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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the §485.638 Condition of Participation Clinical Records was out of compliance.

C-1114: For each patient receiving health care services, the CAH maintains a record that includes, as applicable--(ii) Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings. Based on interviews and record review, the facility failed to maintain complete medical records for two out of three medical records reviewed of patients who received care for psychiatric emergencies in the emergency department (Patients #3 and #25). Specifically, the facility failed to have a standard process to ensure services provided by an external mental health provider on behalf of the facility included complete medical records with a mental health evaluation.

Based on interviews and record review, the facility failed to maintain complete medical records for two of three medical records reviewed of patients who received care for psychiatric emergencies in the emergency department (Patients #3 and #25). Specifically, the facility failed to have a standard process to ensure services provided by an external mental health provider on behalf of the facility included complete medical records with a mental health evaluation.

Findings include:

Facility policies:

The Medical Record Content Policy read, consultation reports contain a written or dictated opinion by the consultant that reflect an actual examination of the patient, when applicable, and the patient's medical record. All patient-generated information is documented (i.e., information entered into the record over the Internet or various forms of electronic media from laboratory or other diagnostic avenues, pre-visit clinical data or other types of information). The medical record must be completed within 30 days post patient discharge from the facility.

The Patient Access for Medical Records Policy read, prior to permitting an inspection, or providing copies of records, Health Information Management Department staff will review the medical record to ensure completeness of the record.

1. The facility failed to ensure patient medical records were accurate and complete for services provided by an external mental health provider entity at the request of the facility.

A. Record review

i. Medical record review showed Patient #3 presented to the emergency department on 2/24/23 at 10:45 p.m. via ambulance for suicidality. Patient #1 had a history of depression. On 2/25/23, an external mental health facility performed a crisis evaluation on Patient #1. Upon review, there was no evidence or documentation of a psychiatric medical screening exam in Patient #3's medical record. The medical record indicated patient #3 was then admitted as an inpatient on 2/25/23.

ii. Medical record review showed Patient #25 presented to the emergency department on 7/4/23 at 1:59 p.m. with complaints of depression, anxiety, and suicidality. Patient #25 had a history of bipolar disorder, depression, and anxiety. On 7/4/23, a crisis evaluation was performed on Patient #25 by an external mental health facility. Upon review, there was no evidence or documentation of a psychiatric medical screening exam in Patient #25's medical record. Patient #25 was then discharged from the emergency room to home on 7/4/23 at 4:16 p.m.

The above medical records were in contrast to the Medical Record Content Policy which read consultation reports contained a written or dictated opinion by the consultant that reflected an actual examination of the patient, when applicable, and the patient's medical record.

B. Interviews

i. An interview was conducted with the revenue cycle director (Director #2) on 7/19/23 at 12:24 p.m. Director #2 stated a clerk reviewed each medical record to ensure completeness. Director #2 stated when a medical record was missing items, the clerk requested the missing items for medical record completion. Director #2 stated there was no current auditing process in place to ensure the clerk's reviews were adequate in determining the completeness of medical records. Director #2 stated completed medical records were important because they provided a full picture of care provided to the patient.

ii. An interview with the director of quality (Director #1) was conducted on 7/19/23 at 8:36 a.m. Director #1 stated the expectation was for the external mental health facility to place the completed evaluations in the medical record. Director #1 stated she was unsure of why the evaluations were not in the medical records reviewed.