HospitalInspections.org

Based on medical record review and staff interview, the hospital staff failed to provide the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission and a signed copy not more than two calendar days before the patient's discharge for 5 of 10 medical records reviewed. (#2, #3, #4, #8 and #1)

Findings included:

1. Review on 01/03/2018 of the medical record for Patient #2 revealed an 83 year-old male admitted to the hospital on 11/11/2017 at 0947 and discharged on 11/16/2017 at 1757. Review of the medical record revealed documentation of an IM notice signed by the spouse on 11/11/2017 at 0959. Further review of the medical record revealed no available documentation of a signed copy of the IM notice provided to the patient prior to discharge on 11/16/2017.

Interview on 01/03/2018 at 1230 with the CM #1 (Case Manager) during record review revealed all Medicare patients should receive an IM notice within 2 days of admission and "should have one on day of discharge per regulation." Interview revealed there was no available documentation of a second IM notice provided to Patient #2 prior to discharge.

2. Review of the medical record for Patient #3 revealed a 71 year-old female admitted to the hospital on 12/05/2017 and discharged on 12/07/2017. Review of the medical record revealed no available documentation of an IM notice provided to the patient from 12/05 - 12/07/2017. Review of the medical record revealed Patient #3 was re-admitted on 12/08/2017 at 1300 and discharged on 12/11/2017 at 1626. Review of the medical record revealed documentation of an IM notice signed by the patient on 12/08/2017. Further review of the medical record revealed no available documentation of a signed copy of the IM notice provided to the patient prior to discharge on 12/11/2017.

Interview on 01/03/2018 at 1230 with the CM #1 (Case Manager) during record review revealed all Medicare patients should receive an IM notice within 2 days of admission and "should have one on day of discharge per regulation." Interview revealed there was no available documentation of an IM notice provided to Patient #3 during her admission from 12/05/2017 through 12/07/2017. Interview revealed there was no available documentation of a second IM notice provided to Patient #3 during her 12/08/2017 re-admission prior to discharge on 12/11/2017.

3. Review of the medical record for Patient #4 revealed an 86 year-old male admitted to the hospital on 12/21/2017 and discharged on 12/27/2017. Review of the medical record revealed documentation of an IM notice with documentation on the signature line which read "pt (patient) unable to sign" and dated 12/21/2017. Further review of the medical record revealed no available documentation of a signed copy of the IM notice provided to the patient prior to discharge on 12/27/2017.

Interview on 01/03/2018 at 1230 with the CM #1 (Case Manager) during record review revealed all Medicare patients should receive an IM notice within 2 days of admission and "should have one on day of discharge per regulation." Interview revealed there was no available documentation of a second IM notice provided to Patient #4 prior to discharge (expired) on 12/27/2017.

4. Review of the medical record for Patient #8 revealed an 84 year-old female admitted to the hospital on 12/26/2017 at 0327 and discharged on 12/30/2017 at 1415. Review of the medical record revealed no available documentation of an IM notice provided to the patient from 12/26/2017 to 12/30/2017.

Interview on 01/03/2018 at 1230 with the CM #1 (Case Manager) during record review revealed all Medicare patients should receive an IM notice within 2 days of admission and "should have one on day of discharge per regulation." Interview revealed there was no available documentation of an IM notice provided to Patient #8 from 12/26/2017 to 12/30/2017.

5. Review of the medical record for Patient #1 revealed an 89 year old male admitted to the hospital on 12/04/2017 at 1712 and discharged on 12/07/2017 at 1115. Review of the medical record revealed documentation of an IM notice signed by Patient #1 on 12/04/2017 at 1745. Further review of the medical record revealed no available documentation of a signed copy of the IM notice provided to the patient prior to discharge on 12/07/2017.
Interview on 01/03/2018 at 1230 with the CM #1 (Case Manager) during record review revealed all Medicare patients should receive an IM notice within 2 days of admission and "should have one on day of discharge per regulation." Interview revealed there was no available documentation of a second IM notice provided to Patient #1 prior to discharge.

NC00134109