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Based on record review, document review, medical staff bylaw review, and staff interview, the facility failed to ensure the medical staff enforced bylaws to carry out its responsibilities regarding completing 10 of 10 closed charts reviewed, Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10.


Findings Include:


10 closed medical records were selected at random from a list of discharges from March 1, 2016 through April 12, 2016. Review of these 10 records revealed:
Eight (8) patient records, Patient #1, #2, #3, #4, #6, #7, #8 and #9, contained Physician Progress Notes which had not been signed by the Physician;
Nine (9) patient records, Patient #1, #2, #4, #5, #6, #7, #8, #9, and #10, contained Physician Orders which had not been signed, dated and/or timed by the Physician; and
Eight (8) patient records, Patient #1, #2, #3, #5, #6, #7, #8, and #9, did not have documented evidence of a discharge summary on the chart.


Review of the facility's "Incomplete Records List by Days Outstanding/Records Outstanding at Least 30 Days" report revealed that by their count, the facility had 155 incomplete medical records as of 05/18/16 by 16 different providers/physicians. The report indicated the dates the report was sent to the providers ranged from 12/11/13 to 4/22/16. The report also indicated the reasons the records were incomplete included the following was needed: Dictate History and Physical (DHP), Dictate Discharge Summary (DDS), Sign Voice Order (SVO), Sign Progress Note (SPO), Sign Consult (SCO), Sign Discharge Summary (SDS), Sign History and Physical (SHP) and Sign Physician Order (SPO).



Review of the facility's "Medical Staff Bylaws" revealed: "...2.1 Purposes, The purposes of the Medical Staff are: (a) To be the formal organizational structure through which (1) the benefits of membership on the Staff may be obtained by individual practitioners and (2) the obligations of Staff membership may be fulfilled. (b) To serve as the primary means for accountability to the Governing Body for the appropriateness of the professional performance and ethical conduct of its members and allied health professional ant to strive toward the continual upgrading of the quality and efficiency of patient care delivered in the Hospital consistent with the state of the healing arts and the resources locally available ...7.3 Automatic Suspension 7.3-3 Medical Records: An automatic suspension shall, after written warning of delinquency via certified mail, and within twenty-four (24) hours advance notice, be imposed for failure to complete medical records in a timely fashion ...".


In an interview on 05/18/16 at 2:25 p.m. the Registered Health Information Technician (RHIT) stated, "When a patient is discharged, the chart goes to Health Information Management where it is checked and flagged for missing signatures, history and physicals, discharge summaries and any other incomplete component. It is then taken to the Physician's Dictation Room for completion by the provider. I think there is a glitch in my computer system because it doesn't look like there are 155 charts in here." A count that was made with the RHIT present revealed 121 delinquent records in the Physician's Dictation Room.

Based on record review, policy and procedure review, Medical Staff Bylaw review, and staff interview, the facility failed to maintain a medical record for each patient which is accurately written, promptly completed, properly filed and retained, and accessible. This involved 10 of 10 closed patient records reviewed, Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10.


Findings Include:


10 closed medical records were selected at random from a list of discharges from March 1, 2016 through April 12, 2016. Review of these 10 records revealed:
Eight (8) patient records, Patient #1, #2, #3, #4, #6, #7, #8 and #9, contained Physician Progress Notes which had not been signed by the Physician;
Nine (9) patient records, Patient #1, #2, #4, #5, #6, #7, #8, #9, and #10, contained Physician Orders which had not been signed, dated and/or timed by the Physician; and
Eight (8) patient records, Patient #1, #2, #3, #5, #6, #7, #8, and #9, did not have documented evidence of a discharge summary on the chart.


Review of the facility's "Hospital Chart Completion" policy, last revised 4/15/14, revealed: "Purpose: To ensure that the medical records at (facility) fully and accurately reflect a patient's care and are completed in accordance with federal and state law and the requirements of accrediting agencies and (facility). Policy: (Facility) shall utilize standardized Health Information Management (HIM) procedures for determining incomplete medical records, based on regulatory documentation requirements, and for determining when an incomplete medical record has reached delinquent status. The Medical Staff Bylaws/Rules and Regulations of each hospital shall include provisions for the suspension of a physician's admitting privileges as a result of delinquent medical records ...Procedure: A. Hospital Chart Completion ...6. Missing signatures cannot be excluded when counting incomplete and/or delinquent medical records. 7. A medical record is considered to be delinquent if it remains incomplete 30 days after discharge ...B. Documentation Requirements ...3. Discharge Summary: The following information must be included in all discharge summaries: the reason for hospitalization; significant findings; procedures performed and treatment rendered; the condition of the patient at the time of discharge; and instructions to the patient and family ...".


Review of the facility's "Medical Staff Bylaws" revealed: "...2.1 Purposes, The purposes of the Medical Staff are: (a) To be the formal organizational structure through which (1) the benefits of membership on the Staff may be obtained by individual practitioners and (2) the obligations of Staff membership may be fulfilled. (b) To serve as the primary means for accountability to the Governing Body for the appropriateness of the professional performance and ethical conduct of its members and allied health professional ant to strive toward the continual upgrading of the quality and efficiency of patient care delivered in the Hospital consistent with the state of the healing arts and the resources locally available ...7.3 Automatic Suspension 7.3-3 Medical Records: An automatic suspension shall, after written warning of delinquency via certified mail, and within twenty-four (24) hours advance notice, be imposed for failure to complete medical records in a timely fashion ...".


During an interview on 05/17/16 at 11:00 a.m., the Registered Health Information Technician (RHIT) stated, "Two (2) of the Physicians, a father and son, have the most delinquent records and the son, is over the Medical Records Department."


During an interview on 05/17/16 at 11:45 a.m. the Administrator stated that the hospital hired a Physician to oversee the Medical Record Department. When asked if this Physician had delinquent records, he stated, "He is possibly a guilty party."


During an interview on 05/18/16 at 10:20 a.m. the RHIT stated that she does mail letters to the Physicians regarding delinquent medical records, but she does not send them via certified mail.


During an interview on 05/18/16 at 10:25 a.m. the Administrator confirmed the Physicians were not being sent a written warning of delinquent medical records via certified mail.

Based on record review, policy and procedure review, and staff interview, the facility failed to ensure all patient medical record entries are complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure. This involved 10 of 10 closed patient records reviewed, Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10.


Findings Include:


10 closed medical records were selected at random from a list of discharges from March 1, 2016 through April 12, 2016. Review of these 10 records revealed:
Eight (8) patient records, Patient #1, #2, #3, #4, #6, #7, #8 and #9, contained Physician Progress Notes which had not been signed by the Physician;
Nine (9) patient records, Patient #1, #2, #4, #5, #6, #7, #8, #9, and #10, contained Physician Orders which had not been signed, dated and/or timed by the Physician; and
Eight (8) patient records, Patient #1, #2, #3, #5, #6, #7, #8, and #9, did not have documented evidence of a discharge summary on the chart.


Review of the facility's "Hospital Chart Completion" policy, last revised 4/15/14, revealed: " Purpose: To ensure that the medical records at (Facility) fully and accurately reflect a patient's care and are completed in accordance with federal and state law and the requirements of accrediting agencies and (Facility). Policy: (Facility) shall utilize standardized Health Information Management (HIM) procedures for determining incomplete medical records, based on regulatory documentation requirements, and for determining when an incomplete medical record has reached delinquent status. The Medical Staff Bylaws/Rules and Regulations of each hospital shall include provisions for the suspension of a physician's admitting privileges as a result of delinquent medical records ...Procedure: A. Hospital Chart Completion ...6. Missing signatures cannot be excluded when counting incomplete and/or delinquent medical records. 7. A medical record is considered to be delinquent if it remains incomplete 30 days after discharge ...B. Documentation Requirements ...3. Discharge Summary: The following information must be included in all discharge summaries: the reason for hospitalization; significant findings; procedures performed and treatment rendered; the condition of the patient at the time of discharge; and instructions to the patient and family ...".


During an interview on 05/17/16 at 11:00 a.m. the Registered Health Information Technician (RHIT) confirmed the delinquent medical records contained Progress Notes which were missing Physician signatures, telephone orders which had not been signed, dated and/or timed by the Physician and that eight (8) of the 10 closed records reviewed did not have a Discharge Summary.

Based on record review, policy and procedure review, and staff interview, the facility failed to ensure all orders, including verbal orders, were dated, timed and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient. This involved 10 of 10 closed records reviewed, Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10


Findings Include:


10 closed medical records were selected at random from a list of discharges from March 1, 2016 through April 12, 2016. Review of these 10 records revealed:
Eight (8) patient records, Patient #1, #2, #3, #4, #6, #7, #8 and #9, contained Physician Progress Notes which had not been signed by the Physician;
Nine (9) patient records, Patient #1, #2, #4, #5, #6, #7, #8, #9, and #10, contained Physician Orders which had not been signed, dated and timed by the Physician; and
Eight (8) patient records, Patient #1, #2, #3, #5, #6, #7, #8, and #9, did not have documented evidence of a discharge summary on the chart.


Review of the facility's "Hospital Chart Completion" policy, last revised 4/15/14, revealed: " Purpose: To ensure that the medical records at (facility) fully and accurately reflect a patient's care and are completed in accordance with federal and state law and the requirements of accrediting agencies and (Facility). Policy: (Facility) shall utilize standardized Health Information Management (HIM) procedures for determining incomplete medical records, based on regulatory documentation requirements, and for determining when an incomplete medical record has reached delinquent status ...Procedure: ...B. Documentation Requirements 1. Verbal orders As required by the Hospital Conditions of Participation published by the Centers for Medicare and Medicaid Services (CMS), physicians may only authenticate their own chart entries, with the exception of verbal orders ...All verbal orders must be authenticated within the timeframes specified by federal and state law. If there is no specific timeframe designated by state law, then verbal orders must be authenticated within 48 hours ...4. Authentication It is the responsibility of the clinicians/staff members/individuals who make a chart entry, dictate a report for transcription or give a verbal order to authenticate that item within the medical record as described by law or regulation ...Each entry must be authenticated, dated and timed."


During an interview on 05/17/16 at 11:00 a.m. the Registered Health Information Technician (RHIT) confirmed the 10 delinquent medical records contained telephone orders which had not been signed, dated and/or timed by the Physician.

Based on record review, policy and procedure review, and staff interview, the facility failed to maintain documented evidence of a discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care for eight (8) of 10 closed medical records reviewed, Patient #1, #2, #3, #5, #6, #7, #8, and #9.


Findings Include:


10 closed medical records were selected at random from a list of discharges from March 1, 2016, through April 12, 2016. Review of these records revealed that Patient #1, #2, #3, #5, #6, #7, #8, and #9's records did not have documented evidence of a discharge summary on the chart.


Review of the facility's "Hospital Chart Completion" policy, last revised 4/15/14, revealed: "Purpose: To ensure that the medical records at (Facility) fully and accurately reflect a patient's care and are completed in accordance with federal and state law and the requirements of accrediting agencies and (facility). Policy: (Facility) shall utilize standardized Health Information Management (HIM) procedures for determining incomplete medical records, based on regulatory documentation requirements, and for determining when an incomplete medical record has reached delinquent status ...Procedure ...B. Documentation Requirements ...3. Discharge Summary: The following information must be included in all discharge summaries: the reason for hospitalization; significant findings; procedures performed and treatment rendered; the condition of the patient at the time of discharge; and instructions to the patient and family ...".


During an interview on 05/17/16 at 11:00 a.m., the Registered Health Information Technician (RHIT) confirmed that the eight (8) closed records did not have documented evidence of a Discharge Summary. She stated, "They're just not there."

Based on record review, policy and procedure review, and staff interview, the facility failed to notify the Organ Procurement Organization (OPO) of all patient deaths.


Findings Include:


Review of the 2015 and 2016 Mississippi Organ Recovery Agency (MORA) Tissue Donation Report for the facility, revealed two patient deaths were not reported to MORA during the last 12 months.

Review of the facility's "Organ Procurement" policy revealed: "Purpose: To ensure that the families of all potential donors are offered the opportunity to donate organs and/or tissues and are allowed to accept or to decline that option ...To comply with federal and state laws to provide guidelines for the safe and ethical donation of organs and tissues ...Procedure: A. Assessment and Pre-Donation Processing ...6. The OPO hot line is available twenty-four (24) hours a day. They are to be notified within one hour of each death. Federal and state routine referral legislation mandates that the OPO be notified of ALL potential donors. A notification should be made on every death that occurs in the facility regardless of the cause of condition leading to death ...B. Donor Referral Process ...1. Call the OPO to refer any potential organ/tissue donor ...4. Tissue Donor Referral, a. Potential tissue donors should be referred within thirty (30) minutes but no later than one hour following cardiac death ...".


During an interview on 05/18/16 at 10:45 a.m. the Director of Nursing (DON) confirmed that two (2) patient deaths were not reported to MORA, in the last 12 months.