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A. Based on medical record review and staff interview, it was determined that the facility failed to present all patients, or their legal next of kin, with a copy of the signed "An Important Message from Medicare (IM)" in advance of their discharge from the facility.

Findings include:

1. Review of Medical Record #1 indicated the patient arrived at the Emergency Department (ED) on 2/4/16, and was admitted to the facility.

a. The IM notice was signed by a representative for the patient and a facility staff member that delivered the IM on 2/4/16.

b. Patient #1 was discharged to a skilled nursing facility on 2/10/16.

2. Review of Medical Record #2 indicated the patient arrived at the ED on 2/4/16, and was admitted to the facility.

a. The IM notice was signed by a representative for the patient and a facility staff member that delivered the IM on 2/4/16.

b. A review of Social Work notes dated 2/10/16, 2/11/16, and 2/12/16 indicated the discharge plan for the patient was for hospice care, and the Social Worker was reviewing hospice service arrangements with the family.

c. Patient #2 expired on 2/13/16 at the facility.

3. There was no evidence of a Second Deliverer's Initial's on the area provided on the IM notice to indicate a signed copy of the notice was presented to Patient #1 or Patient #2, or a patient's representative, in advance of their discharge from the facility.



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B. Based on medical record review, document review and staff interview, it was determined that the facility failed to ensure each patient and/or the patient's representative is provided with information of the patient's rights.

1. On 5/16/16, as requested, an admission packet that is given to patients on admission was provided for review. Written 'Patient Rights' were included in the packet.

a. At 10:05 AM, Staff #1 explained that a staff member from the Guest Relations department brings the 'Admission Packets' and places them in the patient's room whether the patient and/or patient representative is there or not.

(i) Upon review of Medical Record #2, there was no evidence of 'Patient Rights' being provided and received by the patient and/or patient representative.

2. Staff #1, Staff #2, and Staff #5 confirmed that the facility cannot provide documented evidence that patients and/or patient representatives have been provided and explained in a language or manner that the patient (or the patient's representative) can understand information regarding the patient's rights.

Based on medical record review, staff interview and review of facility policy and procedure, it was determined that the facility failed to implement and comply with the patient's advance directives/ power of attorney (POA) directive.

Findings include:


1. Review of Medical Record #2 revealed the following:

a. On 2/4/16 at 4:40 PM, in the ED (Emergency Department) chart, Patient #2 arrived to the ED via walk-in status. The ED physician documented, "Chief Complaint: - Dr. Sent Admit poss dementia ... In the "ROS" (review of systems) section under "neuro" assessment states, "Positive for altered mental status, confusion."

b. Documentation in the "Screening" section of the "Nurse's Notes" states, "4:49 PM Advance Directive: Yes Patient has an advanced directive but no copy available."

2. On 2/4/15 at 8:35 PM, the ED physician placed an order for the patient to be admitted to the hospital.

a. On 2/5/16 at 5:50 PM, the admission RN (register nurse) documented in the "Admission Assessment Report" the following:

(i) Mental Status: Judgement: Impaired

(ii) Understands Illness: No

(iii) Cognitive: ... Lacking insight into Illness

(iv) Patient History: Contact Person: (daughter's name - Durable Power of Attorney)

3. Copies of the following were found in Medical Record #2:

a. On 2/28/2000, Patient #2 had authorized (daughter's name) as his/her "General Durable Power of Attorney."

b. On 7/23/1998, Patient #2 had a "Living Will Declaration" documented, witnessed and notarized.

4. On 5/16/16 at 10:50 AM, Staff #16 explained that if/when a patient has a designated POA, the registration staff updates the "Face Sheet." Under the "Insurance Coverage" section, in "See Notes," a notation is documented for staff to use as a reference and identify the POA as the designated person.

a. The "Face Sheet" found in Medical Record #2 was not updated and did not contain the POA name and/or contact information under the "Emergency Contact," "Next of Kin," or under the "Insurance Coverage - See Notes" notation for staff to identify that the patient legally designated.

b. Staff #14, #15, #16, and #18 confirmed that a POA (Power of Attorney) is the default person to be the contact.

5. On 5/17/16 at 10:10 AM, Staff #5 and Staff #23 confirmed that the POA for Patient #2 was not clearly identifiable as the designated default contact for communication and decision making as the patient representative.

A. Based on medical record review, review of facility policy and procedure, and review of the facility's medical staff bylaws, rules, and regulations on May 16-17, 2016, it was determined that the facility failed to ensure the limited use of, and forty-eight (48) hour physician authentication of all telephone orders.

Findings include:

Reference #1: Facility policy and procedure titled Verbal and Telephone Orders, Document Number: MHC-ADMIN-02-1279, states "... POLICY: Verbal and telephone orders are error prone and should be limited to avoid medical errors. Verbal and telephone orders are to be used only when necessary in urgent situations or to maintain smooth flow of patient care procedures (i.e., during procedures). ..."

Reference #2: Facility Medical Staff Bylaws Rules and Regulations states "... III. GENERAL CONDUCT OF CARE: ... [page 9] ... All oral orders shall be authenticated, date and time verbal orders as soon as possible or within 48 hours. ..."

1. Review of the Physician Orders in Medical Record #2 dated 2/3/16 through 2/13/16,
indicated the use of telephone orders was not limited for urgent situations or to maintain smooth flow of patient care during procedures. All seventeen (17) physician orders documented during the patient's admission were telephone orders. (Reference #1).

2. The seventeen (17) telephone physician orders lacked evidence of authentication by the ordering physician within forty-eight (48) hours per the medical staff bylaws rules and regulations. (Reference #2).

B. Based on medical record review, review of facility policy and procedure, and review of the facility's medical staff bylaws, rules, and regulations on May 16-17, 2016, it was determined that the facility failed to ensure all medical records are completed within thirty (30) days of patient discharge.

Findings include:

Reference #1: Facility Medical Staff Bylaws Rules and Regulations states "[page 7] The patient's medical record shall be complete in accordance with the Medical Record Completion Policy. ..."

Reference #2: Facility policy and procedure titled Medical Records Completion and Suspension states, "POLICY: Medical Records are to be completed within 30 days of a patient's discharge from the hospital. ..."

1. Medical Record #2 lacked evidence of completion within 30 days of the patient's discharge from the facility. Patient #2 was discharged (expired) from the facility on 2/13/16.

a. Seventeen (17) telephone physician orders lacked evidence of authentication by the ordering physician within 30 days of the patient's discharge. (References #1 and #2). The medical record is greater than one month over due for completion per facility policy.

Based on staff interview, and review of facility documentation, it was determined that the facility failed to disclose the post-hospital providers that it has a financial interest in, on the lists of these providers given to patients for discharge planning.

Findings include:

1. On 5/16/16, Unit 4 West was toured. Staff #11 was interviewed regarding discharge planning procedures and arrangements for patients requiring care post hospitalization. Staff #11 stated he/she provides the Discharge Planning Guide to the patient to select three (3) possible choices for discharge arrangements to be made. He/she stated the facility's healthcare system has several facilities, and named several neighboring towns in which some of these facilities are located.

a. The Discharge Planning Guide 2016 was reviewed and has lists of post-acute care facilities and agencies attached. There was no indication as to which facilities or agencies this facility, or its healthcare system, has a shared financial interest.

b. Staff #11 stated if the patient asks if the facility's healthcare system has a final interest any of these facilities or agencies, he/she would tell them.