitted to the medical-surgical floor on 10/8/14 at 10:00 AM.

Patient #21 presented in the ED on 10/9/14 for abdominal pain and "COPD." The physician documented Patient #21's disposition was "discharged to home." Review of Patient #21's medical record indicated the patient was admitted to the medical-surgical floor on 10/10/14 at 12:35 AM.

Patient #24 presented in the ED on 11/11/14 for "left flank pain and chest pain." The physician documented Patient #24's disposition was "discharged to home." Review of Patient #21's medical record indicated the patient was transferred to another facility for a higher level of care.

2) Patient #15 was admitted to the facility on 7/18/14 at 12:00 PM for anemia and blood transfusion. Patient #15 was discharged on 7/20/14. A discharge summary was not completed.

Patient #21 was admitted to the facility on 10/10/14 for abdominal pain and "COPD." Patient #21 was discharged on 10/12/14. A discharge summary was not completed.

3) Personnel #15 performed assessments on the following patients and were not co-signed by a physician as required:
- Patient #18's History and Physical (H&P) on 9/2/14 and Discharge Summary on 9/3/14;
- Patient #19's H&P on 10/6/14 and Discharge Summary on 10/14/14; and
- Patient #22's ED provider assessment on 10/20/14.

In an interview on 11/19/14 from 11:00 AM to 12:00 PM, Personnel #2 (Chief Nursing Officer) was with the surveyor reviewing patient medical records. Personnel #2 confirmed all the above findings.

Medical Staff Rules and Regulations amended on 8/19/14 required "D. Medical Records: 1. Required Content of a Medical Record. The attending physician is ultimately responsible for the timely, legible, accurate, and complete preparation of a medical record for each patient in the hospital...When history and physical examination is recorded by...allied health professionals, the attending physician...will countersign to indicate his/her approval of contents..."