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Based on interview and record review, the facility failed to ensure staff implemented their plan of correction to ensure adherence to their policy and procedure on the completion of patient medical records when four of 10 sampled backlog medical records were missing sections upon review (Patients 5, 6, 8, and 10).

This failure had the potential to result in medical records missing important patient information, negatively affecting the facilitation of care between providers, which could lead to compromised patient safety.

Findings:

According to the Plan of Correction (POC) provided by the facility to the Department on 7/17/2025, the POC outlined, "Work is underway by nursing staff to complete the 407 backlog of incomplete clinical documentation ... in accordance with policy ... with 100% completion of all 407 backlogged charts by August 31, 2025 ..."

During a concurrent interview and document review on 9/8/25 at 3:49 p.m. with the Medical Records Manager (MRM), the document titled, "SV Charts Needing Completion Summary - SV Staff Not Including MDs", with the date range 5/20/25-9/5/25 was reviewed. The document's columns indicated, "Total # (Number) Charts Out-of-Compliance: 9/5/2025 = 53 ..." The MRM stated per their current audit, the facility currently has 53 incomplete charts.

During an interview the following day, 9/9/2025 at 9:00 a.m., MRM indicated the oldest incomplete medical record dated back to 4/20/2025. MRM indicated focus is on the "backlog" and not current medical records. MRM further indicated that no one person is focusing on current medical records to ensure completion. MRM stated approximately 5 to 7 medical records were not complete.

Upon further discussion with MRM on 9/9/2025 at 10:00 a.m., MRM provided the "SV Charts Needing Completion Summary - SV Staff Not Including MDs" log which MRM indicated was accurate indicating 53 medical records were incomplete dating back to 1/9/2025, not April of 2025 as previously stated.

The MRM provided a document identified by the MRM as "the transportation log". The MRM stated this log is generated by the Senior Medical Records Clerk to account for the patient medical records being taken offsite to be scanned into the electronic medical record. The log revealed the following:

January 2025 = 13 discharges with 2 records complete with documents scanned and in the electronic medical record;
February 2025 = 16 discharges with 16 records complete with documents scanned and in the electronic medical record;
March 2025 = 20 discharges with 4 records complete with documents scanned and in the electronic medical record;
April 2025 = 19 discharges with 2 records complete with documents scanned and in the electronic medical record;
May 2025 = 17 discharges with 0 records complete with documents scanned and in the electronic medical record;
June 2025 = data was not provided as requested;
July 2025 = 24 discharges with 0 records complete with documents scanned and in the electronic medical record;
August 2025 = 25 discharges with 0 records complete with documents scanned and in the electronic medical record.

On 9/9/2025 at 10:00 a.m., the MRM acknowledged the "Transportation Log" indicated there was 88 patient medical records incomplete from January 2025 to August of 2025 but according to the "SV Charts Needing Completion Summary - SV Staff Not Including MDs" log indicated 53 patient medical records were incomplete. The MRM indicated he believed if paper records were waiting to be transported to the offsite facility and scanned that the record was complete even if the documents had not been scanned into the electronic record. MRM indicated he was not aware the facility policy was for medical records to be completed within 14 days after discharge.

During a concurrent interview and record review on 9/9/25 at 11:22 a.m. with Ward Clerk (WC), Patient 8's medical records, dated 2/13/25, were reviewed using the SV Audit Checklist. The medical records indicated Patient 8 was admitted to the facility on a 5150-hold (a legal procedure in California that allows for the temporary detention of individuals who are believed to be a danger to themselves or others due to a mental health crisis) on 2/13/25. WC stated she was unable to locate the "Legal" section in Patient 8's medical records. The medical records indicated it did not have Patient 8's Client Information, Important Message from Medicare, Advanced Directive, Involuntary Patient Advisement (a legal form that allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 5150-hold), and Patient Notification of Firearms Prohibition and Right to Hearing forms. The WC stated the forms were not scanned in, and she did not know why they were not scanned in. Further review of Patient 8's records indicated she was discharged on 3/12/25.

During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 10s medical records dated 3/13/2025 were reviewed using the SV Audit Checklist. The medical records indicated Patient 10 was admitted to the facility on 2/27/2025on a 5150 -hold. MRM was unable to locate the history and physical, laboratory results and medication advisement. MRM indicated the records "might" be paper and not yet scanned. MRM indicated he did not know why the records had not been scanned. Further review of Patient 10's medical record indicated she was discharged on 3/13/2025.

During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 6's medical records dated 3/24/2025, were reviewed using the SV Audit Checklist. The medical records indicated Patient 6 was admitted to the facility on 3/7/2025 on a 5150-hold. The suicide risk assessment was present but only had partial documentation with none of the required questions answered to determine Patient 6's risk of committing suicide. The MRM confirmed the suicide risk assessment was blank and the questions had not been answered. MRM did not know why the suicide risk assessment had not been completed. Further review of Patient 6's records indicated she had been discharged 3/24/2025.

During a concurrent interview and record review on 9/9/2025 at 11:00 a.m., with the MRM, Patient 5's medical records dated 4/25/2025 were reviewed using the SV Audit Checklist. The medical records indicated Patient 5 was admitted to the facility on 4/10/2025 on a 5150- hold. MRM indicated the medical record was not complete because the treatment plan nursing progress notes, legal documents, discharge documents and laboratory results were not present in the medical record. MRM stated he though the paper version might not yet be scanned into the electronic medical record. Further review of Patient 5's medical record indicated Patient 5 was discharged on 4/25/2025.

During a concurrent interview and policy review on 9/9/25 at 3:09 p.m. with MRM, the facility's policy titled, "TIMELINES FOR COMPLETION AND CORRECTION OF INPATIENT CHARTS", dated 7/20/20, was reviewed. The policy 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..." The MRM confirmed scanning was part of the 14-day process of completing a chart.