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Based on record review and interview the hospital failed to have discharge summaries completed within 30 days after discharge for 1 (#13) of 5 patient records reviewed for discharge summaries out of a sample of 16. Findings:

Review of the hospital policy for Health Record Completion, Policy Number 2135201, revised 04/2015 revealed in part: The health record documentation shall be completed in an ongoing manner through the stay. When data entries are not completed by the time of discharge, the following time frames and definitions shall apply: Discharge Summary, 30 days.

Review of patient #13's medical record revealed an admission on 06/19/17 with a diagnosis of Cerebral Vascular Accident with Left Hemiparesis. The patient was discharged from the hospital on 06/24/17 there was no discharge summary documented in the medical record.

In an interview on 08/01/17 at 2:30 p.m. with S5HIM (Health Information Manager) confirmed there was no discharge summary dictated for patient #13.

Based on observation, record review and interview, the facility failed to ensure that medical records were completed within 30 days following discharge by having 2 physicians with a total of 53 incomplete records over 30 days after discharge.

Findings:

On 08/01/17 at 8:25 a.m., observation of the physician's dictation room with S5HIM revealed a number of medical records sitting in cabinets awaiting completion by physicians. S5HIM stated that the records are placed in the cabinets and each physician is given a printed listing of the records needing completion, which is placed in a clear plastic bin on the wall near the cabinet.

Review of the delinquent records lists provided by S5HIM revealed S6MD had 26 delinquent records, 19 of which were over 90 days. S7MD had 27 records which were over 30 days. Review of the physician communication files revealed weekly faxes and monthly letters were sent to the physicians who had delinquent records.

Review of the facility policy dated 02/16 entitled Practitioner Disciplinary Action Plan, F.6.21 revealed the following disciplinary action plan was developed for use when a Practitioner has delinquent medical records or documentation quality issues below benchmark. The action plan is to be followed for consecutive months of non-compliance.

Procedure:
Monthly, the HIM Department will assess delinquencies by physician and will notify the CEO and Medical Director of those Practitioners with Delinquent Charts and/or documentation quality issues. The Medical Director will implement the progressive plan as follows:
Month 1: A letter from administration and/or Medical Director will be sent to the Practitioner.
Month 2: A one on one meeting with administration and/or Medical Director will be scheduled and held with the Practitioner.
Month 3: The Practitioner will be required to submit a written explanation for non-compliance with a plan for gaining compliance.
Month 4: The Practitioner will be required to attend the next scheduled MEC for discussion regarding the noncompliance.
Month 5: The Practitioner will be placed on focused review for documentation quality and timeliness for the next quarter.
Month 6: The Practitioner's admitting/consulting privileges will be suspended.

On 08/02/17 at 9:30 a.m., an interview with S5HIM confirmed that the above policy was not followed to ensure physician compliance with completion of medical records.

Based on record review and interview, the hospital failed to ensure a Registered Pharmacist was appointed as the director of Pharmaceutical Services. This was evidenced by the failure of the hospital to notify S4Pharmacist that he had been appointed as the Director. Findings:

Review of the Governing Body Meeting Minutes dated 02/22/17 revealed S4Pharmacist was designated as the Director of Pharmaceutical Services.

On 08/01/17 at 2:50 p.m. a telephone interview was conducted with S4Pharmacist. During the interview, S4Pharmacist was asked if he was the Director of Pharmacy at the hospital and he replied he was only the director of the consulting pharmacy services. S4Pharmacist did not know he had been appointed by the Governing Body to be over the hospital's Pharmaceutical Services.