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Based on observation, policy/procedure review and interview, the hospital failed to ensure patient's care in a safe setting by failing to lock door to rooms containing potentially hazardous materials. This deficient practice was evidenced by the hospital leaving rooms with potentially hazardous materials unlocked and accessible to 24 of 24 patients residing on the C-Hall.
Findings:

Observation on 8/27/18 at 10:45 a.m., accompanied by S12 Director of Plant Operations, revealed the C-Hall Dirty Utility room door was unlocked and was accessible to the patients. The room contained bottles of liquid floor cleaners and disinfectants, a spray bottle of disinfectant; and a package of powdered detergent bars.

Observation on 8/28/18 at 2:25 p.m., accompanied by S12 Director of Plant Operations, revealed the C-Hall Staff Lounge door was unlocked and was accessible to the patients. The room contained a spray bottle of disinfectant spray, a bottle of liquid bleach, a container of Sani-wipes, and a glass coffee carafe.

Observation on 8/28/18 at 2:35 p.m., accompanied by S12 Director of Plant Operations, revealed the C-Hall Dirty Utility room door was unlocked and accessible to the patients. The room contained bottles of liquid floor cleaners and disinfectants, a spray bottle of disinfectant; and a package of powdered detergent bars.

Review of the hospital's policy titled "Locked Doors for Inpatient Care" revealed, in part, the following:
Purpose - B. All private offices located on the units, and rooms or closets used for storage of potentially hazardous materials (e.g., cleaning closets, medication rooms, emergency equipment storage) will be kept locked at all times.
Procedure - A. Observe guidelines put forth in this policy. B. Accept individual responsibility for maintaining locked doors as identified in this policy. C. All staff assumes responsibility for maintaining locked doors on the units.

During an interview on 8/27/18 at 10:46 a.m., S12 Director of Plant Operations acknowledged the Dirty Utility room door was unlocked and accessible to the patients.

During an interview on 8/28/18 at 2:26 p.m., S12 Director of Plant Operations acknowledged the Staff Lounge room door was unlocked and accessible to the patients.

During an interview on 8/28/18 at 2:36 p.m., S12 Director of Plant Operations acknowledged the Dirty Utility room door was unlocked and accessible to the patients.

Based on record review and interview, the hospital failed to take actions aimed at performance improvement through the QAPI program activities for Health Information Management by failing to accurately measure and track the completion of delinquent records greater than 30 days. Findings:

Review of the hospital's Performance Improvement Indicators for Medical Records for the months of January 2018 through June 2018 revealed the tracked indicators included completion of the medical records. The review of the indicators for completion of discharge summaries revealed 100% completion each month.

Review of the delinquent records list presented to the surveyor on 08/27/18 revealed a 194 - page document with delinquencies dating as far back as 2015.

On 8/28/18, S2CSDirector presented a revised list of delinquent records showing that all delinquencies had been corrected as of the current date. She stated there were no delinquent records remaining other than those from a deceased physician and other physicians who were no longer on staff. She stated that an attestation had been placed in the front of those records stating they were unable to obtain those signatures for completion.

On 8/28/18 at 2:30p.m., a random sampling of medical records from the 194 - page delinquency list with S3PI/RM Director and S4MR revealed there were medical records from current staff physicians for the current year and prior years that remained delinquent.

On 08/29/18 at 10:00a.m., an interview with S3PI/RM Director confirmed that the medical records included in the monthly QAPI review were selected from the previous month's discharges and did not include any tracking of records greater than 30 days old (for example, the records reviewed for June included only the discharges from the month of May).

On 08/29/18 at 10:30a.m., an interview with S2CSDirector confirmed that the hospital's system for tracking outstanding delinquent records was not accurate and the hospital was not able to determine the current status of delinquent medical records. She further confirmed that this issue had not been identified and monitored through the QAPI activities.

Based on record review and interview, the hospital failed to ensure the medical records service was staffed in accordance with the scope of the hospital's services. This deficient practice was evidenced by failing to appoint a qualified director of medical records that was HIM or RHIA certified.

Findings:

Review of the personnel record for S4MR revealed her date of hire was 11/12/00, as a Mental Health Tech. In May of 2015, S4MR began her employment in the Medical Records Department. In August of 2016, S4MR began her position as Medical Records Supervisor. There was no documented evidence of any credentials in S4MR's personnel record. Further review revealed a job summary which stated, "HIM Supervisor - supervises correspondence, inpatient and outpatient filing. Performs all of the normal supervisory responsibilities of hiring, training, coaching, and evaluating employees. Serves as Acting Health Information Management Department Director."

On 8/29/18 at 9:45 a.m., an interview with S4MR revealed she was not HIM or RHIA certified. She further revealed her resources if she had questions were S1CEO and S3PI/MRNDirector, neither of which were HIM or RHIA certified either.

On 8/29/18 at approximately 10:00 a.m., an interview with S1CEO revealed she was not HIM or RHIA certified and she was unsure of the contact resource person for S4MR in medical records.

On 8/29/18 at approximately 10:15 a.m., an interview with S2CSDirector verified staff was unaware of the resource S4MR should contact with any issues from a qualified individual. S2CSDirector further revealed S4MR's contact person was with the corporate office and was to be contacted with any questions, but would not reach out to S4MR. She further stated she believed the resource person was last contacted by S4MR in November 2017.

Based on record review and interview, the hospital failed to ensure all medical records were completed within 30 days of discharge or outpatient care as evidenced by 3 (#18, #19, #20) of 4 random sampled patient records containing delinquencies from a total sample of 21. The hospital also failed to have a system in place to accurately track the number of deficient medical records in the hospital.

Findings:

Review of Rules and Regulations of the Medical Staff dated effective 8/7/18 revealed:
-All Practitioners shall follow the medical record documentation guidelines;
-All entries to the medical record must be accurate, legibly written, dated, timed, and authenticated;
-Each discharged patient must have a discharge summary authenticated by the attending physician; and
-All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge.

Review of the policy titled Delinquent Medical Records last reviewed 6/2018 revealed:
-It is the policy of the facility to maintain an information management process that supports timely, accurate, and complete documentation of medical record data and information for all patients.
-The procedure:
1) HIM Director will analyze and assemble discharged medical record ASAP not to exceed 4 days of discharge.
2) Notice of identified Practitioner responsible to complete medical record, not to exceed 30 days of discharge.
3) Medical record deemed "DELINQUENT" if it is deficient due to failure to document and authenticate a H/P, Psych Eval, and/or Discharge Summary 30 days after discharge.
4) HIM Director to notify practitioner when an incomplete record is nearing delinquency status
5) HIM Director is to notify CEO and Medical Director of all Delinquencies by practitioner. Then HIM Director is to notify the above immediately upon completion of delinquent medical record.
6) Following are to be reviewed by committee for oversight with a recommendation of administrative closure: 6 month delinquent after unsuccessful attempts; termination of practitioner; or death of practitioner.
Upon administrative closure, the medical record is removed from the list of delinquent medical records.
7) HIM director compiles a list at least monthly of all delinquent medical records.
8) Delinquent medical record count is tabulated on a monthly basis by HIM director.
9) The above delinquent report will be reported on the Acadia Scorecard monthly
10) Delinquent data is to be tracked by Practitioner for OPPE and credentialing.

On 8/27/2018 at 3:40 p.m., an interview with S4MR revealed she was unable to retrieve a list of deficient medical records for the surveyor to review, but she had to call and ask a medical record clerk for assistance, which was unsuccessful. S4MR said she had called the corporate office to attempt to get an accurate list of deficient medical records, but was unfamiliar with the process. S4MR further revealed she was the Supervisor of the Medical Records Department since 2016 and she did not send any letters of deficient medical records to physicians because she was, "On top of it."

Review of 2 delinquent medical record reports from 1/1/18 to 7/31/18 presented as current and accurate revealed the following contradictory information:
1) Report time stamped 8/28/18 between 7:43 a.m. and 7:51 a.m. from S3PI/MRNDirector and S1CEO revealed:
Report title: Unresolved chart deficiencies by patient
Total number of deficiencies is "345"
2) Report time stamped 8/28/18 between 8:22 a.m. and 8:51 a.m. from S2CSDirector revealed:
Report title: Unresolved chart deficiencies by patient
Total number of deficiencies is "0"

On 8/28/18 at 9:20 a.m. in an interview with S2CSDirector revealed the above report #2 displayed "0" deficiencies because the hospital had the physicians stay last night and all the delinquent records were no longer delinquent and they "cleared" the delinquency from the report. Report #1 shown to S2CSDirector and she stated she was unsure how the delinquent medical record data was cleared so quickly.

Review of 4 closed medical records from which were stated were no longer delinquent revealed 3 (#18, #19, #20) of the 4 were delinquent.

Patient #18
Review of Patient #18's medical record revealed an admission date of 12/26/16 and a discharge date of 1/2/17.
Further review of the patient's medical record revealed that as of 8/28/18 (date of the record review) there was no signed or authenticated discharge summary in the patient's medical record. The discharge summary was not signed by S13MD.

Patient #19
Review of Patient #19's medical record revealed an admission date of 4/25/18 and a discharge date of 5/14/18.
Further review of the patient's medical record revealed that as of 8/28/18 (date of the record review) there was no signed, authenticated, or discharge summary in the patient's medical record. Patient #19's medical record did not have a discharge summary on the chart by S13MD.

Patient #20
Review of Patient #20's medical record revealed an admission date of 3/2/17 and a discharge date of 3/8/17.
Further review of the patient's medical record revealed that as of 8/28/18 (date of the record review) there was no signed or authenticated discharge summary in the patient's medical record. The discharge summary was not signed by S13MD.

On 8/28/18 at 4:30 p.m. in an interview with S2CSDirector and S4MR, S2CSDirector verified the above information for #18, #19, and #20 demonstrated delinquent medical records, which contradicted Report #2. S2CSDirector further verified there is a big problem and the hospital had no way of knowing how many records were delinquent and is unsure how the records were accidently cleared without going through every one of the charts in the medical records department (records on site were stated by S4MR to be from 2016) to verify there are no delinquent records.

Based on record review and interview, the hospital failed to maintain documented evidence of training for nursing personnel assigned to perform specific respiratory procedures. This deficient practice was evidenced by failure of the hospital to maintain documented evidence of respiratory service training for 7 (#S5CNO, #S6LPN, #S7RN, #S8RN, #S9RN, #S10LPN, and #S11LPN) of 7 nursing personnel records reviewed.

Findings:

Review of the hospital policy titled Administration of Respiratory Therapy, Document Number TX-04-38, revised 7/2015 revealed in part: Longleaf hospital will provide respiratory care services that shall meet the needs of the patients in accordance with acceptable standards of practice. Oxygen Administration. Nebulizer Treatment.

Review of the personnel records for #S5CNO, #S6LPN, #S7RN, #S8RN, #S9RN, #S10LPN, and #S11LPN revealed no documented evidence of all respiratory services provided per hospital policy.

Interview on 08/29/18 at 10:45 a.m. with S1CEO and S5CNO confirmed that there was no documented evidence of respiratory service training for nebulizer treatments and respiratory medication administration documented in the nursing personnel records.