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Based in interview and record review the facility failed to document medical history and physical examinations in a timely manner for 9 of 10 sampled patients (#9, #10, #11, #12, #13, #15, #16, #17, #18) resulting in the potential for incomplete information necessary for health care staff to provide for the patients' health care needs. Findings include:

On 01/07/19 starting at 1345, an interview and record review was conducted with the medical records supervisor (Staff U) to determine patient medical history and physical (H&P) completion and documentation time frames. Staff U indicated the submission date on the H&P form represented the final draft of the document. Staff U indicated data could be entered into the H&P prior to the submission of the final draft. The following patients were noted to have untimely documentation of the H&P. The results were, as follows:

Patient Identifier Admission Date H&P Submission Date
#9 10/11/17 01/16/18
#10 04/10/18 05/14/18
#11 06/04/18 08/09/18
#12 07/11/18 08/23/18
#13 05/07/18 06/05/18
#15 07/23/18 08/23/18
#16 02/15/18 10/20/18
#17 03/21/18 03/23/18
#18 08/01/18 08/23/18

During an interview with the Medical Director (MD CC) on 01/09/19 at 1045, MD CC said the expectation was that the medical history and physical would be completed and documented within 24 hours of the patients' admission to the facility.

On 01/09/19 at 1140 a review was completed of the Medical Staff Bylaws, Rules and Regulations dated 03/01/18. This document indicated on page 42, "Admission History and Physical examinations are to be completed and documented within 24 hours of a patient's admission...".

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

On 01/07/19 starting at 1345, an interview and record review was conducted with the medical records supervisor (Staff U) to determine medical record completion compliance including reviewing medical record delinquency data. Staff U said the expectation was that each patients' medical record was completed within 30 days following discharge. Staff U said the medical record would be delinquent if not completed within 30 days of discharge. Staff U said the facility had notification systems in place to remind clinicians when documentation becomes deficient and/or delinquent but, despite utilizing these systems, some clinicians did not complete the required documentation in a timely manner.

The time frames reviewed were from 09/01/18 through 11/30/18. The data reviewed consisted of the total number of patients discharged in the time period and the actual number and percentage of delinquent charts for the time period. Note, some percentages were rounded for clarity. The results were, as follows:

Month/Year Total Discharges # Delinquent Records % Delinquent
September 2018 8 5 62.5%
October 2018 16 3 18.8%
November 2018 12 4 33.3%

Total number of discharges from 09/01/18 through 11/30/18.
36

Total number of delinquent records from 09/01/18 through 11/30/18.
12

Total percentage of medical records delinquent from 09/01/18 through 11/30/18.
33.3%

During an interview with the Medical Director (MD CC) on 01/09/19 at 1045, MD CC said the expectation was that staff follow facility policy and procedures for medical record documentation.

On 01/09/19 at 1125 a review was completed of facility policy titled, "Medical Records Management" last revised 10/07/18. This policy indicated, under Standards section 5.15, "All medical records shall be completed within 30 days following discharge. The medical record is considered complete when the required contents, including discharge summaries, are assembled and signed.".