The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ROSELAND COMMUNITY HOSPITAL 45 W 111TH STREET CHICAGO, IL 60628 Jan. 10, 2020
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on document review and interview, it was determined that the Hospital failed to ensure an effective and well-organized medical record service to maintain medical records and ensure efficient continuity of patient care. As a result, the Condition of Participation CFR 482.24, Medical Records, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients' medical records were accessible. See deficiency at A-0438.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that the Hospital failed to ensure patients' complete medical records were accessible. This potentially affected approximately 256 patients that were seen at the Hospital.

Findings include:

1. On 1/8/2020 at approximately 9:25 AM, the Hospital's policy titled, "Medical Records Documentation" (reviewed by the Hospital 12/2017) included, "Policy: A medical record is initiated and maintained for every individual assessed or treated. The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, and facilitate continuity of care among health care providers ... A complete medical record is a medical record in which: 1. Its contents reflect the diagnosis, results of diagnostic tests, therapy rendered ... progress, and conditions at discharge. 2. Its content including any required clinical summary of final progress notes, are assembled and authenticated, with all final diagnoses and any complications ... Procedure ... E. Minimum Required Content of Each Medical Record ... 3. Emergency care provided to the patient prior to arrival, if any. 4. The record and findings of the patient's assessment. 5. Conclusions of impressions drawn form the medical history and physical examination. 6. The diagnosis or diagnostic impression. 7. The reason(s) for admission or treatment. 8. The goals of treatment and the treatment plan. 9. Evidence of advanced directives ... 11. Diagnostic and therapeutic orders ... 14. Progress notes made by the medical staff and other authorized individuals. 15. All reassessments and any revision of the treatment plan. 16. Clinical observations. 17. The patient's response to the care provided ... 18. Every medication ordered or prescribed ... 22. All relevant diagnosis established during the course of care ... 24. Conclusions at the termination of hospitalization ... 26. A final progress notes ..."

2. On 1/8/2020 at approximately 9:45 AM, the Hospital's policy titled, "Storage and Security of Medical Records" (reviewed by the Hospital 12/2017) included, "Policy: All primary and secondary health records shall be housed in secure areas under the immediate control of the Health Information Management Services (HIMS) Director. Medical records must be secured and retained in their original or legally reproduced form for a period of at least 10 years ... Access to areas housing health information records shall be limited to the HIMS personnel. Because health records must be available and accessible at all times for patient care ..."

3. On 1/8/2020 at approximately 10:00 AM, the Hospitals' policy and procedure titled, "Release of Information" (revised 10/2016) included, "Policy: The release of confidential patient information will be released only after the Hospital has received proper authorization ... Disclosure of Confidential Medical Information ... External Disclosure ... 5. Accreditation ad Licensure Surveys - Information in the medical record shall be made available upon request to assure compliance with applicable standards and regulations ... 8. Public Health - Information relative to ... deaths will be released to the appropriate public health organizations without patient or surrogate authorization ..."

4. On 1/8/2020 at approximately 12:45 PM, an email dated 12/11/19 was reviewed and included, "Memorandum ... From Health Information Management Department ... Re: Medical Record Request. We are unable to comply with your request at this time due to system problems. Please resubmit your request; we will comply as soon as our system problems have been corrected."

5. On 1/8/2020 at approximately 1:00 PM, sample letter that were sent to patients admitted before 11/8/19 requesting for medical records was reviewed and included, "From (the Hospital) ... To ... We are unable to comply with your request at this time for the following reason(s):Due to the server being down. We have no answer at this time when the system will be back up and running. We apologize for any inconvenience that this may have cause."

6. On 1/10/2020, the Hospital provided an email dated 1/8/2020 for patient's request for medical records that included, " ... I got a total of 256 request that we sent out with correspondence letters due to the system being down ..."

7. On 1/7/2020 at approximately 11:45 AM, the clinical record of Pt. #1 was requested. Pt. #1 presented to the to the Hospital's ED (Emergency Department) on 9/26/19 with a chief compliant of abdominal pain. However, as of 1/10/2020, Pt. #1's complete medical record for the ED visit dated 9/26/19 was not accessible upon request. The clinical record lacked physician's order sheet, medication administration record, and nursing assessment sheet.





8. On 1/10/20 at approximately 10:35 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a [AGE] year old female that (MDS) dated [DATE] with a chief compliant of abdominal pain. Pt. #2's complete medical record for the ED visit dated 7/1/19 was not accessible for review upon request. The only documents presented for review on 1/10/20 were the Nurses Note dated 7/1/19 from 4:50 AM thru 8:40 AM and a generic" Note (Physician Note) dated 7/1/19 at 5:39 AM. Additionally, Pt. #2's complete medical record was requested on 1/8/2020 at approximately 9:30 AM. However, the clinical records reviewed were provided not until 1/10/2020 at 9:30 AM.

9. On 1/10/20, the clinical record for Pt. #3 was reviewed. Pt. #3 was a [AGE] year old female that (MDS) dated [DATE] with a chief compliant of abdominal pain. Pt. #3's complete medical record for the ED visit dated 8/2/19 was not accessible for review upon request. The only documents that were presented for review were the "History and Physical" dated 8/2/19 and "Nurses Progress Notes" dated 8/1/19 at 5:42 PM thru 8/3/19 at 9:12 PM. Additionally, Pt. #3's complete medical record was requested on 1/8/2020 at approximately 9:30 AM. However, the clinical records reviewed were provided not until 1/10/2020 at approximately 9:30 AM.

10. On 1/10/20, the clinical record of Pt. #4 was reviewed. Pt. #4 was a [AGE] year old male that (MDS) dated [DATE] with a chief complaint of abdominal pain. Pt. #4's complete medical record for the ED visit dated 9/13/19 was not accessible for review upon request. The only document that were presented for review were the "History and Physical" dated 9/13/19, "Physician Progress Note" dated 9/14/19, "Nurses Notes" dated 9/12/19 11:11 PM thru 9/14/19 12:00 AM, and the "Dietary Progress Note" dated 9/13/19 at 4:31 PM. Additionally, Pt. #4's complete medical record was requested on 1/8/2020 at approximately 9:30 AM. However, the clinical records reviewed were provided not until 1/10/2020 at approximately 9:30 AM.

11. On 1/10/20, the clinical record of Pt. #5 was reviewed. Pt. #5 was a [AGE] year old female that presented to the ED with a chief complaint of abdominal pain. Pt. #5's complete medical record for the ED visit dated 10/2/19 was not available for review. The only documentation provided was the "OB/GYNE H & P" (Obsetritics/Gynecology History and Physical) dated 10/2/19 at 3:12 PM. Additionally, Pt. #4's complete medical record was requested on 1/8/2020 at approximately 9:30 AM. However, the clinical records reviewed were provided not until 1/10/2020 at approximately 9:30 AM.

12. On 1/7/2020 at approximately 11:30 AM, an interview was conducted with E #1 (Chief Nursing Officer). E #1 stated that on November 8, 2019, the person on-call stated that the Hospital's electronic health record system was infected by a computer virus. E #1 stated, "Our electronic record system such as the patient medical records (physician's order, documentation, medication administration, etc.) was affected. Since 11/8/2020, the Hospital has been on downtime ..." Regarding access to medical records for patients admitted to the Hospital, E #1 stated, "From January 2019 to about November 2019, a patient's complete medical record could not be accessed ..." Regarding notification of patients concerning the attack on the Hospital's computer system, E #1 stated that the Hospital has not yet sent letters to patients.

13. On 1/8/2020 at approximately 11:04 AM and at 12:45 PM, interviews were conducted with E #3 (Coding Supervisor/Supervisor, Medical Records). E #3 stated that she is the supervisor for the Hospital's medical records department. As the supervisor, E #3 stated that she oversees the operation within the medical records. E #3 stated, " We have been on downtime procedure since November 8, 2019 ... " Regarding requests for patient's medical records for patients admitted to the Hospital before 11/8/2019, E #3 stated, "We sent out letters (to patients requesting medical records admitted prior to 11/8/2019) that we could not provide medical records due to the computer system being down." E #3 stated that a patient's medical records should be readily accessible and available. Regarding Pt. #1, Pt. #2, Pt. #3, Pt. #4, and Pt. #5's medical records, E #3 said that when requested, " We normally keep the records for 10 years, but I could not get access (nor obtain) the patients' complete medical records due to the electronic system being down." E #3 stated that there is no other way that the records could be obtained.