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Based on medical record review, review of the hospital's "Important Message from Medicare about your Rights (IM )" procedure, the patient's IM forms, and staff and patient representative interviews, the hospital failed to ensure that IM notices were provided to Medicare patients within the 2 days after admission and that copies of notices were provided within 2 days before discharge. This occurred in 6 of 8 Medicare beneficiary patients (Patient #'s 1,3,4,6, 8,and 9) in a total sample of 10 patients.
The hospital failed to establish an effective hospital policy that ensured Medicare discharge rights information was provided eligible patients.

Findings include:

1) Patient #1, a Medicare Part A patient, was admitted to the hospital from an Assisted Living facility on 9/19/09, with diagnosis of Altered Mental Status (severe confusion) and Agitation (combativeness). Patient #1 has an activated HCPOA (Health Care Power of Attorney) which list Patient Representative E and Patient Representative F as alternate.

The 2/11/10 medical review of Patient #1's "Important Message from Medicare about your Rights (IM notice)" form was not signed by Patient Representative E until 9/25/09. There was no documented evidence that Patient Representative E was contacted within the required 2 day period after admission for the provision of these discharge appeal rights.

There was no documented evidence that Patient Representatives E or F were given a copy of the IM notice before patient discharge on 9/30/09.

This was verified by Director of Quality Management P on 2/16/10 at approximately 2 p.m.

Interview with SSCM (Social Service/Case Management) Director H on 2/16/10 at approximately 2 p.m. reflects that the hospital has a written procedure for use of the Medicare discharge rights notice ("Important Message from Medicare about your Rights") but that the hospital has no formal policy that dictates how the federal requirement is suppose to be met, and who is responsible for ensuring that the notices are given in a timely manner.

The 2/16/10 review of the procedure reflects no evidence of formalized hospital policy or procedural review associated with this document. There is no documented evidence that this procedure has been reviewed by the hospital's governing body to ensure compliance with federal regulations. This procedure states the following:
"Important Message from Medicare (IM) Fact Sheet
...2) Hospital must issue the IM on or near inpatient admission (at least within 2 calendar days) the patient or their representative must sign that he or she has received the notice.
-Upon admission to the unit, the HUC (unit secretary) will present the IM and obtain the signature of the patient or their representative and date it...
-After it is signed, the original copy is given to the patient and the remaining 2 copies are filed in the chart behind the "Consent forms" tab.
3) A copy of the previously signed IM must also be provided within two calendar days of discharge...
-The Case Manager will deliver the copy of the IM using the script "Here is a copy of the form you signed on admission about your Medicare discharge rights."
-On the day of discharge, the nurse caring for the patient should check to see that the form has been delivered and deliver it if the patient has not yet received it.
-On the rehab unit, the Social Worker will deliver the copy of the IM.
-A second signature by the patient /representative is not necessary, and whoever delivers the second notice competes (sic) the information on the second page related to "Second Copy" in the "For Hospital Use only " box..."

"When the patient cannot sign the Important Message:
If the patient can comprehend the IMM (IM), but can not sign:
-Document on the IMM patient understood, but is unable to sign.
-Date the IMM.
-Give the original, page 1, to the patient.
-Place the remaining 2 copies in the chart under the Consents tab.
If the patient is unable to comprehend the IMM:
-Issue the IMM to the patient's representative and have them sign and date the form.
-If the patient's representative is not available, they should be telephoned and advised of the patient's rights per the IMM. Ask them what address they would like the IMM mailed to.
-Document the information on page 2 of the IMM. Specify the name of the representative, date, time, phone number, method of delivery and your name.
-Mail the original on the same day to the representative.
-Place the remaining 2 copies in the chart under the Consents tab.
-When direct phone contact cannot be made, send the original notice to the representative by certified mail, return receipt requested to the Case Management department. The date that the certified mail is signed for or refused is the date of the receipt of the IMM. Document on the copy of the IMM: attempted telephone contact, name, number and time, your name and sent certified mail with date sent.
If the patient refuses to sign:
-Document the date of the refusal as the date received on the IMM.
-Document on the signature line that the patient refused to sign the IMM.
-Give the original, page 1, to the patient.
-Place the remaining 2 copies in the chart under Consents tab.
**Follow this same process with the second notice giving or sending the second copy and documenting in the appropriate area on the IM."
This procedure had no author, date of origination or revision, but had a dated of "WAMH (hospital's name) 2/08" at the bottom of the last page.

Interview with HCPOA F on 2/24/10 at approximately 12 noon reflects that he received no Medicare discharge appeal notice on patient admission or discharge.

Interview with HCPOA E on 2/26/10 at approximately 3:30 p.m. stated that the hospital discharge planner called him on 9/30/09 (day of discharge) stating that Patient #1 was being discharged to the nursing home today. HCPOA E stated that he did not know that he could appeal the discharge. When HCPOA E was told that his signature (dated 9/25/09) was on an "Important Notice from Medicare" he stated that he signed a lot of papers but did not necessarily read them. HCPOA E stated that he did not receive a copy of this signed form nor get any additional copies (or sign them) before discharge.


2) Patient #3, a Medicare Part A patient, was admitted to the hospital on 9/1/09, with diagnosis of inability to talk, Confusion and Agitation. Patient #3's daughter was noted to sign the treatment agreement on 9/1/09 on behalf of Patient #3.

The 2/11/10 medical review of Patient #3's "Important Message from Medicare about your Rights (IM notice)" form was not signed by Patient Representative E until 9/9/09. There was no documented evidence that Patient #3's daughter or other patient representative was contacted within the required 2 day period after admission for the provision of these discharge appeal rights.

This was verified by Director of Quality Management P on 2/16/10 at approximately 2 p.m..

3) Patient #4, Medicare Advanta Freedom patient, was admitted to the hospital on 9/30/09, with diagnosis of Psychosis. The hospital face sheet lists Patient #4's aunt as a 1st contact person with aunt's phone number.

On 2/11/10 a copy of Patient #4's IM notice was requested. On 2/16/10 at approximately 9:30 a.m., Director of Quality Management P verified that Patient #4's IM notice could not be found.

4) Patient #6, a Medicare Part A patient, was admitted to the hospital on 9/24/09 with diagnosis of Fracture of Right Hip and Confusion. Patient #6's son was listed as 1st contact person on the hospital face sheet.

The 2/11/10 medical review of Patient #6's "Important Message from Medicare about your Rights (IM notice)" form was not signed by the patient or the patient representative . Under the signature line, it is written "son (listed as 1st contact) will sign if he visits today 9/29/09". The "For Hospital Use Only" box states that information was given by phone on 9/29/09 at 9:46 a.m. There is no documented evidence that the patient /patient representative was contacted within the required 2 day period after admission for the provision of these discharge appeal rights. There is no documented evidence that the patient /patient representative was given a copy of the IM notice before patient discharge on 9/29/09.

This was verified by Director of Quality Management P on 2/16/10 at approximately 2 p.m..

5) Patient #8, a Medicare Humana patient, was admitted to the hospital on 10/17/09 with diagnosis of Closed Head Injury, Dementia and Inability to Care for Self. The hospital face sheet lists Patient #8's husband as 1st contact person along with a contact phone number.

The 2/11/10 medical review of Patient #8's "Important Message from Medicare about your Rights (IM notice)" form was not signed by the patient or the patient representative . Under the signature line, it is written "Patient unable to sign-dementia".
There is no documented evidence that the a patient representative was contacted within the required 2 day period after admission for the provision of these discharge appeal rights. There is no documented evidence that the patient /patient representative was given a copy of the IM notice before patient discharge on 10/20/09.

This was verified by Director of Quality Management P on 2/16/10 at approximately 2 p.m.

6) Patient #9, a Medicare Part A patient, was admitted to the hospital on 10/12/09 with diagnosis of Altered Mental Status (Confusion). The hospital face sheet lists Patient #9's wife as 1st contact person along with a contact phone number.

The 2/11/10 medical review of Patient #9's "Important Message from Medicare about your Rights (IM notice)" form was not signed by the patient or the patient representative . Under the signature line, it is written "Copy to family 10/29/09".
There is no documented evidence that the a patient representative was contacted within the required 2 day period after admission for the provision of these discharge appeal rights. The "For Hospital Use Only" box states that information was given by phone and mailed letter on 10/29/09. Patient #9 was discharged on 10/30/09.

This was verified by Director of Quality Management P on 2/16/10 at approximately 2 p.m.

Based on medical record review, review of hospital skin care/ pressure ulcer prevention policy, and staff and patient representative interview, the hospital's RN (registered nurse) staff failed to evaluate and supervise skin abnormalities in 1 of 3 patients (Patient #1), having pressure sores/wounds, in a sample of 8 patients evaluated as being at risk for pressure ulcer development. This occurred in a total sample of 10 patients. Patient #1's coccyx wound deteriorated during hospital stay, without nursing acknowledgement or physician notification.

Findings include:

Patient #1 was admitted to the hospital on 9/19/09, with diagnosis of Altered Mental Status (severe confusion) and Agitation (combativeness) per the hospital face sheet.

The 2/9/10 review of "Policy 1004, revised 4/09-Skin Integrity Alteration-Potential/ Actual for Adult Inpatients" reflects on pages 2 and 3 of 28 that "Registered nurses will perform the following:
B. Assess integumentary system...4) daily and prn (as needed) if at Risk for pressure ulcers, surgical wound present or a Interdisciplinary Plan of Care in place for Skin Integrity-Potential/ Actual.
C. Conduct a Comprehensive Wound Assessment, including staging for patients with a pressure ulcer, for a wound of measurable size with visible wound bed at the following times:...5) when wound deterioration symptoms are noted during daily/prn integumentary assessment:
a. abnormal exudate (drainage) odor (after cleansing)
b. abnormal exudate (drainage) color (purulent)
c. abnormal peri-wound color (erythema)
d. abnormal peri-wound conditions (induration, maceration, pain increase, or temperature increase)
6. With discharge assessment...".

On page 6 of 28 , the policy identifies the components of a comprehensive wound assessment, and documents:
"4. Conduct a comprehensive wound assessment within 4 hours of arrival if skin abnormality is a pressure ulcer (any stage) or a wound that is measurable with visible wound bed:
a. wound measurements(centimeters) in length, width and depth( if greater than .1 cm.),
b. wound bed tissue type (percentage) listing epithelial tissue, granulation tissue, slough, and eschar,
c. other visible structures, such as tendon, bone , muscle and other,
d. pressure ulcer stages...,
e. tunneling...,
f. undermining...
5. Identify wound deterioration symptoms and notify physician:
a. abnormal exudate odor,
b. purulent exudate,
c. abnormal periwound color (erythema),
d. abnormal periwound condition (induration, maceration, increase in pain or temperature)...".

On page 10 of 28 the policy states that with stage 2 pressure ulcers that the physician should be notified.

The 2/11/09 record review reflects the following:
The 9/19/09 "Daily Physical Assessment" reflects Patient #1's skin integrity (color, temperature, turgor, moisture) was documented as being "WNL (within normal limits)" at 10:20 a.m. (day of admission) by RN C.

At 9/19/09 at 7:35 a.m., RN C documented that Patient #1 has "red erythema (redness of the skin) over the bony prominence that is generalized over middle buttock" (over the tail bone) area. There is no documented evidence of measurement of this skin abnormality, and there is no documented evidence of any definable characteristic that would indicate whether it was blanchable (turns white or pale when pressure applied), a sign of minor skin irritation, injury or inflammation; or non-blanchable, a symptom of a Stage 1 pressure ulcer ( non-blanchable redness on intact skin).

On 9/22/09 at 9:27 a.m., the physical nursing assessment notes by RN I documents middle buttock bony prominence erythema remains.
On 9/23/09 at 5:10 p.m., the physical nursing assessment notes by RN J documents middle buttock bony prominence erythema remains.
On 9/24/09 at 1:28 a.m., the physical nursing assessment notes by RN K documents middle buttock bony prominence erythema remains.
On 9/25/09 at 2:06 a.m., the physical nursing assessment notes by RN L documents middle buttock bony prominence erythema remains.
The 9/25/09 physical nursing assessment notes by RN M at 8:28 a.m. reflects that the middle buttock bony prominence erythema remains.
The 9/26/09 at 7:16 p.m. and 9/2709 at 8:25 p.m. physical nursing assessment notes by RN N reflects that the middle buttock bony prominence erythema remains.
The 9/28/09 at 2:14 p.m. the physical nursing assessment notes by RN O reflects that the middle buttock bony prominence erythema remains.
The skin assessments show that on 9/28/09 at 4:48 p.m. by RN J reflects that the middle buttock bony prominence erythema remains.

The 9/29/09 and 9/30/09 (day of discharge) notes reflect no change in the documentation (middle buttock bony prominence erythema) of the middle buttock of Patient #1. The last skin integrity assessment completed on 9/30/09 at 11:33 a.m. by RN O is unchanged, stating that Patient #1 has the middle buttock bony prominence erythema.

Interveiew on 2/11/10 at approximately 4:30 p.m., with Director of Quality Management P verified that there was no additional descriptive information that could be found about these skin abnormalities. There was no measurement of the areas to reflect improvement or decline, no staging or description of the areas to define whether the buttock area was a pressure ulcer versus other skin conditions (irritation or inflammation).

There was no nursing documentation of measurement or wound bed characteristics of the wound as described by Policy 1004. This was verified by Director of Quality P on 2/16/09 at approximately 2 p.m.

On 3/1/10 information was obtained from the nursing home that received Patient #1 on 9/30/09, and the skin condition was documented as follows:
Nursing Home RN Q documents on 9/30/09 (day of admission) at approximately 11 p.m. that Patient #1 was admitted with a 10 cm. by 10 cm. Stage 2 (partial thickness skin loss involving top layers of skin and some underlying tissue under the skin's surface) pressure ulcer with distinct clearly outlined edges that were even and attached to the wound base. In the center of this Stage 2 pressure ulcer, was a 2 cm. in diameter black area (dead skin black in color called eschar), there was a 1 cm. by 1 cm. blister located onto the left side of to the left of the blackened area.

There was no documented evidence that Patient #1's attending physician was contacted about any skin abnormalities. This was verified by Director of Quality P on 3/2/10 at approximately 10 a.m.

Based on medical record review and staff interview, the hospital failed to ensure that nursing staff responsible for the care of 1 of 3 patients (Patient #1), having pressure ulcers, revised and kept current a skin integrity care plan that met the patient's needs. This occurred in a total sample of 10 patients. (Cross-reference A0395 for pertinent information regarding Patient #1)

Findings include:

The 2/11/10 medical record review reflects:
At 9/19/09 at 7:35 a.m.( day of admission), RN C documented that Patient #1 has "red erythema (redness of the skin) over the bony prominence that is generalized over middle buttock" (over the tail bone) area.

Patient #1 has a "Skin Integrity Alteration Potential/ Actual" care plan initiated 9/20/09. this care plan shows RN review dates of 9/24/09, 9/27/09 and 9/30/09 under the pressure ulcer prevention plan. This plan does not identify nor document whether this patient is at risk for or has an actual skin integrity alteration (pressure sores). Outcomes defined as significant in this care plan are: Understanding of pressure ulcer risk factors, independent position changes, and skin care on page 1 of 10, nursing standards of care interventions such as assessment and diagnosis of skin integrity alterations, basic skin care, and incontinence care on page 3 of 10, and pressure ulcer prevention plan regarding use of speciality mattress, pressure ulcer education with patient and family, use of transfer device to minimize shear, avoidance of prolonged bedrest, positioning to reduce pressure, relieving duration and intensity of pressure over bony prominences/ pressure points/ medical devices on page 4 of 10.

On 9/22/09 throughout 9/30/09 (day of discharge), the nursing staffs documented the same details (as above) about Patient #1's skin condition over the coccyx area.

On 3/1/10 skin assessment information was obtained from the nursing home that received Patient #1 on 9/30/09. This pressure sore assessment information reflects that Patient #1 was admitted with a 2 cm. in diameter Stage 4 pressure sore surrounded by a Stage 2 pressure sore that was 10 cm. in diameter.

There is no documented evidence that the hospital nursing staff that cared for Patient #1 revised the skin integrity care plan to reflect that the coccyx area erythema was non-blanchable (skin remains red when pressure applied indicating a Stage 1 pressure area) remaining the same for the 9 day period (9/22/09 through 9/30/09) There is no documented evidence that the nursing staffs developed a "pressure sore management plan" when the coccyx are skin abnormality became stageable.

This was verified by Director of Quality P on 3/2/10 at approximately 10 a.m.