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Based on a review of facility documents, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to provide the Important Message from Medicare (IMM) on admission for one of 30 medical records reviewed (MR11); and failed to provide the IMM on discharge for three of 30 medical records reviewed (MR10, MR12, and MR30).

Findings include:

Review of "UPMC Policy and Procedure Manual Policy HS-QM0884* Index Title: Corporate Care Management Subject: Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal Date: December 20, 2023 revealed " ... V. Procedure ... C. Important Message from Medicare (IMM) 1. All Medicare/Medicare Advantage plan enrollees who are hospital inpatients must receive the IMM. 2. The IMM informs hospitalized inpatient beneficiaries/representatives of their rights as a hospital patient, including discharge appeal rights. 3. The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative, and a copy must be provided to the beneficiary/representative. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge. ... ."

Review of MR10 revealed that the patient was admitted on May 26, 2024 and discharged on June 1, 2024. There was no evidence of a discharge IMM.

Review of MR11 revealed that the patient was admitted on May 23, 2024 and discharged on June 3, 2024. There was no evidence of an admission IMM.

Review of MR12 revealed that the patient was admitted on June 21, 2024 and discharged on June 27, 2024. There was no evidence of a discharge IMM.

Review of MR30 revealed that the patient was admitted on June 27, 2024 and discharged on June 30, 2024. There was no evidence of a discharge IMM.

Interview on July 16, 2024, at approximately 12:00 PM, EMP2 confirmed the above findings.

Based on a review of facility documentation, medical record (MR) review, and staff interview (EMP), it was determined the facility failed to ensure patients were informed of their rights prior to receiving care for four of 30 medical records reviewed (MR9, MR10, MR11, and MR17).

Findings include:

Review of "UPMC Policy And Procedure Manual Policy: HS-HD-PR-01* Index Title: Patient Rights/Organizational Ethics Subject: Patients' Notice and Bill of Rights and Responsibilities Date: May 29, 2024, revealed " ... III. Purpose The Patients' Notice and Bill of Rights and Patient Responsibilities is made available to patients, their family members* and representatives via patient information materials and postings. ... The following sections of this policy present the information that is provided to patients, family members and their representatives to assure that they are informed of their rights while receiving services at UPMC. ... IV. Patients' Notice And Bill Of Rights ... Attachment A. ... ."

Review of MR9, MR10, MR11, and MR17 revealed no documented evidence that the patients or their representatives were given the admission packet, which contained the patient rights.

Interview on July 16, 2024, at approximately 12:00 PM, EMP2 confirmed the above findings.

Based on a review of facility documents, medical record (MR), and staff interview (EMP), it was determined that UPMC Altoona failed to obtain a Physician Order for the implementation of restraint or seclusion in 1 of 2 medical records reviewed (MR1).

Findings

UPMC POLICY AND PROCEDURE MANUAL POLICY: HS-NA0416 INDEX TITLE: Nursing SUBJECT: Restraint and Seclusion DATE: July 10, 2023 ... B. General Guidelines: A physician or a registered nurse (RN) may implement the use of restraint or seclusion in emergent situations based on clinical judgment and evaluation of the present situation. ... A written time limited order from a physician and documentation of the reason must accompany all episodes of restraint or seclusion. ... "

A review of MR1 revealed no documented evidence of a Physician Order for restraints or seclusion.

An interview was conducted with EMP2 on July 16, 2024 at approximately 12:00 PM. EMP2 confirmed that the patient was placed in four point hard/vinyl restraints and in seclusion on February 8, 2024 at 1121 and that there was no physican order for the restraints or seclusion documented in the medical record.