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Based on interview, observation, policy and procedure and record review, it was determined the Medical Records Department staff failed to assure records were completed timely by physicians and failed to assure policy and procedures were followed when records were delinquent for 1136 clinical records. The ability to meet regulatory requirements related to completion, filing, and retrieval of clinical records was impaired. The failed practice affected the 1136 patients with clinical records that were incomplete after 30 days. The findings follow:

A. In an interview 10/20/11 at 1035 with the Business Office Director, stated she was also responsible for the Medical Record Department and did not have a Manager for that Unit at this time. She stated they were in the interview process and the position had been vacant since July 21, 2011. There was not a RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) on staff at present and no formal contract for services to be provided on site by a RHIA.

B. Observation on 10/20/11 at 1210 revealed a room within the Medical Record Department labeled "Dictation Room". This room contained a large number of patient medical records stacked on shelves, on a desk and on a stool in the corner. The Business Office/Medical Records Director was asked by Surveyor #1 what was the purpose of the patient clinical records stacked in the room. She stated "all of these are incomplete patient clinical records." Surveyor #1 asked how many records were over 30 days old? A printed document titled "Medical Park Hospital Deficiency Report by Physician/Employee Statistics of Deficiencies" was received on 10/20/11 at 1255. The Business Office Director/Medical Records Director confirmed the contents of the document that revealed a total of 1136 incomplete charts, with 207 of the records 30 - 60 days incomplete and 929 charts over 60 days incomplete.

C. Review of the Medical Record policy #MR 25, "Incomplete/Delinquent record notification" stated: "Policy: a review of incomplete medical records will be conducted the 1st of every month to assure documentation is being conducted in a timely manner. All charts should be complete within 30 days in order to be in compliance with Medical Staff Bylaws, State and JACHO (Joint Commission on Accrediaton of Healthhcare Organizations) standards." The policy outlined the procedure: "The incomplete listing will be run on the 1st of each month for incomplete records 15 days and older. A memo will be sent to each physician weekly notifying regarding the number of incomplete records that need to be completed by the 30th day of the month. Physicians are notified on the 20th of each month by phone and fax the records that are still incomplete. Physician is notified by phone daily for the last three days before suspension of incomplete records. If these records are not completed by the specified date, the records will be considered delinquent and physician's admission privileges will be suspended as per Medical Staff Bylaws. The suspension list will be comprised by the HIM (Health Information Management) Supervisor and/or HIM Technician on the 1st working day following the 30th day of the month. The HIM Supervisor and/or HIM Technician will be responsible for e-mailing the suspension lists to all departments currently receiving a suspension list. This e-mail will be sent within 30 minutes after a doctor has worked on their charts. The Physician is notified on the 30th of each month of suspension of admission privileges by certified mail. The HIM Supervisor and/or HIM Technician will add in the terminal which doctors are off staff in order to alert Admitting Personnel, should they try to admit a patient to a physician who is off staff."

D. In an interview with the Business Office/Medical Records Director 10/21/11 at 0915, she stated she did not have documentation of physician notification of delinquent medical records per policy. A copy of the last physician suspension for delinquent medical records was provided and the date was 08/14/09.

E. The Administrative Assistant responsible for Medical Staff and Governing Body Minutes was asked for the meeting minutes for the last 12 months. She confirmed on 10/20/11 at 1650 that there was no report of the delinquent medical records. She stated "in May there was a report of filing of some incomplete medical records but there has not been a medical records report since June 2011."

Based on observation, interview and review of clinical records, it was determined the facility failed to assure clinical records were completed within 30 days of discharge; failed to assure incomplete records were stored in an easily retrievable manner and failed to assure the integrity of the clinical record was maintained in the facility onsite and offsite storage. The record storage in the Dictation Room, onsite and offsite storage areas was not maintained in a manner that promoted prompt retrieval and accessibility. The failed practice affected the 1136 incomplete clinical records and all clinical records boxed for storage onsite, offsite and in the Medical Records Department, and had the potential to affect all patients who were treated at the facility. The findings are:

A. Observation on 10/20/11 at 1210 revealed a room within the Medical Record Department labeled "Dictation Room". That room contained a large number of patient clinical records stacked on shelves, on a desk and on a stool in the corner. The individual patient charts were not filed by patient name or medical record number; they were grouped by physician name. The Business Office/Medical Records Director was asked by Surveyor #1 the purpose of the patient clinical records in the room. She stated "all of these are incomplete patient clinical records." Surveyor # 1 asked how many records were over 30 days old. A printed document titled "Medical Park Hospital Deficiency Report by Physician/Employee Statistics of Deficiencies" was received on 10/20/11 at 1255. The Business Office Director/Medical Records Director confirmed the contents of the document revealed a total of 1136 incomplete charts, with 207 of the records 30 - 60 days incomplete and 929 charts over 60 days incomplete. The number of records contained in the room and the grouping by physician name was not easily accessible for patient clinical record retrieval.

B. The Medical Records Department was observed 10/20/11 at 1230 and contained 35 cardboard storage boxes identified by the Business Office/Medical Records Director as ready to be moved to the onsite storage room. A count of the boxes revealed 21 of 35 storage boxes stacked directly on the floor. The boxes were not stored in any specific order within the Department for ease of retrieval. The Business Office/Medical Records Director confirmed the findings at the time of observation.

C. On 10/20/11 at 1335 a room identified by the Director of Nursing as used for onsite storage of clinical records was observed and contained 86 boxes of clinical records of which 21 were stored directly on the floor. The boxes within the room were not stored in any specific order for ease of retrieval. The room had an operational sink which created the potential for water damage should a leak occur. The findings were confirmed at the time of observation by the Director of Nursing and the Business Office/Medical Records Director.

D. A tour of the offsite storage for clinical records was conducted on 10/20/11 from 1420 - 1500. The brick and wood structure with metal roof contained a separately locked area within the large storage room enclosed behind a metal fence. Behind the locked fence area, multiple boxes were noted opened with records spilling onto the concrete floor. Large wire shelving contained boxes of clinical records. There were 134 facility cardboard type boxes that contained clinical records that were stacked in the isles between the shelves and at the ends of rows of wire shelving. Of the 134 boxes that were not on the shelves, 50 were stored directly on the concrete floor. Seven torn boxes were noted with the contents spilled on the floor of the storage area. The boxes with patient clinical records were not maintained in a specific order for ease of retrieval. Hospital Maintenance Engineer #1 and the Director of Nursing confirmed the findings at the time of observation.

Based on observation, interview and policy and procedure review, it was determined the facility failed to follow their policy and failed to have a process in place to assure the medical records of minors were retained in accordance with the Rules and Regulations for Hosptials and Related Institutions in Arkansas, 2007, Section 14.A.19 which required medical records of minors be retained for a period of two years after the age of majority. Medical information would not be available for minors if requested as the facility had no process in place to differentiate the medical records of minors from adults prior to destruction. The deficient practice had the potential to affect all minors who received treatment at the facility. The findings were:

A. The facility policy #MR 53, dated 08/10 was provided by the Medical Records Director on 10/21/11 at 0925 and revealed "Medical Records shall be retained in their original or legally reproduced form for a period of at least 10 years. After a period of 10 years the record can be destroyed provided that the facility permanently maintains the information maintained in the Master Patient Index. Records of minors shall be retained for a period of two years past the age of majority. In the event the facility closes the records will be maintained in a manner that the patients will still have access to the records upon written signed authorization. Records will be destroyed by either burning or shredding."

B. In interview with the Director of Nursing and the Medical Records Director on 10/20/11 at 1700, a "Letter of Destruction" was presented for the last time medical records were destroyed, dated 11/30/2009. The document listed the hospital name, a box count as 1,430 boxes. A category listed "1997 and below inpatient and 1998-1999 ER (Emergency Room) Medical Records". The date received was 05/19/03. The letter of destruction provided conformation of destruction of those items on 11/30/09. The facility was unable to provide documentation of minor records destroyed and stated they did not have a process to separate minor records from adults. The Medical Records Director and Director of Nursing confirmed the findings 10/21/11 at 0925.

Based on interview and clinical record review, it was determined the facility failed to assure physician telephone orders were verified and signed as specified by the Rules and Regulations for Hospitals and Related Institutions in Arkansas, 2007, Section 14.D.2.c. of 96 hours for 2 (#10 and #20) of 19 (#3, #5-22) open clinical records reviewed. Verification of telephone or verbal orders by the physician or ordering practitioner was an opportunity to identify and correct errors. The failed practice affected patients #10 and #20 and had the potential to affect all patients admitted to the facility. The findings follow:

Clinical record review was conducted on 10/21/11 from 1130 - 1340 and revealed Patient #20 was admitted 10/15/11. A telephone order was noted 10/15/11 at 1110 for "Rocephin 1 gram IVPB (Intravenous Piggy back) daily and Vancomycin IVPB - Pharmacy to calculate dose and repeat K+ (potassium) level at 1400." As of 10/20/11, the telephone order was not signed by a physician. On 10/1511 at 1525 a telephone order was taken for PT (Protime), PTT (Partial Thromboplastin Time), BMP (Basic metabolic Panel) at 1900 today. At 1620, a telephone order was noted to Give one amp of D50 (Dextrose 50%) IVP (Intravenous push) now, place in contact isolation due to history of MRSA (Methacilllin-resistant Staphylococcus aureus) Left foot change IVF (intravenous fluids) with next bag to D5NS (Dextrose 5% in water) at 150 ml/hr IV (milliliters/hour intravenous)." As of 10/20/11, the telephone orders were not signed by a physician.

Patient #10, admitted 10/13/11 had the Physician orders for DVT/PE (Deep Venin Thrombosis/ Pulmonary Embolism) Prophylaxis Protocol in the chart, signed by a nurse on 10/13/11 at 1630. As of 10/20/11, the physician ordered protocol was not signed or dated by a physician. The findings were confirmed by RN #1 on 10/21/11 at 1330.