HospitalInspections.org

Based on a review of medical records (MR), facility documentation, and employee interviews (EMP), it was determined that the facility failed to consistently provide the patient or the patient's representative a copy of the "Important Message from Medicare (IMM)" within two days of admission or not more than two days before the patient's discharge for four of four Medicare medical records reviewed (MR4, MR7, MR8, and MR9).

Findings include:

A review of facility policy "Important Message From Medicare (IMM)" last reviewed March 2015, revealed, "...8. Medicare covered patients will complete the Important Message from Medicare and the Medicare Questionnaire."

A review on December 19, 2016, of MR4, revealed the patient was admitted on July 16, 2016, and discharged on July 20, 2016. There was no documentation in the MR that the patient was provided a copy of the Important Message from Medicare upon admission.

A review on December 19, 2016, of MR7, revealed the patient was admitted on July 7, 2016, and discharged on July 22, 2016. There was no documentation in the MR that the second Important Message from Medicare was given to the patient within two days of discharge.

A review on December 19, 2016, of MR8, revealed the patient was admitted on July 10, 2016, and discharged on July 28, 2016. There was no documentation in the MR that the second Important Message from Medicare was given to the patient within two days of discharge.

A review on December 19, 2016, of MR9, revealed the patient was admitted on July 19, 2016, and discharged on August 11, 2016. There was no documentation in the MR that the second Important Message from Medicare was given to the patient within two days of discharge.

An interview conducted on December 19, 2016, at 2:00 PM with EMP4 confirmed the medical records reviewed did not have documentation of a signed copy of the "Important Message From Medicare" either following admission or prior to discharge. Interview also confirmed the policy did not specify timeframes for obtaining the signed copies of the IMM.

Based on review of facility documents, medical records, and interview with staff (EMP), it determined that the facility failed to ensure that a patient's primary care physician (PCP) was contacted as soon as possible after the patient was admitted for five of 10 medical records reviewed (MR2, MR3, MR4, MR5, and MR9).

Findings include:

A review on December 19, 2016, of facility policies revealed no policy to address the notification of the PCP of the patient's admission.

A review on December 19, 2016, of MR2, MR3, MR4, MR5, and MR9 revealed no documentation that the patient's PCP was notified as soon possible after the patient was admitted to the hospital.

An interview conducted on December 19, 2016, at 2:10 PM with EMP4 confirmed that MR2, MR3, MR4, MR5, and MR9 did not contain documentation that the facility asked the patients if they wanted their physician to be contacted. Further interview with EMP4 confirmed that the facilty did not have a policy that addressed physician notification of a patient's admission.