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Based on interview, medical record review and review of the facility's policies, it was determined the facility failed to ensure the accuracy of medical record entries (A438). The facility failed to ensure discharge summaries were completed in the time frame specified by the facility's policy (A468). The facility failed to ensure medical records were completed within 30 days of patient discharge (A469). The cumulative effect of these systematic practices resulted in the facility's inability to ensure medical records were complete and accurate.

Based on medical record review, policy review and staff interview, it was determined the hospital failed to ensure the accuracy of medical record entries as it pertains to the patient's level of consciousness for two (Patient #7 and #11) of eleven records reviewed. The census at the time of the survey was 346.

Findings include:

1. The medical record for Patient #7 was reviewed on 4/10/14. Patient #7 was admitted to the hospital on 3/8/14. The charge nurse for the intensive care unit the patient was admitted reported, and the nursing notes reflect, the patient had been sedated since the time of admission. An operative report for a bronchoscopy and tracheostomy performed by the physician on 3/31/14 revealed, "Due to prolonged intubation, the patient wanted the above procedure." The consent for the procedure of 3/31/14 was signed by the patient's mother. This finding was confirmed with Staff C on 4/10/14 at 9:05 AM.

2. The medical record review for Patient #11 was completed on 4/10/14. Patient #11 was admitted to the facility on 3/21/14. The record contained evidence an Echocardiogram was completed on 3/22/14 at 7:46 AM. The Echocardiogram procedure notes stated Patient #11 verbally identified self and expressed understanding of the procedure.

On 4/10/14 at 8:21 AM, Staff A and Staff G were interviewed. The Staff A reported that he/she had spoken to the physician who documented in the medical record that Patient #11 verbally identified self prior to a procedure. Staff A stated that the physician reported Patient #11 did not verbally identify his/herself and that the physician had selected the incorrect statement from a drop down box in the electronic medical system. During this interview Staff G reported Patient #11 arrived to the facility intubated and was not extubated during Patient #11's admission, therefore, Patient #11 would not be able to verbally identify self.

The electronic medical system contained neurological exams completed by registered nurses. On 3/24/14, nurses documented "Yes" to signify Patient #11's pupils were equally round and responded to light and accommodation from 3:00 AM on 3/24/14 until 6:00 PM on 3/24/14. On 3/24/14 at 2:35 AM, a neurologist documented Patient #11 had unequal pupils which are both non-reactive.

Staff G was interviewed on 4/10/14 at 8:36 AM and stated the nurses incorrectly documented "Yes" to indicate Patient #11's pupils were equally round and responding to light and accommodation from 3:00 AM through 6:00 PM on 3/24/14.

Review of the facility's policy titled "EMR-4- Master UH Care Clinical Documentation by licensed Independent Practitioners Policy & Procedure", last review date 11/11/13, stated as with paper records, Licensed Independent Practitioners (LIPs) are responsible for assuring the accuracy, completeness and timeliness of clinical documentation in
the facility.

Based on medical record review, policy review and interview, the facility failed to ensure the medical record of one patient (Patient #11) of 11 medical records reviewed contained a discharge summary according to the facility's policy. This had the potential to affect every patient who is discharged from the facility. The facility's active census at the time of the survey was 346.

Findings include:

The medical record review for Patient #11 was completed on 4/11/14. Patient #11 was admitted to the facility on 3/21/14 and expired on 3/26/14. The medical record did not contain a discharge summary on 4/9/14 at 2:18 PM.

On 4/9/14 at 2:55 PM, the findings were shared with Staff H and confirmed. Staff H reported the facility has 48 to 72 hours after a patient's discharge to complete a discharge summary.

On 4/9/14 at 2:58 PM, the facility's policy titled "GM-49- Medical Records Completion", last reviewed 8/2013, stated a delinquent record is defined as a medical record that does not have evidence of a dictated and authenticated discharge summary, within one week, for stays greater than 48 hours and all deaths.

Based on review of facility documents, policy review and interview, the facility failed to ensure medical records were completed within 30 days of patient discharge for 2638 patients who were discharged greater than 30 days ago. This had the potential to affect every patient who is discharged from the facility. The facility had 346 active patients at the time of the survey.

Findings include:

On 4/9/14 at 10:38 AM, the facility's delinquent case report was reviewed. The report revealed the facility had 2638 incomplete medical records greater than 30 days after the patient was discharged.

The Record Processing and Release of Information Manager (RHIT), Staff B, was interviewed on 4/10/14 at 10:38 AM. Staff B reported the facility currently had a total of 2638 incomplete medical records of patients discharged greater than 30 days ago. Staff B stated the physicians are not actually suspended. Staff B stated the delinquency reports are emailed to the chiefs weekly and it is up to the chiefs to determine what enforcement actions are placed on the physicians who have delinquent records.

On 4/9/14 at 2:58 PM, review of the facility's policy titled "GM-49- Medical Records Completion", last reviewed 8/2013, policy stated:

1. A delinquent medical record is defined as a medical record that is incomplete thirty (30)
days post-patient discharge.

2. For purposes of delinquency tracking, a delinquent record is defined as a medical record
that does not have evidence of a(n):

2.4 Dictated and authenticated discharge summary, within one week, for stays greater
than 48 hours and all deaths.