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Based on document review and interview, the facility failed to ensure medical staff followed their by-laws related to authentification of medical record (MR) documents in 7 (patient 2, 3, 4, 5, 6, 7, 8) of 10 MR's reviewed:

Findings:

1. Patient 2's MR: Review of Discharge Summary dated 12/10/20 per medical staff D5 (Nurse Practitioner [N.P.]) lacked documentation of review/authentification by a Doctor of Medicine (MD) per signature/time/date.

2. Patient 3's MR: Review of Discharge Safety Plan dated 4/5/21 per staff N11 (Licensed Mental Health Counselor [LMHC]) lacked documentation of an MD's review and authentification per signature/date/time. Review of Discharge Suicide Risk Assessment Note dated 4/5/21 at 1100 hours per staff N12 (Registered Nurse [RN]) lacked documentation of an MD's review, approval and discharge decision per signature/date/time.

3. Patient 4's MR: Review of Discharge Safety Plan dated 4/11/21 at 1800 hours lacked documentation of an MD's review and authentification per signature/date/time. Review of Discharge Suicide Risk Reassessment dated 4/12/21 lacked documentation of an MD's authentification for review, approval, assessment and discharge decision per signature/date/time.

4. Patient 5's MR: Review of Discharge Safety Plan per staff N11 (Therapist) lacked documentation MD's authentification for review/approval per signature/date/time.

5. Patient 6's MR: Review of Discharge Safety Plan dated 1/11/21 per staff N12 lacked documentation of an MD's authentification for review/approval per signature/date/time. Review of Discharge Suicide Risk Reassessment note dated 1/12/21 per staff N12 (Registered Nurse [RN]) lacked documentation of an MD's authentification of review, assessment and discharge decision per signature/date/time. Review of Physician Progress Note dated 1/9/21 at 1230 hours and 1/10/21 at 1305 hours per medical staff D10 (N.P.) lacked documentation of an MD's review per signature/date/time. Review of Physician Progress Note dated 1/11/21 at 1346 hours per medical staff D6 (N.P.) lacked documentation of an MD's review per signature/date/time.

6. Patient 7's MR: Review of patient 7's MR indicated the Discharge Plan was initiated on 3/5/21 at 0800 hours per medical staff D2. Review of Discharge Safety Plan dated 3/5/21 at 1124 hours per staff N13 (Licensed Social Worker [LSW])) lacked documentation of an MD's authentification per signature/date/time for review and approval of the assessment. Review of Discharge Suicide Risk Assessment dated 3/5/21 lacked documentation of an MD's authentification per signature/date/time for review, approval, assessment and discharge decision.

7. Patient 8's MR: Review of Physician Progress Note dated 12/5/20 at 0927 hours per medical staff D8 (N.P.) lacked documentation of review/approval by an MD per signature/date/time. Review of Physician Progress Note dated 12/6/20 at 1420 hours per medical staff D9 (N.P.) lacked documentation of MD's review/approval by signature/date/time.

8. Medical Staff By-laws, indicated:
a. page 8: "3.3.3 abide by all applicable federal and state laws, rules, and regulations and comply with the applicable standards of The Joint Commission and CMS"
b. page 9: "3.3.10 prepare and complete in a timely manner the medical and other required records for all patients he/she admits or in any way provides care in the Facility".

9. On 4/14/21 at approximately 1215 hours, staff N9 (Chief Executive Officer) was interviewed and confirmed MD's should be reviewing/approving and authenticating medical record documents per signature/date/time completed by mid-level providers such as N.P.'s.

Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for documentation in a medical record (MR) for 5 (patient 1, 3, 5, 6, 8) of 10 MR's reviewed:

Findings:

1. Patient 1's MR: Review of Nursing Progress Note and Observation Rounds/Precautions note dated 4/12/21 each lacked documentation of patient identifying information on the note.

2. Patient 3's MR: Review of Observation Rounds/Precautions note dated 3/31/21 lacked documentation of patient identifiers on the note.

3. Patient 5's MR: Review of Observation Rounds/Precautions note dated 2/2/21 lacked documentation of patient identifying information on the note. Review of patient 5's MR found a blank/undocumented Discharge Suicide Risk Reassessment note containing a patient identification sticker only.

4. Patient 6's MR: Review of Discharge Safety Plan dated 1/11/21 per staff N12 (Registered Nurse [R.N.]) lacked documentation of time the assessment was initiated. Review of Discharge Suicide Risk Reassessment note dated 1/12/21 per staff N12 lacked documentation of time the assessment was initiated.

5. Patient 8's MR: Review of Discharge Suicide Risk Reassessment indicated staff N15 completed the patient assessment on 12/9/20 at 1320 hours but failed to document his/her credentials with his/her name and signature.

6. Policy/procedure, Policy No: 1000.06, Medical Records Documentation Requirements, reviewed/revised 3/17, indicated:
a. page 1: "Bloomington Meadows Hospital requires all individuals who have access to and responsibility for documentation in the Medical Record to know, understand and abide by the documentation requirements for his/her discipline".
b. page 5: "Nursing staff complete the Nursing Assessment documentation includes: identifying information".
c. page 6: "Nursing and/or case management completes the Discharge Plan...".

7. On 4/14/21 at approximately 1545 hours, staff N10 (Director of Clinical Services) was interviewed and confirmed patients' MR documents should be documented accurately and completely.

Based on document review and interview, the facility failed to ensure staff followed their policy/procedure for discharge planning in a medical record (MR) for 5 (patient 1, 3, 5, 6, 8) of 10 MR's reviewed:

Findings:

1. Patient 1's MR: Review of patient 1's MR lacked documentation of initiation of a discharge plan. Patient 1 was admitted on 4/12/21.

2. Patient 2's MR: Review of Discharge Plan indicated it was initiated on 12/2/20 per medical staff D5 (Nurse Practitioner [N.P.]). Patient 2 was admitted on 11/25/20.

3. Patient 3's MR: Review of Discharge Plan indicated it was initiated on 4/5/21 per staff N11 (Licensed Mental Health Counselor [LMHC]). Patient 3 was admitted on 3/31/21.

4. Patient 4's MR: Review of Discharge Plan indicated it was initiated on 4/12/21 per staff N11. Patient 4 was admitted on 4/5/21.

5. Patient 5's MR: Review of Discharge Plan indicated it was initiated on 2/12/21 per medical staff D2 (Doctor of Medicine [M.D.]). Review of patient 5's MR found a blank/undocumented Discharge Suicide Risk Reassessment note containing a patient identification sticker only. Patient 5 was admitted on 2/2/21.

6. Patient 6's MR: Review of Discharge Plan indicated it was initiated on 1/12/21 per medical staff D1 (M.D.). Patient 6 was admitted on 1/7/21.

7. Patient 7's MR: Review of Discharge Plan indicated it was initiated on 3/5/21 at 0800 hours per medical staff D2. Patient 7 was admitted on 2/22/21.

8. Patient 8's MR: Review of Discharge Plan indicated it was initiated on 12/9/20 per medical staff D7 (M.D.). Patient 8 was admitted on 12/1/20.

9. Policy/procedure, Policy No: 703.02, Aftercare/Discharge Plan, reviewed/revised 1/20, indicated: "Interdisciplinary team begins discharge planning at time of admission...".