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Based on record review and interview, the hospital failed to ensure 10 Physicians (S5, S7, S8, S9, S10, S11, S12, S13, S14, and S15) followed Medical Staff By-laws and hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days.

Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body revealed, ADDENDUM XI: The Medical Staff shall adopt such Rules and Regulations as may be necessary for the proper conduct of its work. It is the policy of Louisiana Extended Care Hospital of Natchitoches to ensure completion of medical records within thirty (30) days of discharge.

Review of the Medical Records Chart Deficiencies Listing dated 01/07/20 given to surveyor by S4HIM revealed the following physicians had delinquent records over 30 days:

S5 Physician - #6 records (32-130 days)
S7 Physician - #9 records (43-95 days)
S8 Physician - #5 records (54-99 days)
S9 Physician - #2 records (83-120 days)
S10 Physician - #7 records (47-112 days)
S11 Physician - #5 records (58-105 days)
S12 Physician - #1 records (90 days)
S13 Physician - #6 records (35-83 days)
S14 Physician - #1 records (64 days)
S15 Physician - #1 records (47 days)

Interview on 01/08/20 at 1:00 p.m. with S1Administrator confirmed that he was unaware of the delinquent records past 30 days that were not completed.

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Based on record review and interview, the hospital failed to ensure each patient had a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by having H&Ps performed more than 24 hours after admission for 11 (#1, #3, #4, #5, #8, #10, #12, #13, #23, #24, and #26) of 30 patient records reviewed for H&Ps from a sample of 30 patients.

Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body revealed, 11.1 ADMISSIONS: The admitting practitioner shall be responsible for the coordination of medical care, treatment, and services of the patient, for the prompt completion and accuracy of the medical record, including performance of the History and Physical within twenty four (24) hours of admission, for necessary instructions to hospital personnel, and for communicating reports of the condition of the patient. Notwithstanding the foregoing, if the patient has been discharged from a hospital within thirty (30) days prior to admission, the History and Physical need not be repeated so long as the prior History and Physical is included in the chart, and a physical assessment of the patient is performed by a physician to update any components of the patient's current medical status that may have changed since the prior History and Physical or to address any areas where more current data is needed, within 7 days prior to admission.

Patient #1
Review of the medical record revealed the patient #1 was admitted on 12/31/19 with a diagnosis of S/P Left TKR. The History and Physical was not dictated by S7Physician until 01/06/20, 6 days after admission.

Patient #3
Review of the medical record revealed the patient #3 was admitted on 12/20/19 with a diagnosis of S/P Heart Failure. The History and Physical was not dictated by S6Physician until 12/23/20, 3 days after admission.

Patient #4
Review of the medical record revealed the patient #4 was admitted on 12/02/19 with a diagnosis of S/P Pneumonia. The History and Physical was not dictated by S6Physician until 12/09/19, 7 days after admission.

Patient #5
Review of the medical record revealed the patient #5 was admitted on 12/27/19 with a diagnosis of S/P CABG. The History and Physical was not dictated by S7Physician until 12/31/19, 3 days after admission.

Patient #8
Review of the medical record revealed the patient #8 was admitted on 01/03/20 with a diagnosis of S/P Pneumonia. The History and Physical was not dictated by S7Physician until 01/06/20, 3 days after admission.

Patient #10
Review of the medical record revealed the patient #10 was admitted on 12/09/19 with a diagnosis of S/P Respiratory Failure. The History and Physical was not dictated by S7Physician until 12/11/19, 2 days after admission.

Patient #12
Review of the medical record revealed the patient #12 was admitted on 12/05/19 with a diagnosis of S/P Sacral Fracture. The History and Physical was not completed by S5Physician until 12/08/19, 3 days after admission.

Patient #13
Review of the medical record revealed the patient #13 was admitted on 11/21/19 with a diagnosis of S/P Spinal Stenosis. The History and Physical was not dictated by S6Physician until 11/23/19, 2 days after admission.

Patient #23
Review of the medical record revealed the patient #23 was admitted on 10/03/19 with a diagnosis of S/P Pneumonia. The History and Physical was not dictated by S7Physician until 10/15/19, 12 days after admission.

Patient #24
Review of the medical record revealed the patient #24 was admitted on 10/09/19 with a diagnosis of S/P Respiratory Failure. The History and Physical was not dictated by S8Physician until 10/23/19, 14 days after admission.

Patient #26
Review of the medical record revealed the patient #26 was admitted on 11/04/19 with a diagnosis of S/P Malnutrition. The History and Physical was not dictated by S7Physician until 11/20/19, 16 days after admission.

Interview on 01/07/20 at 2:00 p.m. with S4HIM confirmed the History and Physical should be completed within 24 hours after the patient is admitted to the hospital and placed in the patient's medical record.



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Based on record review and interview, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure a completed discharge summary was on all patient records within 30 days of discharge for 1 (#26) of 19 discharged patient records reviewed for discharge summaries from a total sample of 30.


Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body revealed, ADDENDUM XI: The Medical Staff shall adopt such Rules and Regulations as may be necessary for the proper conduct of its work. It is the policy of Louisiana Extended Care Hospital of Natchitoches to ensure completion of medical records within thirty (30) days of discharge.

Patient #26
Review of the medical record for patient #26 revealed the patient was admitted to the hospital on 11/04/19 with a diagnosis of S/P Malnutrition, and was discharged on 11/22/19. The Discharge Summary was dictated by S7Physician on 01/06/20, 45 days after the patient was discharged.

Interview on 01/08/20 at 2:00 p.m. with S4HIM confirmed the Discharge Summary was not completed within 30 days of discharge.