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Based on interviews and document reviews, the hospital failed to ensure there was an effective governing body that was responsible for the conduct of the hospital and it's operations when:

1. The governing body failed to ensure an ongoing Quality Assessment Process Improvement (QAPI) program was implemented and showed measurable improvement of indicators with potential quality outcomes and set priorities for performance improvement activities for problem prone areas including a medical record completion process (refer to A-0263); and

2. The governing body failed to ensure a total of 407 patient medical records, including documentation of observations, treatments, nursing care, outcomes, and physician's orders, were complete and accurate (refer to A-0431).

These failures prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population.

The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Governing Body.

Findings:

During an interview on 6/5/2025 at 8:40 A.M., Deputy Director (DD) confirmed a document titled Psychiatric Health Facility (PHF) Governing Body Bylaws, dated April 2024, were the most recent Governing Bylaws for the facility. The DD indicated the Governing Body meets every quarter and includes himself, the Director of Nurses (DON), Quality Director (QD), and two members of the Board of Supervisors and the Hospital Administrator (HD). The DD acknowledged the governing body was responsible for operations and quality of patient care provided in the facility.

Review of the document titled, [Hospital Name] Psychiatric Health Facility (PHF) Governing Body Bylaws", dated April 2024, indicated, "The PHF Governing Body that is legally responsible for the conduct of the hospital...(a) Assure that all services, including care and treatment provided to patients, is adequate and safe at all times... (d) Provide for the control and use of appropriate physical and financial resources and personnel required to meet the need of [Hospital Name] patients. (e) Assure that [Hospital Name] facility and its operation conforms to all applicable federal, state and local law laws and regulations, including those relating to licensure...(f) Additional duties include:...review the [Hospital Name] continuous quality improvement work plans..."

Based on interviews and document review, the hospital failed to maintain a Quality Assurance Process Improvement (QAPI) program when the hospital failed to implement a process to track, monitor, and create actionable plans to complete documentation for 407 patient medical records that were incomplete (refer to A-0283).

This failure to develop a comprehensive program that identified opportunities for improvement of a high- volume and problem-prone area resulted in the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care and potential to compromise patient outcomes.

The cumulative effects of these systemic problems resulted in the hospital's inability to maintain an effective quality assessment and performance program in accordance with the statutorily-mandated Conditions of Participation for Quality Assessment and Performance Improvement Program.

Based on interviews and record review, the hospital failed to ensure complete and accurate patient medical records were kept in accordance with hospital policy when:

1. 2 of 19 sampled medical records (Patient 15 and 9) reviewed were incomplete (Refer to A-0450); and

2. The Medical Records Department had a backlog of 407 incomplete patient medical records lacking documentation, and were left stored in boxes and on shelves in the Medical Records Department. (Refer to A-0450).

These failures prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population. These failures hinder effective communication between providers resulting in gaps in patient care that negatively affect coordinated care for the patients, which could lead to compromised patient safety.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily mandated compliance with the Condition of Participation for Medical Records Services.

Based on interviews and document review, the hospital failed to ensure a Quality Assurance Process Improvement (QAPI) plan was developed, thoroughly implemented, assessed and monitored by the QAPI Committee when the hospital failed to investigate and implement a process towards the completion of 407 patient medical records stored in boxes and on shelves in the Medical Records Department.

This failure prevented all members of the healthcare team from having access to accurate, vital medical information potentially affecting clinical decision making and ensuring safe, effective care for a vulnerable mental health patient population.

Findings:

During an interview on 6/4/25 at 9 a.m., Medical Records Manager (MRM) stated the facility maintains a log of charts with outstanding corrections and/or completions. A log of incomplete medical records from the past 12 months was requested and provided.

During an interview on 6/4/24 at 11:20 a.m., Ward Clerk (WC) stated after a patient's discharge, the ward clerks audit the paper charts while two staff working offsite audit the electronic charts. WC stated the incomplete medical records were usually due to missing signatures, initials or dates, and misplaced forms or pages. WC stated while ward clerks enter their findings of chart incompleteness on an Excel spreadsheet, she was not sure if anybody has tracked or analyzed the numbers in greater detail, but added the spreadsheet was accessible by "almost everyone in Management". WC stated the facility currently has about "400" incomplete charts. WC stated she was not aware, nor have been involved, with any performance improvement project to improve the ongoing issues with the medical records.

A review of the graph titled, "Monthly Count Charts Waiting for Completions", indicated the following:
1. 5/31/2024 = 350,
2. 6/28/2024 = 359,
3. 7/19/2024 = 367,
4. 8/30/2024 = 394,
5. 9/20/2024 = 399,
6. 10/25/2024 = 426,
7. 11/22/2024 = 455,
8. 12/20/2024 = 472,
9. 1/31/2025 = 460,
10. 2/28/2025 = 441,
11. 3/28/2025 = 424,
12. 4/25/2025 = 432,
13. 5/30/2025 = 407.

During a concurrent interview and document review on 6/4/24 at 3:19 p.m., the Director of Nursing (DON) stated she was part of the QAPI Committee, and the committee meets monthly and quarterly. The DON stated she was aware of the ongoing problem with the incomplete medical records. The DON stated to ensure timely completion of medical records, Nurse Supervisors were expected to complete a daily checklist to review all medical records to make sure that everything was signed and completed, as well as night shift staff conducting nightly chart audits to further catch any misses.

During a review of the "Monthly Count Charts Waiting for Completions", the DON confirmed the number of incomplete charts rose from 350 to 407 in a 12-month period. The DON stated there has been no formal process to analyze the numbers to determine specific opportunities for improvement. The DON stated to help improve the numbers, since 2023, the audit reports and policy reviews were discussed during the monthly nursing huddles, emails were sent to staff on Fridays to remind them to complete their charts, and the Nurse Supervisors had taken some staff off the unit to let them complete their charts but had not been happening often due to staffing limitations.

The DON stated she and her Assistant Director of Nursing had started a new plan to address the charting issues in the past two months; details of said plan were requested but were not provided.

The DON stated she expected staff to complete their charts by the end of their shift, and added it was "not fair to the patients" when their care was not fully documented on their medical records.

During an interview on 6/5/2025 at 8:40 A.M., Deputy Director (DD) indicated the Governing Body meets every quarter and includes himself, the Director of Nurses (DON), Quality Director (QD), two members of the Board of Supervisors, and the Hospital Administrator (HD). The DD acknowledged the governing body was responsible for operations and quality of patient care provided in the facility. When asked about the missing documentation in patient medical records dating back to 2022, the DD indicated the DON was responsible for the records, stating "that is her job". The DD stated his expectation was the nursing supervisors were checking the records every night for complete documentation but acknowledged that he had not verified the medical record checks were being completed.

A review of the document, "[Hospital Name] Continuous Quality Improvement Work Plan Fiscal Year 2024-25", approved 10/14/25, included, " 4. Scope of CQI (Continuous Quality Improvement) Activities... The CQI program review, tracks, trends and evaluates the following quality assurance and improvement activities:...Medical records monitoring...".

A policy and procedure titled, "Quality Improvement Tracking Process", revised 3/28/22, stipulated, " Quality Improvement (QI) ensure continuous improvement by providing a feedback system to programs; the following procedure will be used to track concerns discovered during QI review process."

Based on interviews and record review, the hospital failed to ensure patient medical record were complete and accurate, in accordance with hospital policy. The facility further failed to ensure staff adhered to the facility's policy and procedure to promptly complete all medical records within 14 days of patient discharge when:

1. 2 of 19 sampled medical records reviewed were incomplete (Patient 15 and 9); and

2. The Medical Records Department had a current log of 407 incomplete medical records.

This failure had the potential to result in medical records lacking vital patient health information, hinder an effective communication between providers resulting in gaps in patient care that negatively affect coordinated care for the patients, which could lead to compromised patient safety.

Findings:

During an interview and record review on 6/3/25 at 9:05 a.m. with Medical Records Manager (MRM), Patient 15's medical records during his facility admission from 6/7/24-10/2/24 was reviewed. MRM stated Patient 15's restraint orders were still with the rest of his paper chart, which was yet to scanned into the electronic medical records system. MRM stated patient charts cannot be scanned into the electronic medical records until they were complete.

During an interview on 6/5/25 at 8:25 a.m., Senior Medical Office Assistant (SMOA), SMOA stated Patient 15's medical records were still missing staff signatures and initials on several forms, 244 days after his discharge date on 10/2/24.

During a concurrent interview and record review on 6/4/25 at 10:36 a.m. with the Sr. Medical Office Assistant (SMOA), Patient 9's electronic health record (EHR) and paper medical Chart Audit Report were reviewed. The Chart Audit Report noted 198 paper chart errors and 4 EHR errors which SMOA stated, "The errors have not yet been resolved." SMOA stated, "We stopped documenting the type of error noted as it was taking too much time, so we only track the number of chart errors. The types of errors were things like signatures or initials were missing. The management team is aware we were only tracking the number of chart errors." SMOA also stated she is not aware of what actions the management team takes to resolve errors as she and her colleagues only audit charts to track the number of incomplete charting errors found.

During a concurrent observation and interview on 6/4/25 at 11 a.m. with SMOA in the Medical Records Department, two shelves spanning a wall of the room contained numerous plastic binders. SMOA stated the binders were the incomplete patient records which await corrections and/or completions. SMOA stated staff were expected to complete patient records within 14 days of their discharge. SMOA stated the facility has a log of incomplete charts, with the oldest chart still incomplete 254 days after the patient's discharge on 9/22/24.

During an interview on 6/4/25 at 11:20 a.m., Ward Clerk (WC) stated the incomplete medical records were usually due to missing signatures, initials or dates, and misplaced forms or pages.

During an interview on 6/4/25 at 2:26 p.m., MRM stated as of 5/30/25, the facility has 407 charts awaiting completions.

During an interview on 6/4/25 at 3:19 p.m., the Director of Nursing (DON) stated she was aware of the ongoing problem with the incomplete medical records. The DON stated most of the nursing staff were travelers, which made corrections/completions very difficult as they were hard to reach once their contracts were up.

During an interview on 6/5/25 at 8:25 a.m. SMOA stated she could only recall two complete charts during her audits, during her eight-year employment in the facility.

A review of the facility policy and procedure titled, "TIMELINES FOR COMPLETION AND CORRECTION OF INPATIENT CHARTS", dated 7/20/20, indicated, "Policy: Inpatient charting will be complete and correct within 14 days of patient discharge, in accordance with MediCare/MediCal guidelines ... Procedure: ...3. The Ward Clerk will audit the EHR and paper chart for completion and clerical accuracy ... 4. Any identified corrections are completed by the original author, or supervisor if author is not available. If correction cannot be made, form #1226 - Request to File Chart as Incomplete is to be completed by Medical Records staff, signed by the Director of Nursing (for Nurses and Mental Health Worker staff corrections) or Medical Director (for Physician corrections)
and scanned to the chart. 5. All the above steps shall be completed within 14 days of patient's discharge..."