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SAINT AGNES HOSPITAL
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on the review of 8 open and 3 closed medical record, it was determined that 2 of 3 Medicare recipients reviewed lacked notification of their admission status on observation and were not notified of the right to appeal their discharges.
The hospital failed to provide documentation that patient # 9 and 10 received the Important Message from Medicare (IMM) or the Medicare Outpatient Observation Notice (MOON).
For patient# 9, a 70+ year old patient who was hospitalized in mid-October, the medical record review lacked notification of an IMM.
Patient # 10, an 80+ year old patient, also hospitalized in mid-October, the medical record review lacked documentation of a MOON for notification of observation status.
PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES
Tag No.: A0122
Based on review of hospital policy and five grievance records, it was determined the hospital failed to complete a timely resolution for 5 of the 5 grievances reviewed and failed to inform 4 of 5 complainants of an anticipated time frame for a written response.
Per hospital policy titled, "Patient Complaints and Grievances" (revised 10/2011), "When a grievance is received, it is to be forwarded to the Patient Relations Department for follow up, which begins with: 1) a written acknowledgement of the grievance within 7 to 10 days." "The Patients Relations Department coordinates the investigation and, within 30 days, provides a written notice to the complainant which contains...."
Grievance #1 was received on July 26, 2018. An acknowledgement letter was sent on 8/01/18 indicating the hospital will respond within the next 30 days. No resolution letter was found.
Grievance #2 was received on October 11, 2018. No evidence of an acknowledgement or resolution letter was found.
Grievance #3 was received on November 11, 2018. No evidence of an acknowledgement or resolution letter was found.
Grievance #4 was received on November 15, 2018. No evidence of an acknowledgment or resolution letter was found.
Grievance #5 was received on November 16, 2018. No evidence of an acknowledgement or resolution letter was found.