HospitalInspections.org

Based on medical record review, policy review and staff interview the facility failed to ensure Medicare beneficiaries received, signed and dated the required standardized notice form titled An Important Message from Medicare? (IM) regarding patient rights, within two days of admission for two (Patient #5 & #8) of three patients receiving Medicare benefits of 10 medical records reviewed.

Findings include:

The medical record review for Patient #8 was completed on 04/02/13. The patient was admitted to the facility on 03/27/13 with a diagnosis of suicide attempt. The patient was a Medicare beneficiary. The medical record did not contain a signed and dated standardized notice form titled "An Important Message from Medicare". On 04/02/13, the findings were shared with Staff B and confirmed.
The medical record review for Patient #5 was completed on 04/01/13. The patient was admitted to the facility on 03/26/13 with a diagnosis of suicidal ideation. The patient was a Medicare beneficiary. The medical record had the standarized notice titled "An Important Message from Medicare" form signed, however, the form did not have a date to provide evidence the patient received the message within two days of admission. On 04/01/13, the findings were shared with Staff B and confirmed.
Staff A was interviewed on 04/02/13. Staff A stated the nursing staff has never been in-serviced on the standarized notice from Medicare form. Staff A stated the admission's department obtains the patient signatures and dates on these forms. Staff A stated he/she was not aware of the facility having a policy regarding the standarized notice from Medicare.
There was no mention of this standarized notice form in the policy's for Discharge and Aftercare Planning Process policy, Patient Rights and Responsibilities policy and Content of Patient Medical Record policy upon reviewe on 04/02/13.

Based on medical record review, policy review and staff interview; the facility failed to ensure voluntary consent for admission was obtained per the facility's policy for one (Patient #8) of five medical records reviewed of patients who were involuntary admitted to the facility. A total of 10 medical records were reviewed during the survey.

Findings include:

The medical record review for Patient #8 was completed on 04/01/13. The patient was admitted to the facility on 03/26/13 with a diagnosis of suicidal ideation. The patient's medical record had an application for emergency admission form (also referred to as a "Pink Slip") signed on 03/26/13 (Tuesday). The medical record had a voluntary consent form signed by the patient on 04/01/13 (Monday). The record did not provide a reason why voluntary consent was not obtained at an earlier date.
On 04/02/13, the findings were shared with Staff C and confirmed.
On 04/02/13, the facility's Involuntary Patients policy was reviewed. The policy stated a pink slip hold time period may be referred to as a 72 hour hold; however, the hold is actually a three court day hold so holidays and weekends do not count. Once the three day hold is completed the patient must sign a consent for voluntary treatment or probate for involuntary mandatory treatment must be initiated.