HospitalInspections.org

Based on review of facility documents, credential files (CF)and staff interview (EMP), it was determined the facility failed to ensure patient medical records were completed within 30 days following discharge.

Findings include:

Review on November 9, 2017, of the facility's "Medical Staff Rules and Regulations" no review date, revealed "Section 1 - General Conduct of Care ... C. Medical Records ... 13. The patient's medical record shall be completed at time of discharge, including progress notes, final diagnosis and dictated clinical resume. When this in not possible because final laboratory or other essential reports have not been received at the time of discharge, the patient's chart will be available in a stated place in the medical records room. If the chart remains incomplete fifteen (15) days after all essential reports have been received, the physician will be sent notification of the delinquency and informed that automatic suspension will occur if the chart remains incomplete at day thirty (30). ..."

Review on November 9, 2017, of the facility's "Medical Staff Bylaws" last reviewed and revised May 24, 2017, revealed "... Article VII ... 7.4-5 Medical Records Practitioners are required to complete medical records within a reasonable time, which may be prescribed by the Medical Staff Rules and Regulations. A limited suspension in the form of withdrawal of admitting and other related privileges until medical records are completed shall be imposed by the President of the Medical Staff after notice of delinquency for failure to complete medical records within the required period. For the purpose of this section, "related privileges" means voluntary on call services for the emergency department, scheduling surgery, assisting in surgery, consulting on Hospital cases, and providing professional services within the Hospital for future patients. ... Practitioners whose privileges have been suspended for delinquent records may admit patients only in life-threatening situations. The suspension shall continue until lifted by the Vice President of Medical Affairs or the President following completion of medical records. ..."

Review on November 9, 2017, of the facility provided "Deficiency Slip" identified by EMP5 as the medical record delinquent report dated November 9, 2017.

1) Review on November 9, 2017, of the delinquent medical record list revealed CF1 had 1 delinquent medical record that was greater than 30 days from the patient's date of discharge. CF1's delinquent medical record list included the following:
MR11 was discharged on November 15, 2016.

2) Review on November 9, 2017, of the delinquent medical record list revealed OTH1 had 11 delinquent medical records that were greater than 30 days from the patient's date of discharge. OTH1's delinquent medical record list included the following:
MR12 was discharged on June 30, 2017, was readmitted and discharged again on July 15, 2017.
MR13 was discharged on July 11, 2017
MR14 was discharged on August 25, 2017
MR15 was discharged on September 1, 2017
MR16 was discharged on September 2, 2017
MR17 was discharged on September 9, 2017
MR18 was discharged on September 10, 2017
MR19 was discharged on September 16, 2017
MR20 was discharged on September 23, 2017
MR21 was discharged on September 23, 2017.

3) Review on November 9, 2017, of the delinquent medical record list revealed OTH2 had three delinquent medical records that were greater than 30 days from the patient's date of discharge. OTH2's delinquent medical record list included the following:
MR22 was discharged on August 9, 2017
MR23 was discharged on August 22, 2017
MR24 was discharged on August 29, 2017.

4) Review on November 9, 2017, of the delinquent medical record list revealed OTH3 had 31 delinquent medical records that were greater than 30 days from the patient's date of discharge. OTH3's delinquent medical record list included the following:
MR34 was discharged on January 6, 2017
MR35 was discharged on March 13, 2017
MR36 was discharged on March 30, 2017
MR37 was discharged on April 6, 2017
MR38 was discharged on April 11, 2017
MR29 was discharged on April 11, 2017
MR40 was discharged on May 5, 2017
MR41 was discharged on May 8, 2017
MR42 was discharged on May 15, 2017
MR43 was discharged on June 23, 2017
MR44 was discharged on June 26, 2017
MR45 was discharged on June 7, 2017
MR46 was discharged on June 8, 2017
MR47 was discharged on June 15, 2017
MR48 was discharged on June 29, 2017
MR49 was discharged on June 26, 2017
MR50 was discharged on July 18, 2017
MR51 was discharged on July 6, 2017
MR52 was discharged on July 10, 2017
MR53 was discharged on July 11, 2017
MR54 was discharged on May 24, 2017
MR55 was discharged on July 21, 2017
MR56 was discharged on August 3, 2017
MR57 was discharged on July 11, 2017, was re-admitted and discharged again on August 23, 2017
MR58 was discharged on August 30, 2017
MR59 was discharged on September 1, 2017
MR60 was discharged on September 5, 2017
MR61 was discharged on September 5, 2017
MR62 was discharged on September 12, 2017.

5) Review on November 9, 2017, of the delinquent medical record list revealed OTH5 had 10 delinquent medical records that were greater than 30 days from the patient's date of discharge. OTH5's delinquent medical record list included the following:
MR25 was discharged on May 27, 2017
MR26 was discharged on June 10, 2017
MR27 was discharged on July 6, 2017
MR28 was discharged on July 22, 2017
MR29 was discharged on July 22, 2017
MR30 was discharged on August 4, 2017
MR31 was discharged on September 9, 2017
MR32 was discharged on September 9, 2017
MR33 was discharged on September 12, 2017
MR35 was discharged on March 13, 2017.

Interview with EMP1, EMP2 and EMP5 on November 9, 2017, at approximately 3:15 PM confirmed CF1, OTH1, OTH2, OTH3 and OTH5 had medical records that were not completed within 30 days of the patients' discharge date.