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Based on record reviews, (Governing Bylaws, Medical Staff Bylaws, and Medical Record Analysis policy), observation, and staff interviews, the hospital's Governing Body failed to ensure the Medical Staff Bylaws were enforced in regards to ensuring compliance with the medical records services. This was evidenced by the licensed practitioners (psychiatrist) failure to comply with the Medical Records Analysis, reference number 4093, policy for all practitioner entries in the medical record must be signed, including date and time by having eight hundred and thirteen (813) medical records delinquent greater than thirty (30) days
with no dates/times recorded by the Psychiatrists, (S4, S5, S14, S15) on their Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 through 04/19/12. These 813 delinquent medical records were filed in the metal filing cabinet in the medical records department as accurate and complete. Findings:

During an observation of the medical records department on 04/20/12 from 9:00 a.m. through 11:25 a.m., a list of the computer's delinquent medical records were printed from 9:29 a.m. through 9:42 a.m. from 06/30/11 through 04/19/12. The computer printout of the hospital's delinquent medical records revealed there were 813 medical records delinquent greater than thirty (30) days for S5Psychiatrist from 06/30/11 to 04/19/12. There were one hundred and twenty-one (121) medical record delinquent greater than thirty (30) days, one hundred and fourteen (114) medical records delinquent greater than sixty (60) days, and three hundred and eighty-nine (389) medical records delinquent greater than one hundred and twenty (120) days for S5Psychiatrist. At this time, there were 13 random delinquent medical records (#R1 through #R13) pulled from the 813 delinquent medical records by the Medical Record Clerk (S10). From 9:35 a.m. through 11:25 a.m., the Medical Record Clerk was observed pulling the 13 random medical records from the metal filing cabinets located up against the back wall in the department. S10Medical Record Clerk indicated all medical records filed in the filing cabinets are accurate and complete. The Medical Record Clerk, (S10) denied knowledge of how many medical records were delinquent greater than 30 days, delinquent greater than 60 days, delinquent greater than 90 days and/or delinquent greater than 120 days. S10 indicated the patient's medical record is brought to the medical records department after the patient is discharged from the hospital. S10Medical Record Clerk indicated she receives the patient's medical record after they are discharged from the hospital. At this time, she reviews the medical record for incompleteness including no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluation in which she flags the record for the practitioner (S4, S5, S14, S15) to complete. The medical record is kept on the counter for thirty (30) days then the flag is removed from the medical record and it is filed in the metal cabinet as accurate and complete. S10Medical Record Clerk indicated all 813 medical records are filed in the cabinet but they are inaccurate and incomplete with no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 to 04/19/12.

Review of the computer delinquent medical records print-out from 06/30/11 through 04/19/12 revealed there were one hundred and twenty-one (121) medical records delinquent greater than thirty (30) days for S5Psychiatrist and there were six hundred and ninety-two (692) medical records delinquent greater than sixty days (60) days for S5Psychiatrist. There were eight hundred and thirteen (813) delinquent medical records for S5Psychiatrist from 06/30/11 through 04/19/12. Further review of the computer delinquent medical records revealed there were no delinquent medical records for the other Psychiatrists, (S4, S14, and/or S15) from 06/30/11 through 04/19/12. The computer printout list failed to have documented evidence of what each deficiency was in each of the 813 delinquent medical records from 06/30/11 to 04/19/12.

A sample selection of 5 of 5 medical records were reviewed (#1, #2, #3, #4, #5) and a random sample of 13 focused medical records (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13) out of the 813 delinquent medical records were reviewed for dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of 13 random sampled patient records, (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13) and 5 of 5 sampled records (#1, #2, #3, #4, #5) with no dates/times recorded on the practitioner's (S4Psychiatrists, S5Psychiatrist, S14Psychiatrist, and/or S15Psychiatrist) Progress Notes. The Progress Notes for the 13 random patient records (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13) and 5 sampled patient records (#1, #2, #3, #4, #5) were filed in each patient's medical records and the medical record was observed filed in the metal filing cabinet as accurate and complete on 04/19/12. Further review revealed there were 9 of the 13 random focused patient records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled patient records (#2, #3) with no dating/timing recorded on the Psychiatric Evaluations by the practitioner's (S4, S5, S14, and/or S15). The Evaluations for the 9 of 13 random patient records and 3 of the 5 sampled patient records were filed in each patient's medical record and observed filed in the metal filing cabinet as accurate and complete on 04/19/12.

In interviews on 04/19/12 from 1:45 p.m. through 2:00 p.m. and on 04/20/12 from 9:15 a.m. through 11:55 a.m. and on 04/20/12 from 9:20 a.m. through 11:55 a.m., S9Medical Record Director confirmed there were 813 medical records delinquent greater than 30 days for S5Psychiatrist from 06/30/11 to 04/19/12. S9 verified there were 121 records delinquent greater than 30 days, there were 114 records delinquent greater than 60 days, there were 189 records delinquent greater than 90 days, and there were 389 records delinquent greater than 120 days. The Medical Record Director S9 confirmed the 13 random patient records (#R1 through #R13) were delinquent records filed in the filing cabinet as accurate and complete on 04/20/12. S9 further confirmed the Psychiatric Progress Notes in the 13 random patient records (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#12, R#13) and 5 sampled patient records (#1, #2, #3, #4, #5) did not have dates/times recorded on them by the Psychiatrists, S4, S5, S14, and/or S15. The Psychiatric Progress Notes for the 13 random sampled patients and 5 sampled patients were all filed in the patient's medical records in the metal filing cabinets as accurate and complete on 04/19/12. The Medical Record Director confirmed there were 9 of 13 random sampled records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled records (#2, #3) with no dates/times recorded on the Psychiatric Evaluations. The Evaluations for these 9 random sampled patients and 2 sampled patients were filed in each patient's medical records and the file was placed in the metal filing cabinets as accurate and complete on 04/19/12. S9Medical Record Director verified there were one hundred and twenty-one (121) delinquent medical records greater than thirty (30) days delinquent for S5Psychiatrist. She further verified there were 692 delinquent medical records greater than sixty (60) days delinquent for S5Psychiatrist that were filed in the metal filing cabinet as accurate and complete with no dates/times recorded on the practitioner's entries (Psychiatric Progress Notes and/or Psychiatric Evaluations) from 06/30/11 through 04/19/12 as per policy. The Medical Record Director (S9) reported the Psychiatrists, (S4, S5, S14, S15) refuse to come to the medical record department to date/time their Progress Notes and/or Evaluations as per policy for the 121 delinquent medical records greater than 30 days delinquent and/or the 692 delinquent medical records greater than 60 days delinquent from 06/30/11 through 04/19/12. S9Medical Record Director indicated all 813 medical records in the medical records department are inaccurate, incomplete and delinquent for no dates/times recorded on the Progress Notes and/or Evaluations from 06/30/11 through 04/19/12.

During an interview conducted on 04/20/12 at 1:35 p.m., S2Administrator verified there were 121 delinquent medical records greater than 30 days delinquent for S5Psychiatrist and there were 692 delinquent medical records greater than 60 days delinquent for S5Psychiatrist from 06/30/11 through 04/19/12. S2 indicated there were 813 delinquent medical records for S5Psychiatrist from 06/30/11 to 04/19/12. S2Administrator verified there were no delinquent medical records for the other Psychiatrists, (S4, S14, S15) in the medical record computer system from 06/30/11 through 04/19/12.

The policy titled, "Medical Record Analysis", reference number 4093, with no initial approval date, retired date, reviewed date and/or revised date indicated it is policy to ensure the patient's care is documented properly in the medical record. The practitioner entries in the medical record must be signed, including the date and time.

Record review of the Medical Staff Bylaws with no documented evidence of the date approved by the Governing Body, Article III. The Medical Staff section, 3.10 read in part, "...The Medical Staff shall see that there is adequate documentation of medical events by review of the discharged patients to ensure that medical records meet the required standards of completeness, clinical pertinence, and promptness or completion of following discharge ...Article XII. Committees, section 12.3.3, Medical Records Committee read in part, "...The Medical records Committee Shall be responsible for assuring all medical records meet the appropriate standards of patient care...and historical validity. The Medical Staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events. The committee shall conduct at least a quarterly review of currently maintained medical records to assure that they properly describe the condition and progress of the patient,...and the identification of responsibility for all actions taken, and that they are sufficiently complete at all times so as to meet the criterion of medical comprehension of the case...It shall also conduct a review of the records of discharged patients to determine the promptness, pertinence, adequacy and completeness thereof. This committee shall include representation from the Medical Staff, nursing service, and medical records...".

Review of the "Governing Bylaws" of the hospital approved by the Governing Body on 06/13, 2007, page 3 of 20, Article 3. Membership & Meetings of the Governing Body, section, "10. Responsibilities", revealed the Board shall be delegated responsibilities for the functions enumerated below and related functions. The responsibilities and obligations of the Board shall include assisting the CEO in establishing medical records policies respecting composition, retention, and other aspects of record keeping. Article 7. Credentialed Practitioners, page 15 of 20, section, "2. Medical Staff Governance", revealed the Medical Staff shall review and revise all Medical Staff Rules and Regulations, and, as applicable, departmental policies and procedures, when warranted, provided that such review shall occur at least every two (2) hears. The Medical Staff shall recommend changes in such policies and procedures for approval by the Board and the Corporation.

Based on record review and staff interview, the Governing Body failed to ensure the consulting for the Medical Records Department followed the contract to perform consultative visits of at the facility no less than quarterly as evidenced by the Registered Health Information Analysis (RHIA), S18 missing two (2) quarterly consult visits in January and March of 2012. Findings:

Review of the contract for RHIA, S18 revealed the consultant shall perform consultative visits at the facility no less than quarterly. The consultant shall perform medical records consultations at each facility. The consultant shall review medical records and related policies and procedures. The consultant shall meet with the facility representative(s) at the conclusion of each visit to review findings.The consultant is to provide a written report to the facility of their findings.

Review of the last visit of facility report from S18RHIA dated October 27, 2011. There were no other contracted RHIA visits from S18 submitted during the survey conducted from 04/16/12 through 04/20/12.

In an interview on 04/20/12 at 1:35 p.m., S2Administrator presented the last visit from S18RHIA was dated 10/27/11. The Administrator indicated this was the last visit S18RHIA made at the facility. The contracted RHIA, S18 is scheduled to come to the facility quarterly. The Administrator stated S18RHIA missed the quarterly scheduled visits in January of 2012 and in March of 2012. S2Administrator indicated the contracted RHIA, S18's next visit to the facility will be this month, April. The Administrator further indicated S18RHIA failed to follow the contract agreement to visit the facility every quarter.

Based on review of the Governing Body Bylaws, record reviews, and staff interviews, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to set priorities for its performance improvement activities that focused on high-risk and/or problem prone areas. This was evidenced by the hospital's failure to: 1) identify and implement corrective measures relating to the dating/timing of the Psychiatric Progress Notes and/or Psychiatric Evaluations entered into the patient's medical record from 06/30/11 through 04/19/12; and 2) identify and implement corrective measures relating to the hospital's inability to accurately track the eight hundred and thirteen (813) delinquent medical records as evidenced by not being able to determine the number of delinquent medical records for S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, and/or S15Psychiatrist in the medical records delinquent greater than thirty (30) days from 06/30/11 through 04/19/12. Findings:

Review of the computer delinquent medical records print-out from 06/30/11 through 04/19/12 revealed there were one hundred and twenty-one (121) medical records delinquent greater than thirty (30) days for S5Psychiatrist and there were six hundred and ninety-two (692) medical records delinquent greater than sixty days (60) days for S5Psychiatrist. There were a total of eight hundred and thirteen (813) delinquent medical records for S5Psychiatrist from 06/30/11 through 04/19/12. There was no tracking system of what each deficiency was for the 813 delinquent medical records from 06/30/11 to 04/19/12.

Further review of the computer delinquent medical records system revealed there were no delinquent medical records for the other Psychiatrists, (S4, S15, S16) from 06/30/11 through 04/19/12. There was no documentation in the computer delinquent record system of the 5 of 5 sampled medical records (#1 through #5) and/or of the 13 of 13 random sampled medical records reviewed (#R1 through #R13) were identified with no dating/timing recorded on the Psychiatric Progress Notes. There was no documented evidence in the computer delinquent record system of the 9 of 13 random sampled medical records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled medical records (#2, #3) were identified with no dating/timing recorded on the Psychiatric Evaluations by the Psychiatrists, S4, S5, S14, S15. There was no identification of the other 800 delinquent medical records were identified with no dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations by the Psychiatrists, S4, S5, S14, S15 from 06/30/11 through 04/19/12 noted in the computer delinquent medical record system.

A sample selection of 5 of 5 medical records (#1 through #5) and a random sample of 13 focused medical records (#R1 through #R13) out of a total of 813 delinquent medical records were reviewed for dating/timing of Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 through 04/19/12. There were 13 of 13 random sampled records (#R1 through #R13) and 5 of 5 sampled records (#1 through #5) with no recorded dating/timing on the Psychiatrists, (S4, S5, S14, S15) Progress Notes. The 13 random sampled patients records (#R1 through #R13) and 5 sampled patient records (#1 through #5) had the Psychiatrist Progress Notes filed in each patient's medical records on 04/19/12. These 13 random patient records and 5 sampled records were filed in the filing cabinet as accurate and complete on 04/19/12. Further review of 9 of the 13 random focused medical records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled records (#2, #3) revealed there was no dating/timing recorded on the Psychiatric Evaluations by the practitioners' (S4, S5, S14, S15). The 9 random patient records and 2 sampled patient records had the Psychiatric Evaluations filed in each patient's medical record. These patient records were filed in the filing cabinet as accurate and complete on 04/19/12.

In interviews on 04/19/12 from 1:45 p.m. through 2:00 p.m. and on 04/20/12 from 9:15 a.m. through 11:55 a.m., S9Medical Record Director indicated all eight hundred and thirteen (813) medical records filed in the medical records department are inaccurate, incomplete and delinquent for no dates/times recorded on the Progress Notes and/or Evaluations by the practitioners, (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist) from 06/30/11 through 04/19/12. The Medical Record Director (S9) stated the Psychiatrists, (S4, S5, S14, S15) refuse to come and date/time their Progress Notes and/or Evaluations for the 121 delinquent medical records delinquent greater than 30 days and for the 692 medical records delinquent greater than 60 days from 06/30/11 through 04/19/12.

During an interview conducted on 04/19/12 at 2:15 p.m. and on 04/20/12 at 1:35 p.m., S2Administrator indicated the medical records department has 813 delinquent medical records for S5Psychiatrist from 06/30/11 through 04/19/12. S2Administrator reported there was no identification and corrective action implemented for 813 delinquent medical records from 06/30/11 through 04/19/12. The Administrator indicated there were no identification or corrective actions implemented for the Psychiatric Progress Notes and/or Psychiatric Evaluations with no dating/timing of the assessments recorded by the Psychiatrists, (S4, S5, S14, S15) from 06/30/11 to 04/19/12. S2Administrator verified the contracted RHIA (Registered Health Information Management) failed to identify there were 813 delinquent medical records filed in the medical records department as accurate and complete with no dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 through 04/19/12 during the last visit quarterly visit on October 27, 2011. S2Administratro indicated the contracted RHIA failed to follow her contract to make quarterly rounds to the medical records department in January of 2012.

The "Governing Body Bylaws", approved by the Governing Body on 06/13, 2007, page 7 of 20, Article III. 3. Membership & Meetings of the Governing Body, page 8 of 20, section 10d. Responsibilities indicated the Board shall establish, maintain, and support through the CEO comprehensive, hospital-wide program for quality assessment and improvement; receiving reports on a regular basis form the Medical Staff, and assuring that all aspects of the program are performed appropriately and that administrative assistance is available to the Medical Staff.

Based on record reviews, observation, and staff interviews, the hospital failed to meet the Condition of Participation (CoP) for Medical Records as evidenced by:

1) Failing to have a system in place to ensure the qualified staff a) compiled data for quality assurance activities and b) verified the contents of the medical records were completed within thirty (30) days in accordance with State Laws as evidenced by staff assigned to the medical records department filing all medical records after thirty (30) days of discharge from the hospital in the metal filing cabinet as accurate and completed with no dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations for 813 delinquent medical records from 06/30/11 through 04/19/12 (See deficiency cited at A0432);

2) Failing to have a system in place to accurately track the delinquent medical records as evidenced by having 813 delinquent medical records for S5Psychiatrist and no documented evidence of the delinquent medical records for the other Psychiatrists, (S4, S14, S15), A total of thirteen (13) randomly selected focused medical records (#R1 through #R13) out of a total of 813 delinquent medical records from 06/30/11 through 04/19/12 and 5 of 5 sampled medical records (#1, #2, #3, #4, #5) were reviewed for dating/timing of Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of the 13 Random Sampled Records (#R1 through #R13) and 5 of 5 sampled medical records (#1, #2, #3, #4,#5) with no dating/timing recorded on the Psychiatric Progress Notes performed by S4, S5, S14, and/or S15. There were 9 of the 13 random sampled patient records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled patient records (#2, #3) with no dating/timing recorded on the Psychiatric Evaluations performed by S4, S5, S14, and/or S15 (See deficiency cited at A0438); and

3) Failing to ensure all practitioner's (psychiatrist's) entries entered into the patient's medical record were dated/timed by the person responsible for assessing the patient as per policy. This was evidence during the review of the random 13 sampled records (#R1 through #R13) out of a total of 813 delinquent medical records from 06/30/11 through 04/19/12 and 5 of 5 sampled records (#1 through #5) who were reviewed for dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of the 13 random sampled records (#R1 through #R13) and 5 of 5 sampled patient records (#1 through #5) with no dating/timing recorded on the Psychiatric Progress Notes performed by the practitioner's S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, and/or S15Psychiatrist. There were 9 of 13 random sampled records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled medical records (#2, #3) with no dating/timing recorded on the Psychiatric Evaluations by the practitioner's, S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist. (See deficiency cited at A0450).

Based on medical record reviews, policy reviews, observation, and staff interviews, the hospital failed to have a system in place to ensure the qualified staff a) compiled data for quality assurance activities, and b) verified the contents of the medical records were completed within thirty (30) days in accordance with State Laws as evidenced by staff assigned to the medical records department filing all medical records after thirty (30) days of discharge from the hospital in the metal filing cabinet as accurate and completed with no dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations for the 813 delinquent medical records from 06/30/11 through 04/19/12. Findings:

During an observation of the medical records department on 04/20/12 from 9:00 a.m. through 11:25 a.m. with S10Medical Record Clerk, there was a computer delinquent medical records printout from 06/30/11 through 04/19/12. The computer printout indicated there was a total of 813 delinquent medical records from 06/30/11 to 04/19/12. There were 13 random delinquent medical records (#R1 through #R13) out of the total of 813 delinquent medical records pulled by the Medical Records Clerk (S10) from the metal filing cabinets located up against the back wall in the department. At this time, S10 indicated all medical records filed in these cabinets are accurate and complete. The Medical Record Clerk, (S10) denied knowledge of how many medical records were delinquent greater than 30 days, delinquent greater than 60 days, delinquent greater than 90 days and/or delinquent greater than 120 days. S10 indicated she goes and picks up the patient's medical record from the unit after the patient is discharged from the hospital and brings it back to the department for review. At this time, she reviews the medical record for incompleteness including no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluation in which she flags each medical record entry with a colored flag so the practitioner's (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist) know which entries they need to complete. The medical record is kept on the counter for thirty (30) days then she removes the flag from the patient's medical record and files it in the metal cabinet as accurate and complete. S10Medical Record Clerk indicated all 813 medical records are filed in the cabinet but they are inaccurate and incomplete with no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 to 04/19/12.

Review of the computer delinquent medical records print-out from 06/30/11 through 04/19/12 revealed there were one hundred and twenty-one (121) medical records delinquent greater than thirty (30) days for S5Psychiatrist and there were six hundred and ninety-two (692) medical records delinquent greater than sixty days (60) days for S5Psychiatrist. There were a total of eight hundred and thirteen (813) delinquent medical records for S5Psychiatrist from 06/30/11 through 04/19/12. Further review revealed there were no delinquent medical records for the other Psychiatrists, (S4, S14, S15) in the computer delinquent medical records system and/or on the computer delinquent medical record printout from 06/30/11 through 04/19/12. There were no deficiencies identified for the 813 delinquent medical records noted in the computer delinquent medical record system and/or on the computer delinquent medical record printout from 06/30/11 through 04/19/12.

A sample selection of 5 of 5 medical records (#1 through #5) and a random sample of 13 focused medical records (#R1 through #R13) were reviewed for dating/timing of Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of 13 random patients (#R1 (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13) and 5 of 5 sampled patients (#1, #2, #3, #4, #5) with no dates/times recorded on the Psychiatric Progress Notes by the Psychiatrists, S4, S5, S14, or S15. All of these patient's medical records had the Progress Notes filed in each record and they were filed in the metal cabinet as accurate and complete on 04/19/12. Further review revealed there were 2 of 5 sampled patients records (#2, #3) and 9 of the 13 random focused patient records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) with no dating/timing recorded on the Psychiatric Evaluations performed by the practitioners' (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, and/or S15Psychiatric). All of these patient's medical records had the Evaluations filed in them and they were all filed in the metal cabinet as accurate and complete on 04/19/12.

In interviews on 04/19/12 from 1:45 p.m. through 2:00 p.m. and on 04/20/12 from 9:15 a.m. through 11:55 a.m., S9Medical Record Director was interviewed. S9 indicated all medical records are reviewed by the Medical Record Clerk (S10) for completeness of the practitioner's (psychiatrist's) entries including the Psychiatric Progress Notes and Psychiatric Evaluations as per policy. The Medical Record Director reported the Medical Record Clerk, S10 places a flag on the Progress Notes and/or Evaluations with no dates/times recorded by the Psychiatrists, (S14, S15, S16, S17) so the psychiatrists know they need to complete the medical record entry and she (S10) places the flagged medical records on the counter for 30 days then she (S10) removes the flags from the medical records and files them in the metal filing cabinet as accurate and complete. S9Medical Record Director indicated all 813 medical records in the medical record department are delinquent for the Progress Notes and/or Evaluations. There are deficiencies for the no dates/times recorded on these Progress Notes and/or Evaluations for the 813 delinquent medical records from 06/30/11 through 04/19/12. The Medical Record Director indicated there is no computer system in place for all deficiencies to be identified in each medical record by each practitioner, (psychiatrists, S4, S5, S14, or S15) as per policy. S9 stated all patients are admitted into the hospital under S5Psychiatrist. There are no other Psychiatrists, (S4, S14, or S15) that admit patients into the hospital. The Medical Record Director, S9 indicated the other Psychiatrists, (S4, S14, S15) have admitting privileges at the hospital. S9Medical Record Director denied knowledge why the other Psychiatrists, S4, S14, or S15 do not admit patients into the hospital. The Medical Record Director verified there were deficiencies noted in the 13 random sampled patient records (#R1 through #R13) and 5 sampled patient records (#1 through #5) that are delinquent, inaccurate, incomplete, and filed in the filing cabinet as accurate and complete.

During an interview conducted on 04/19/12 at 2:15 p.m. and on 04/20/12 at 1:35 p.m., S2Administrator verified the contracted RHIA (Registered Health Information Management) failed to identify there were 813 delinquent medical records filed in the medical records department as accurate and complete with no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 through 04/19/12 during the last visit quarterly visit on October 27, 2011. There was no consultative visit performed quarterly in January of 2012 as per the contract with the RHIA on November 05, 2007.

Review of the policy titled, "Medical Record Analysis", reference number: 4093, with no initial approval date, retired, reviewed and/or revised dates, revealed the policy indicated it was to ensure patient care is documented properly in the medical record. The Practitioner entries in the medical record must be signed, including his/her title, date and time.All blanks on the hospital forms where the physician is designated to sign must be signed.

The policy titled, "Medical Records Department", reference number: 4001, with no initial approval date, retired, reviewed and/or revised dates, revealed the purpose of the Medical Records Department is to provide a central file for medical records which documents the course of the patient's illness and treatment during a particular episode as an inpatient or outpatient. An adequate record serves as a basis for planning patient care, evaluating care and providing a means of communication between the physician and other healthcare providers contributing to the patient's care. The contents of the medical records shall be in accordance CMS, Louisiana State Regulation, and the Hospital Rules and Regulations. A Consulting Registered Health Information Administrator (RHIA) shall be responsible for the supervision of the Medical Records Department. The primary purpose of the Medical Records Department is to assure that an adequate medical record is maintained for every patient in our hospital. The patient's medical record shall include all significant clinical information pertaining to the patient, in order that the purpose stated above may be fulfilled. All entries in the record are to be dated and authenticated. Each medical record must contain sufficient information to identify the patient, justify the diagnosis, to delineate the plan of treatment and to document the results accurately. The medical record must be appropriately documented to meet the standards of licensing and surveying agencies, as well as the hospital's bylaws and rules and regulations.

Based on medical record reviews, policy reviews, observation, and staff interviews, the hospital failed to have a system in place to accurately track the delinquent medical records as evidenced by having 813 delinquent medical records for S5Psychiatrist and no documented evidence of the delinquent medical records for the other Psychiatrists, (S4, S14, S15) from 06/30/11 through 04/19/12. A total of thirteen (13) randomly selected focused medical records out of a total of 813 delinquent medical records (#R1 through #R13) and 5 of 5 sampled medical records (#1 through #5) were reviewed for dating/timing of Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of the 13 random sampled patient records (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12,#R13) and 5 of 5 sampled patient records (#1, #2, #3, #4, #5) with no dates/times recorded on the Psychiatric Progress Notes by the Psychiatrists, S4, S5, S14, and/or S15. There were 9 of the 13 random sampled patient records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 3 of 5 sampled patient records (#1, #2, #3) with no dating/timing recorded on the Psychiatric Evaluations performed by S4, S5, S14, and/or S15. Findings:

During an observation of the medical records department on 04/20/12 from 9:00 a.m. through 11:25 a.m. with S10Medical Record Clerk, there was a computer delinquent medical records printout from 06/30/11 through 04/19/12. The computer printout indicated there was a total of 813 delinquent medical records for S5Psychiatrist from 06/30/11 to 04/19/12. There was no documented evidence of the other Psychiatrist's, S4's, S14's, and/or S15's tracking of delinquent medical records in the computer system and/or on the computer delinquent medical record printout from 06/30/11 to 04/19/12. The Medical Record Clerk, (S10) denied knowledge of how many medical records were delinquent greater than 30 days, delinquent greater than 60 days, delinquent greater than 90 days and/or delinquent greater than 120 days there were for the Psychiatrists, S4, S5, S14, and/or S15 from 06/30/11 through 04/19/12.

Review of the 13 of the 13 random sampled patient records (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12,#R13) and 5 of 5 sampled patient records (#1, #2, #3, #4, #5) with no dates/times recorded on the Psychiatric Progress Notes by the Psychiatrists, S4, S5, S14, and/or S15. There were 9 of the 13 random sampled patient records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 3 of 5 sampled patient records (#1, #2, #3) with no dating/timing recorded on the Psychiatric Evaluations performed by S4, S5, S14, and/or S15.

Patient #R1:
Review of the medical record for #R1 revealed there were no dates/times recorded on six (6) Psychiatric Progress Notes dated as follows: 02/22/12 by S4Pschiatrist, 02/21/12 by S5Psychiatrist, 02/20/12 by S15Psychiatrist, 02/19/12 by S15Psychiatrist, 02/17/12 by S5Psychiatrist, and 02/16/12 by S15Psychiatrist. Further review revealed there was a Psychiatric Evaluation dated 02/15/12 with no time recorded that S15Psychiatrist assessed the patient.

Patient #R2:
Review of the medical record for #2 revealed there were no dates/times recorded on five (5) Psychiatric Progress Notes assessed by S4Psychiatrist on 02/10/12, assessed by S4Psychiatric on 02/08/12, assessed by S5Psychiatrist on 02/07/12 and on 02/06/12, and assessed by S15 Psychiatrist on 02/04/12. Further review revealed there was a Psychiatric Evaluation dated 02/02/12 with no time recorded that S15Psychiatrist assessed the patient.

Patient #R3:
Review of the medical record for #R3 revealed there were no dates/times recorded on four (4) Psychiatric Progress Notes assessed by S4Psychiatrist on 02/22/12, assessed by S5Psychiatrist on 02/21/12, and assessed by S15Psychiatrist on 02/20/12 and 02/19/12. Further review revealed there was a Psychiatric Evaluation dated 02/18/12 with no time recorded of when S15Psychiatrist assessed the patient.

Patient #R4:
Review of the medical record for #R4 revealed there were no dates/times recorded on three (3) Psychiatric Progress Notes dated as follows: assessed by S5Psychiatrist on 02/13/12, assessed by 14Psychiatrist on 02/11/12 and assessed by S5Psychiatrist on 02/10/12. Further review revealed there was a Psychiatric Evaluation dated 02/09/12 that did not have time recorded when S15Psychiatrist assessed the patient.

Patient #R5:
Review of the medical record for #R5 revealed there were nine (9) Psychiatric Progress Notes dated as follows: 03/06/12 for S5, 03/05/12 for S4, 03/04/12 for S15, 03/02/12 for S4, 03/01/12 for S5, 02/29/12 (2 different notes written) for S4, 02/28/12 for S5, and 02/27/12 for S5. Further review revealed there was a Psychiatric Evaluation with a date of assessment of 02/25/12 on the front of the evaluation with an incomplete date documented next the Psychiatrist's S14's signature that read, " 2. (space left).12). There was no time recorded on the assessment by S14 on the Evaluation of the patient.

Patient #R6:
Review of the medical record for #R6 revealed there were (6) Psychiatric Progress Notes with no times recorded as follows: on 03/22/12 by S5Psychiatrist, on 03/21/12 by S4Psychiatrist, on 03/20/12 by S5Psychiatrist, on 03/19/12 by S5Psychiatrist, on 03/17/12 by S15Psychiatrist, and on 03/16/12 by S5Psychiatrist.

Patient #R7:
Review of the medical record for #R7 revealed there were (5) Psychiatric Progress Notes with no times recorded that the Psychiatrists, S5 assessed the patient on 03/23/12 and on 03/22/12, S4 assessed the patient on 03/21/12, and S5 assessed the patient on 03/20/12 and 03/19/12. Further review revealed there was a Psychiatric Evaluation dated 03/17/12 with no time recorded of when S15Psychiatrist assessed the patient.

Patient #R8:
Review of the medical record for #R8 revealed there were eight (8) Psychiatric Progress Notes with no time recorded that S5Psychiatrist assessed the patient on 03/26/12, on 03/23/12, on 03/22/12, on 03/20/12, and on 03/19/12. There was no time recorded when S14Psychiatrist assessed the patient on 03/26/12. There was no time recorded when S4Psychiatrist assessed the patient on 03/21/12. There was no time recorded of when S15Psychiatrist assessed the patient on 03/17/12.

Patient #R9:
Review of the medical record for #R9 revealed there were (9) Psychiatric Progress Notes with no times recorded when the Psychiatrists, S4 assessed the patient on 01/02/12, on 12/30/11, and on 12/27/11. There was no time recorded on the Progress Note of what time S5Psychiatrist assessed the patient on 12/26/11. The Progress Note dated 12/31/11 revealed there was no time recorded of when S14Psychiatrist assessed the patient. There was no time recorded on the Progress Notes dated 12/29/11, 12/28/11, 12/25/11, and 12/24/11 of what time S15Psychiatrist assessed the patient.Further review revealed there was a Psychiatric Evaluation dated 12/23/11 that did not have a time recorded of when S15Psychiatrist assessed the patient.

Patient #R10:
Review of the medical record for #R10 revealed there were twenty-four (24) Psychiatric Progress Notes with no times recorded of when the Psychiatrists, S4 assessed the patient on 01/02/12, 12/30/11, 12/27/11, and 12/21/11; S5 assessed the patient on 01/10/12, 01/09/12, 01/06/12, 01/04/12, 12/26/11, 12/20/11, 12/19/11, and 12/16/11; S14 assessed the patient on 12/31/11, and on 12/17/11; and S15 assessed the patient on 01/07/12, 01/05/12, 01/03/12, 12/29/11, 12/28/11, 12/25/11, 12/24/11, 12/23/11, 12/22/11, and 12/15/11. Further review revealed there was a Psychiatric Evaluation dated 12/14/11 with no time recorded of when S4Psychiatrist assessed the patient.

Patient #R11:
Review of the medical record for #R11 revealed there were (5) Psychiatric Progress Notes with no times recorded that S4Psychiatrist assessed the patient on 12/14/11; S5Psychiatrist assessed the patient on 12/20/11, and 12/17/11; S14Psychiatrist assessed the patient with no date/time recorded on the Note; and there was no time documented of when S15Psychiatrist assessed the Patient on 12/15/11.

Patient #R12:
Review of the medical record for #R12 revealed there were (9) Psychiatric Progress Notes with no times recorded that the Psychiatrists, S4 assessed the patient on 12/21/11; S5 assessed the patient on 12/26/11, 12/20/11, and 12/19/11; S14 assessed the patient on 12/17/11; and S15 assessed the patient on 12/25/11, 12/24/11, 12/23/11, and 12/22/11.

Patient #R13:
Review of the medical record for #R13 revealed there were (8) Psychiatric Progress Notes with no times recorded for the assessment of the patient by the Psychiatrists, S4 on 12/30/11 and 12/27/11; S5 on 12/26/11; and S15 on 12/29/11, 12/28/11, 12/25/11, 12/24/11, and 12/23/11. Further review revealed there was a Psychiatric Evaluation dated 12/22/11 did not have a time recorded of when S15Psychiatrist assessed the patient.

Patient #1:
Review of the medical record for Patient #1 revealed there were (4) Psychiatric Progress Notes with no documented time recorded of what time S4Psychiatrist assessed the patient on 02/29/12; S5Psychiatrist assessed the patient on 02/28/12 and 02/27/12; and S14Psychiatrist assessed the patient on 02/25/12.

Patient #2:
Review of the medical record for #R2 revealed there were no dates/times recorded on five (5) Psychiatric Progress Notes assessed by S4Psychiatrist on 03/21/12, assessed by S5Psychiatric on 03/22/12, assessed by S5Psychiatrist on 03/23/12, on 03/24/12, and assessed by S5 Psychiatrist on 03/26/12. Further review revealed there was a Psychiatric Evaluation dated 03/20/12 with no time recorded that S4Psychiatrist assessed the patient.

Patient #3:
Review of the medical record for Patient #3 revealed there were three (3) Psychiatric Progress Notes with no times recorded for the assessments of the patient by S5 on 04/02/12, 03/30/12, and 03/29/12; and S15 on 04/01/12. Further review revealed there was a Psychiatric Evaluation dated 03/28/12 that did not have time recorded of what time S4Psychiatrist assessed the patient.

Patient #4:
Review of the medical record for #4 revealed there were (5) Psychiatric Progress Notes with no times recorded of when the Psychiatrists, S4 assessed the patient on 04/11/12; S5 assessed the patient on 04/12/12, 04/10/12, and 04/09/12; and S14 assessed the patient on 04/08/12.

Patient #5:
Review of the medical record for Patient #5 revealed there were (6) Psychiatric Progress Notes with no times recorded for the assessments of the patients by the Psychiatrists, S4 on 03/28/12; S5 on 03/29/12, 03/27/12, 03/26/12, and 03/23/12; and S14 on 03/24/12.

In interviews on 04/19/12 from 1:45 p.m. through 2:00 p.m. and 0n 04/20/12 from 9:15 a.m. through 11:55 a.m., S9Medical Record Director was interviewed. S9 indicated all medical records in the medical record department are delinquent for the Progress Notes and/or Evaluations for dates/times from 06/30/11 through 04/19/12. S9 verified there were a total of 813 delinquent medical records for S5Psychiatrist listed on the computer printout from 06/30/11 to 04/19/12. The Medical Record Director, S9 indicated there are deficiencies in each medical record for each practitioner, (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist). S9 confirmed there was no documented evidenced on the computer delinquent medical records printout and/or in the computer system of 813 delinquent medical records for the other Psychiatrists, S4's, S14's, and/or S15's delinquent medical records from 06/30/11 to 04/19/12 as per policy. The Medical Record Director S9 indicated there is no tracking system of the Psychiatrists, S4's, S14's, and/or S15's delinquent medical records in the computer delinquent medical record system from 06/30/11 through 04/19/12 as per policy. S9Medical Record Director reported there is no system in place, the computer delinquent medical record system, to track the delinquent medical records for each Psychiatrists, S4, S14, and/or S15 as per policy. S9 stated all patients are admitted into the hospital under S5Psychiatrist. There are no other Psychiatrists, (S4, S14, or S15) that admit patients into the hospital so these psychiatrists, (S4, S14, or S15) do not have a list of medical records. The Medical Record Director, S9 indicated the other Psychiatrists, (S4, S14, S15) have admitting privileges at the hospital. S9Medical Record Director denied knowledge why the other Psychiatrists, S4, S14, or S15 do not admit patients into the hospital. S9Medical Record Director verified there were a total of 813 delinquent medical records for S5Psychiatrist with deficiencies for no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 to 04/19/12.

During an interview conducted on 04/19/12 at 2:15 p.m. and on 04/20/12 at 1:35 p.m., S2Administrator indicated there is no tracking system in place for the other Psychiatrists, S4's, S14's, and/or S15's delinquent medical records as of today, 04/19/12 as per policy.
The Administrator, S2 verified there were a total of 813 delinquent medical records for S5Psychiatrist and there was no tracking for the other Psychiatrists, S4, S14, and/or S15 as per policy.

Review of the policy titled, "Medical Record Analysis", reference number: 4093, with no initial approval date, retired, reviewed and/or revised dates, revealed the policy indicated it was to ensure patient care is documented properly in the medical record. The Practitioner entries in the medical record must be signed, including his/her title, date and time. All blanks on the hospital forms where the physician is designated to sign must by signed.

Review of the policy titled, "Delinquent Medical Records", reference number: 4081, with no initial approval date, retired, reviewed and/or revised dates, presented as the hospital's current "Delinquent Medical Record" policy indicated it is policy for the Medical Records Department to notify a practitioner of suspension when he/she has delinquent medical records. It is procedure for the physicians to be notified on a weekly basis of their number of incomplete medical records through a letter until the medical records are complete or the physician is on suspension. All deficiencies are noted by the responsible physician on the medical record deficiency computer system. The deficient records are placed in the Physician's Dictation Room in the Medical Records Department. If the Medical Records Department does not receive a physician response to complete his/her medical records within seven (7) days of the first notice, the physician will be notified by the Medical Record Deficiency Clerk via telephone call and a second reminder letter will be mailed to the physician. Should the medical record(s) remain incomplete on the 15th day after patient discharge, the Medical Record Department will notify the physician, by certified mail, that his/her admitting and/or consultative privileges have been suspended until the medical records have been completed. The Medical Records Department will submit the physician's name to administration, the Medical Executive Board and other departments. A copy of all suspension letters mailed will be placed in the physician's peer review filed housed in the Medical Staff Office. The hospital departments are notified by the Medical Records Department when the physician's suspension of privileges have been lifted.

Record review of the Medical Staff Bylaws with no documented evidence of the date approved by the Governing Body, Article III. The Medical Staff section, 3.10 read in part, " ...The Medical Staff shall see that there is adequate documentation of medical events by review of the discharged patients to ensure that medical records meet the required standards of completeness, clinical pertinence, and promptness or completion of following discharge ...Article XII. Committees, section 12.3.3, Medical Records Committee read in part, "...The Medical records Committee Shall be responsible for assuring all medical records meet the appropriate standards of patient care...and historical validity. The Medical Staff representatives shall also conduct a review of the records of discharged patients to determine the promptness, pertinence, adequacy and completeness thereof. This committee shall include representation from the Medical Staff, nursing service, and medical records..."

The "Governing Body Bylaws", approved by the Governing Body on 06/13, 2007, page 7 of 20, Article III. 3. Membership & Meetings of the Governing Body, page 8 of 20, section 10.. Responsibilities d. indicated the Board shall establish, maintain, and support through the CEO comprehensive, hospital-wide program for quality assessment and improvement; receiving reports on a regular basis form the Medical Staff, and assuring that all aspects of the program are performed appropriately and that administrative assistance is available to the Medical Staff.

Based on medical record reviews, policy reviews, observation, and staff interviews, the hospital failed to ensure all practitioner's (psychiatrist's) entries entered into the patient's medical record were dated/timed by the person responsible for assessing the patient as per policy. This was evidenced during the review of the random 13 sampled records (#R1 through #R13) out of a total of 813 delinquent medical records from 06/30/11 through 04/19/12 and 5 of 5 sampled records (#1 through #5) who were reviewed for dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of the 13 random sampled records (#R1 through #R13) and 5 of 5 sampled patient records (#1 through #5) with no dating/timing recorded on the Psychiatric Progress Notes performed by the practitioner's S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, and/or S15Psychiatrist. There were 9 of 13 random sampled records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) and 2 of 5 sampled medical records (#2, #3) with no dating/timing recorded on the Psychiatric Evaluations by the practitioner's, S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist. Findings:


Review of the computer delinquent medical records printout from 06/30/11 through 04/19/12 revealed there were one hundred and twenty-one (121) medical records delinquent greater than thirty (30) days for S5Psychiatrist and there were six hundred and ninety-two (692) medical records delinquent greater than sixty days (60) days for S5Psychiatrist. There were a total of eight hundred and thirteen (813) delinquent medical records for S5Psychiatrist from 06/30/11 through 04/19/12. Further review there were no delinquent medical records for the other Psychiatrists, (S4, S14, and/or S15) noted in the computer delinquent medical record system and/or on the computer delinquent medical records printout from 06/30/11 through 04/19/12. There were no deficiencies identified for the 813 delinquent medical records in the computer system from 06/30/11 to 04/19/12. There was no documentation in the computer delinquent record system of the 5 of 5 sampled medical records (#1 through #5) and/or of the 13 of 13 random sampled medical records (#R1 through #R13) that identified there were no dates/times recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations by the practitioner's, S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, or S15Psychiatrist.

A sample selection of 5 of 5 medical records (#1 through #5) and a random sample of 13 focused medical records out of a total of 813 delinquent medical records were reviewed for dating/timing of Psychiatric Progress Notes and/or Psychiatric Evaluations. There were 13 of 13 random sampled patients records , (#R1 through #R13) and 5 of 5 sampled patients records (#1 through #5) with no dates/times recorded on the practitioner's (S4Psychiatrists, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist) Progress Notes. Further review revealed there were 2 of 5 sampled records (#2, #3) and 9 of the 13 random focused records (#R1, #R2, #R3, #R4, #R5, #R7, #R9, #R10, #R13) with no dates/times recorded on the Psychiatric Evaluations by the practitioner's (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist).

In interviews on 04/19/12 from 1:45 p.m. through 2:00 p.m. and on 04/20/12 from 9:15 a.m. through 11:55 a.m., S9Medical Record Director indicated all eight hundred and thirteen (813) medical records in the medical records department are inaccurate, incomplete and delinquent with no dates/times recorded on the Progress Notes and/or Evaluations by the practitioner's (S4Psychiatrist, S5Psychiatrist, S14Psychiatrist, S15Psychiatrist) from 06/30/11 through 04/19/12 as per policy. The Medical Record Director (S9) stated the Psychiatrists, (S4, S5, S14, S15) refuse to come and date/time their Progress Notes and/or Evaluations for the 121 medical records delinquent greater than 30 days and the 692 medical records delinquent greater than 60 days from 06/30/11 through 04/19/12.

During an interview conducted on 04/19/12 at 2:15 p.m. and on 04/20/12 at 1:35 p.m., S2Administrator indicated the medical records department has 813 delinquent medical records for S14Psychiatrist from 06/30/11 through 04/19/12. S2Administrator reported there was no identification and corrective action implemented for 813 delinquent medical records from 06/30/11 through 04/19/12. The Administrator indicated there were no identification or corrective actions implemented for the Psychiatric Progress Notes and/or Psychiatric Evaluations with no dating/timing of the assessments recorded by the Psychiatrists, (S14, S15, S16, S17) from 06/30/11 to 04/19/12. S2Administrator verified the contracted RHIA (Registered Health Information Management) failed to identify there were 813 delinquent medical records filed in the medical records department as accurate and complete with no dating/timing recorded on the Psychiatric Progress Notes and/or Psychiatric Evaluations from 06/30/11 through 04/19/12 during the last visit quarterly visit on October 27, 2011.

Review of the policy titled, "Medical Record Analysis", reference number: 4093, with no initial approval date, retired, reviewed and/or revised dates, revealed the policy indicated the practitioner entries in the medical record must be signed, including his/her title, date and time.