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Based on record review and interview, facility staff failed to inform patients of their Medicare discharge rights upon admission for 1 of 8 Medicare-eligible inpatients (Patient #6) and failed to inform patients of their rights upon discharge for 2 of 8 discharged patients reviewed (Patients #1, #9), in a total sample of 10.

Findings include:

Review of Patient #6's medical record on 9/30/2019 at 3:03PM and revealed that Patient #6 was admitted on 9/12/2019 and discharged on 9/16/2019. There was one Important Message from Medicare (IMM) in the medical record that was signed 9/16/2019.

Review of Patient #1's medical record on 9/30/2019 at 1:00PM revealed that Patient #1 was admitted on 9/3/2019 and discharged on 9/10/2019. There was one signed Important Message from Medicare dated 9/5/2019.

Review of Patient #9's medical record on 9/30/2019 at 3:30PM revealed that Patient #9 was admitted on 9/18/2019 and discharged on 9/26/2019. There was one signed Important Message from Medicare dated 9/18/2019.

On 9/30/2019 at 3:40PM an interview conducted with Quality Nurse B who stated "I would expect all eligible patients with a qualifying stay to have two signed IMMs in their record."

Based on record review and interview the facility failed to ensure a comprehensive Care Plan that is individualized, and based on assessing the patient's nursing care needs, treatment goals, and admitting diagnosis', in 7 of a total sample of 10 medical records reviewed. (Patient # 1, #2, #4, #6, #7, #9, #10)

Findings:
Review on 9/30/2019 at 1:45PM of Patient #1's medical record revealed a 48 year old admitted on 9/3/2019 with a diagnosis of fever, abdominal pain, recurrent urinary tract infections and malignant (the presence of cancerous cells that have the ability to spread to other sites in the body) tumor. The patient had a nephrostomy (surgical opening between the kidney and the skin) tube. The Care Plan for Patient #1 had actions and interventions for fall prevention. There was no Care Plan to address pain management or skin integrity. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/2019 at 2:05PM of Patient #2's medical record revealed a 61 year old admitted on 8/29/2019 with a diagnosis of ascities (accumulation of fluid in the peritoneal cavity, causing abdominal swelling). Patient had a history of pancreatitis (inflammation of the pancreas) and alcoholism and was admitted for voluntary detoxification (medical treatment of an alcoholic involving abstention from drink until the bloodstream is free of toxins). The Care Plan for Patient #2 had actions and interventions for fluid imbalance, fall prevention and impaired mobility. There was no Care Plan specifically addressing alcohol withdrawal. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/3019 at 2:45PM of Patient #4's medical record revealed a 79 year old admitted on 7/2/2019 with pneumonia. Past medical history revealed diabetes and chronic constipation. The Care Plan for Patient #4 had actions and interventions for impaired gas exchange and cardiac output. There was no Care Plan addressing diabetes or chronic constipation. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/2019 at 3:02PM of Patient #6's medical record revealed a 66 year old admitted on 9/12/2019 for cellulitis (a common, potentially serious bacterial skin infection). Past medical history revealed diabetes and hypertension. The Care Plan for Patient #6 had actions and interventions for risk for infection, urinary incontinence, skin integrity and fall prevention/management. There was no Care Plan addressing diabetes or hypertension. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/2019 at 3:10PM of Patient #7's medical record revealed an 80 year old admitted on 9/13/2019 for hip pain. Past medical history revealed diabetes, obesity and hypertension. The Care Plan for Patient # 7 had actions and interventions for fall prevention and management. There was no Care Plan addressing pain management, diabetes or hypertension. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/2019 at 3:30PM of Patient #9's medical record revealed a 86 year old admitted on 9/18/2019 for a gastrointestinal bleed (bleeding occurs in any part of the gastrointestinal tract). Past medical history revealed that Patient #9 was on an anticoagulant (a blood thinner), had congestive heart disease and coronary heart disease. The Care Plan for Patient # 9 had actions and interventions for fluid volume imbalance. There was no Care Plan addressing bleeding precautions. This was confirmed with Quality Nurse B at the time of review.

Review on 9/30/2019 at 3:40PM of Patient #10's medical record revealed a 39 year old admitted on 7/18/2019 for chest pain with a history of pulmonary emboli (a blockage in one of the pulmonary arteries in the lungs. In most cases,it is caused by blood clots that travel to the lungs from the legs). Past medical history revealed a diagnosis of metastatic breast cancer. The Care Plan for Patient #10 had actions and interventions for pain management. There was no care plan addressing pulmonary emboli prevention and precautions. This was confirmed with Quality Nurse B at the time of review.

In interview with Nurse Manager A on 9/30/2019 at 3:45PM Nurse Manager A stated, "I would expect that patients with other diagnosis such as diabetes and blood thinners would have those addressed in their Care Plans. Pain Management should always be included if it pertains. I looked and we do not have a care plan specifically for alcohol withdrawal but nurses could choose symptoms to address."

Based on record review and interview, the facility failed to provide adequate reassessment of the patients needs for discharge when the patients needs changed from the initial assessment in 1 of 10 records reviewed (Pt #1)

Findings
Review of Pt #1's medical record on 9/30/2019 at 1:00PM revealed that the patient was admitted through the Emergency Room on 9/3/2019 to the medical/surgical unit and was discharged to home on 9/10/2019. Patient's presenting symptoms were fever and abdominal pain. Past medical history included metastatic neuroendocrine tumor with metastasis (development of secondary malignant growth at a distance from a primary site of cancer) to liver, chronic abdominal pain and recurrent urinary tract infections. Patient had a right nephrostomy (a surgical opening between the kidney and the skin) tube for obstructive uropathy ( a hindrance of normal urine flow) from pelvic lymphadenopathy (disease affecting the lymph nodes). On the admission nursing assessment completed on 9/4/2019 at 5:15AM the patient was asked regarding the date of his/her last bowel movement. It is documented in the nursing assessment as, "per patient 9/2/2019." Daily nursing assessments from 9/5/2019 through 9/10/2019 documented under the assessment "Number of stools" "0".

Review of the Hospital Progress Notes in Patient #1's medical record revealed documentation on 9/4/2019 physical assessment at 12:08PM by the Hospitalist, "GI (gastrointestinal): soft, tender right side. No rebounding or guarding." Progress note on 9/5/2019 at 12:19PM by the Hospitalist, "GI: soft, tender right side. No rebounding or guarding." 9/6/2019 note at 9:06AM by the Physicians Assistant (PA), "no real change, still with chronic abd (abdominal) pain. Nausea seems somewhat better. No diarrhea. GI: non-distended, chronic mild most right sided tenderness, pos bs (positive bowel sounds)." 9/7/2019 note at 8:50AM by the Hospitalist, "GI: soft, tender right side. No rebounding or guarding." 9/8/2019 note at 9:13AM by the Hospitalist, "GI: soft, tender right side. No rebounding or guarding." 9/9/2019 note at 8:33AM by the Hospitalist, "GI: soft, non-distended, mildly tender, pos bs." Note on 9/9/2019 at 10:55AM by the Hospitalist after the patient experienced a fall, "having some abd (abdominal) pain, feels as if he/she needs to have a BM (bowel movement)." The Discharge Summary from 10/10/2019 at 12:07PM by the Hospitalist documented, "GI: soft, tender right side. No rebounding or guarding."

Report of a radiology scan performed on 9/3/2019 revealed, in part, "GI tract: moderate stool.

Review of the Progress Note-Nurse in the medical record revealed documentation by Registered Nurses on 9/3/2019 at 3:05PM, "waiting for a stool sample", on 9/3/2019 at 6:51PM , "patient has not has a BM since admission.", 9/4/2019 at 11:40AM, "waiting for a stool sample, no BM this shift", 9/5/2019 2:14PM, "pt has not had a bowel movement since Monday 9/2 so contact isolation d/c'd (discontinued)", 9/6/2019 at 4:59PM, "Last BM 9/2. Receiving scheduled miralax (an oral laxative). Will continue to monitor", 9/7/2019 at 5:46PM, "pt having constipation, refusing to take Miralax or MOM (milk of magnesia).9/8/2019 at 5:30PM, "pt having constipation, took scheduled Miralax and senna (stool softener) today", 9/9/2019 at 6:30PM, "pt having constipation, took scheduled Miralax and senna today. Per report, this is "normal" per pt.".

Review of the electronic medication administration record (EMAR) revealed administration of MiraLax powder (an oral laxative used to treat occasional constipation) on 9/5/2019 at 1:48PM, 9/6/2019 at 12:23PM, 9/8/2019 at 8:27AM, 9/9/2019 at 7:58AM and at 9/10/2019 at 8:53AM. The EMAR documented that Patient #1 refused the MiraLax on 9/3/2019, 9/4/2019 and 9/7/2019. The EMAR documented the administration of docusate-senna (an oral stool softener)50mg (milligrams)-8.6mg tab on 9/7/2019 at 9:27AM and 1:16PM, on 9/8/2019 at 8:27AM, on 9/9/2019 at 8:02AM and on 9/10/2019 at 8:53AM. The EMAR documented an order received on 9/10/2019 at 11:19AM from the Hospitalist for Dulcolax laxative 10mg suppository (per rectum). At 9/10/2019 at 1:23PM the Registered Nurse documented on the EMAR, "Dulcolax laxative 10mg suppository not given - patient discharging." Patient's discharge was documented as 1:45PM on 9/10/2019.

Review of the Discharge Instructions given to the patient revealed in part on the Medication List; "stool softener docusate-senna with directions to take 2 tabs once a day and MiraLax powder once a day as needed constipation (sic)". There were no directions/instructions regarding the lack of a bowel movement.

Review of facility policy on 9/30/2019 "Discharge Management, AW" last revised 6/2019, revealed in part Procedure "B. Documentation of a patient's response to treatment, current needs, and discharge planning is on-going and will include the plan shared with patient/family." G. The discharge plan will address short and long term patient needs. It includes plans and opportunities required to deal with specific disabilities and limitations which will in turn maximize the patient's functional independence and dignity. L. The patient and family members or interested persons will be counseled to prepare them for post-hospital care. It is important that the patient and caregivers who are expected to provide the case know, and as appropriate, can demonstrate or verbalize care needed by the patient."

Interview with Nurse Manager A on 9/30/2019 at 2:00PM when asked about patient's elimination status at discharge replied, "I would expect nursing to address the lack of a bowel movement at discharge."