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Based upon record review and interviews, the hospital failed to ensure the contracts for Laboratory Services and Radiology Services included provisions for routine and STAT services. This was evidenced by the failure of the contracts to identify the turn around times for routine and STAT Laboratory and Radiology services.
Findings:

Review of the Laboratory and Radiology contracts revealed these services were to be provided by the host hospital. Further review revealed the contracts failed to identify the type of services to be provided and the turn around times for routine and STAT results.

Interview with S1Administrator and S2DON on 3/22/15 at 10:30 a.m. revealed when asked if there were any addendems to the Laboratory and Radiology contracts which identified the services and turn around times, both replied "no".

Based on observation and interview, the hospital 1) failed to ensure patients' medical records were stored where they were protected from water damage as evidenced by folders of medical records stored on rolling open metal shelving in a room that had active sprinklers and 2) failed to ensure that 5 physicians followed hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days (S5MD, S6MD, S7MD, S8MD, S9MD).
Findings:

1) Failed to ensure patients' medical records were stored where they were protected from water damage

Observations with S3Medical Records Director on 03/22/17 at 2:00 p.m. of the room that stored medical records revealed it contained rolling metal shelves that had paper medical records on them. The shelves were not covered and the room had sprinkler heads in the ceiling. Interview with S3Medical Records Director at that time confirmed that the paper records were not protected from water damage.

In a phone interview on 03/21/17 at 2:10 p.m. with S1Administrator, he confirmed that the paper medical records on the above open metal shelves were not protected if the sprinklers were activated or if there was a water leak from the ceiling.

2) Failed to ensure that 5 physicians followed hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days

Review of the hospital policy and procedure titled Documentation Completion Time Frames, presented as current by S3Medical Records Director, revealed that once the medical record remains incomplete for 30 days, the Administrator shall notify the practitioner that the practitioner's elective privileges have been automatically suspended. The automatic suspension will remain in effect until the delinquent medical records have been verified as complete.

Review of the list of delinquent medical records, provided by S3Medical Records Director, revealed the following physicians had delinquent patient records:
S5MD - patient record delinquent for 133 days
S6MD - 3 patient records delinquent for 104 days, 137 days and 172 days
S7MD - patient record delinquent for 66 days
S8MD - patient record delinquent for 173 days
S9MD - 2 patient records delinquent for 48 days and 70 days

On 03/20/17 at 2:50 p.m., interview with S3Medical Records Director confirmed the above delinquent patient records. She stated that when she identifies incomplete medical records, she notifies the responsible physicians at 11 days, 21 days and at 30 days per faxed notice. She stated that the hospital's policy states to suspend physicians with incomplete records that are past 30 days, but stated that S1Administrator was responsible for the suspensions.

On 03/21/17 at 10:00 a.m., telephone interview with S1Administrator confirmed that he was aware of the above physicians who had delinquent patient records. He further confirmed that the hospital policy indicated that the physicians should be suspended if patient records are incomplete after 30 days, but stated none of the above had been suspended.

Based on occurrence report reviews, record review and interview, the hospital failed to ensure drug administration errors were reported to the physician and documented in the patients' medical records for 2 (Patient #6, 29) of 2 patients reviewed for medication errors.
Findings:

Review of the hospital's occurrence reports revealed medication errors involving Patient #6 (errors on 06/20/16 and 06/21/16) and Patient #29 (errors on 10/27/16, 10/31/16, 11/02,/16, 11/03/16) had been identified. Review of their medical records revealed no documented evidence of an account of the medication errors referenced in the occurrence reports, including physician notification.

On 03/21/17 at 10:40 a.m., S2DON reviewed the records of Patient #6 and #29 and confirmed that there was no documentation in the medical records of the medication errors referenced in the above occurrence reports.