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Based on record review and interview, the CAH failed to ensure the clinical records system was maintained in accordance with written policies and procedures. This deficient practice was evidenced by failure to ensure all delinquent medical records were completed as set forth in the CAH's policies for completion of medical records.

Findings:

Review of the hospital policy titled," Chart Analysis" revised 08/29/14 revealed in part: The medical record will be analyzed to ensure that all documents are completed and authenticated at the time of discharge.

Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part: 3.B Relinquishment Related to Medical Records. 3. B.1 Failure to Complete Medical Records: A staff member shall be considered to have delinquent medical records if, after 30 days from the date the chart of a discharged patient is presented for completion, the record remains incomplete. After 15 days have elapsed from the time the record is presented for completion and it is incomplete, the physician's office staff will be notified by email by Health Information Management that there are 15 days remaining before the record is delinquent. If the record remains incomplete after the 23rd day, the physician will be notified by hand delivered mail that he or she has 7 days in which to complete the record ...If, after this 7 day period, the record remains incomplete, this will be taken as evidence of voluntary resignation from the Medical Staff.

Review of the Deficiency Report by Physician dated 06/12/17 provided by S6Medical Records Director, revealed the following:

S7Physician: #1 record - 36 days deficient; #1 record - 31 days deficient.
S8Physician: #1 record - 43 days deficient; #1 record - 39 days deficient; #1 record - 34 days deficient.
S9Physician: #1 record - 136 days deficient; #1 record - 109 days deficient; #1 record - 108 days deficient.
S10Physician: #1 record - 192 days deficient; #1 record - 63 days deficient.

Interview on 06/13/17 at 9:15 a.m. with S6Medical Records Director confirmed the delinquent medical records and stated that she was unaware of any letters sent to the physicians concerning their delinquent records.

Based on observation and interview, the CAH failed to ensure patient medical records were protected against loss or destruction as evidenced by failure to protect approximately 52 boxes of patient medical records from 2002 to 2005 that had not been scanned, copied or backed up, from potential destruction/damage from fire and/or water.

Findings:

An observation was made of the hospital's medical records storage area at the Armory on 06/13/17 at 10:45 a.m. There were approximately 52 large cardboard bankers boxes that contained paper patient medical records dated from 2002 to 2005. The boxes were stacked on the floor against the back wall of the room. The room contained no sprinklers but the records were not protected from fire or water damage.

Interview on 06/14/17 at 12:50 p.m. with S4RHIA/CFO stated that there was no hospital policy for the protection of the medical records that were stored at the Armory. S4RHIA/CFO further stated that those records were in the process of being scanned into the electronic system.