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Based on interview and record review the facility failed to ensure that all medical records were complete within 30 days after discharge, resulting in the potential for inaccessible information necessary for health care staff to monitor the patients condition. Findings include:

On 12/01/2015 at 1100 during medical record review with staff K, she provided a report of incomplete medical records, 44 medical records were listed as incomplete greater that 30 days, 20 of those records were incomplete greater that 60 days. The list was alphabatized by physician and listed the number of incomplete records by physician.

On 12/02/2015 at 1000 staff K was interviewed and confirmed that there were "44 incomplete medical records greater than 30 days."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated December 2, 2015.
K-0025
K-0029
K-0046
K-0052
K-0056

Based on document review and interview, the facility failed to have all data elements for an operating room register, resulting in the lack of a comprehensive and up to date operating room register as required. Findings include:

Examination of the operating room register for November 2015 with Surgery Manager #A and Assistant Clinical Manager #S, on 12/1/15 at approximately 1100, revealed that the facility used the Operating Room Schedule as the Register. Some information was added on the side, but the log did not include the actual or total time of the surgery, or the post-operative diagnosis as required. This was verified with the Nurse Manager #B on 12/1/15 at 1115. Surgery Manager #B stated, "We're working on a report to capture that information."