HospitalInspections.org

Based on hospital policy and procedure reviews, medical record reviews and staff interviews, the hospital staff failed to obtain "Important Message from Medicare" per hospital policy for 3 out of 6 patients. (#5, #10, and #17).
The findings include:
Review of current hospital policy, "Important Message from Medicare", reviewed November 2009, revealed, "Within two days of admission, Admitting staff must issue the 'Important Message' and obtain the signature of the patient or his/her representative to indicate that he/she received and understood the notice. The form is printed as two copies on NCR paper. The patient should sign and date the form and receive the copy. The original will be placed in the patient's Medical Record located on the Nursing Unit, along with an unsigned copy of the form."
Review of current hospital policy "Support of Important Message from Medicare (IM) and Detailed Notice of Discharge" reviewed September 2014, revealed "The nurse Case Manager (NCM) will identify Medicare beneficiaries who should receive a copy of the IM and will deliver to the patient, patient's family, or patient's representative within two (2) calendar days of a planned discharge/transition, that copy which was signed upon admission or, if the original IM is not available on the medical record, will provide another copy to be signed. When the NCM delivers the follow-up IM, he/she will document under the "Additional Information" section of the IM that a second copy was given, obtain the signature of the patient or patient's representative, and include the date, time, and his/her initials. This document will be given to the patient, patient's family, or patient's representative and a copy will be placed in the front of the patient's medical record."
1. Closed medical record review on 04/28/2015 of patient #5 revealed an 84 year old male admitted on 09/09/2014 with diagnosis of recurrent bacteremia (infection in blood). Past medical history is noted for dementia. Further review revealed patient was discharged on 09/16/2014. Further review revealed patient #5 was readmitted on 09/20/2014 with diagnosis of sepsis (body infection). Patient #5 was discharged on 09/24/2014 at 1727. Patient #5 was readmitted for a third visit on 09/24/2014 at 2230 and discharged on 09/27/2014 at 1640. Further review of the medical record revealed IM (Important message) letter dated 09/09/2014 at 1525, admission IM letter for first admission. Further review revealed no further IM letters for admission on 09/20/2014 and 09/24/2014.
Interview with CM (Case Manager) #1 on 04/28/2015 at 1400 revealed a registration clerk was responsible for providing the IM notice at the time of admission. Interview revealed there was no evidence an IM notice was provided to the patient within two days after second admission. Interview revealed there was not an IM letter on admission or discharge for second and third admissions. Interview revealed the facility staff failed to follow the hospital's policy for IM letters.
Interview with AS (Administrative staff) #1 on 04/29/2015 at 1140 revealed "only one admission IM letter on (patient #5). There were no IM letters given or prior to discharge of either admissions. There was not an IM letter given on second admission of 09/20/2014. There is no reason why patient did not get IM letters."
2. Closed medical record review of Patient #10 revealed an 86 year-old female that was admitted on 12/12/2014 with pneumonia. Review of the record revealed the patient had Medicare listed as insurance. Record review revealed the patient was discharged on 12/18/2014. Review of the record revealed an "Important Message (IM) from Medicare" notice was delivered to the patient on 12/18/2014. Review revealed no evidence of an IM notice provided to the patient within two days of admission.
Interview with CM (Case Manager) #1 on 04/28/2015 at 1400 revealed a registration clerk was responsible for providing the IM notice at the time of admission. Interview revealed there was no evidence an IM notice was provided to the patient within two days after admission. Interview revealed the facility staff failed to follow the hospital's policy for IM letters.
3. Closed medical record review of patient #17 revealed a 76 year old female admitted on 04/22/2015 with diagnosis of pneumonia. Patient was discharged on 04/29/2015. Further review revealed IM letter dated 04/28/2015 at 1435 signed by patient's family members. Further review revealed no admission IM letter.
Interview with AS #1 on 04/29/2015 at 1230 revealed there was no admission IM letter for Patient #17. Interview revealed the facility staff failed to follow the hospital's policy for IM letters.



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4. Closed medical record review of Patient #4 revealed an 86 year-old female that was admitted on 12/12/2014 with pneumonia. Review of the record revealed the patient had Medicare listed as insurance. Record review revealed the patient was discharged on 12/18/2014. Review of the record revealed an "Important Message (IM) from Medicare" notice was delivered to the patient on 12/18/2014. Review revealed no evidence of an IM notice provided to the patient within two days of admission.

Interview with CM #1 on 04/28/2015 at 1400 revealed a registration clerk was responsible for providing the IM notice at the time of admission. Interview revealed there was no evidence an IM notice was provided to the patient within two days after admission. Interview revealed the facility staff failed to follow the hospital's policy for IM letters.