HospitalInspections.org

Based on review of the medical records of five Medicare recipients, staff interviews, policies and procedures and other pertinent documents it was found that the hospital failed to effectively ensure that Medicare patients and/or their representative have the information necessary to exercise their rights to appeal their discharge. The hospital failed to provide Medicare patients with notice of the Important Message from Medicare (IMM) within the appropriate time frames. This was found to be true for five of six recipients (#5, #8, #9, #10, and #14.)
Reviewed medical records revealed that the Initial IMM that was to be presented within two days of admission was not found for patients #5, #8, #9, and #10.
The second IMM, which is to be delivered within two days prior to discharge, was not presented to patient #14. Review of patient #14 medical record noted that the patient had been discharged and that the second IMM was mailed to her. Patient #14 was denied the opportunity to exercise the right of Medicare recipients to appeal discharge, by not receiving the second IMM prior to discharge.

Based on review of patient medical record and interviews with the staff during the survey on February 14, 2018, it was found that the hospital failed to document the patient's ability to be involved in the planning of treatment received.

Patient #5 was not deemed to lack capacity to make decisions and no designated representative or surrogate decision maker was documented on the medical record. Review of patient #5's medical record revealed consents and procedure forms signed by multiple persons including a son, a daughter, and one with an unknown signature. No statement of incapacity was found on the chart, nor had the patient designated a surrogate decision maker.

The hospital failed to establish capacity and lacked proper documentation of who was an authorized decision maker on behalf of the patient.

Based on review of two restraint records, hospital policy and procedures, and other pertinent documents during the survey on February 14, 2018, it was found that both patient #5 and patient #6 had orders that were written significantly in advance of or after the initiation of restraint interventions.


The hospitals policy on 'Restraints' states that standing or as-needed PRN orders are not allowed. The policy also states that a licensed independent practitioner (LIP) is notified immediately after the initiation of restraints, and that a verbal or written order is obtained from the LIP and entered into the patient's medical record (SAH policy# SYSRI20.) The review of patient #5's restraint records showed two of three consecutive day of non-violent restraint use documented with orders that were written significantly later than the initiation of the restraints. The first episode of restraint use showed that patient #5 was placed in nonviolent restraints for ten and a half hours prior to the writing of an order. This restraint episode was initiated at 0900; however, the order was not entered into the medical record until 1929. The second restraint episode was initiated at 0900, but the order was not entered until 1836. The third restraint order was written thirty minute in advance of the restraint start time.


Review of patient #6's orders, for non- violent restraint, showed that three of five orders were written greater than one hour prior or post initiation. Patient #6 first restraint order was written three and a half hours after the initiation of the restraints. The fourth order for nonviolent restraints was placed one hour prior to the start time. The fifth order for restraints was entered in the medical record at 0231, six and half hours prior to the 0900 start time of the order.
Based on the regulation and hospital policy the hospital failed to properly implement a process of initiating and documenting restraint orders, in a manner that maintains patient's right to be free from restraints.

Based on review of eight closed records and seven open records it was determined the hospital failed to properly execute an informed consent for 1 of 4 surgical cases reviewed.


Patient # 10 had two consents in their chart for a biopsy procedure. The anesthesia consent was signed and dated by patient. The surgical consent, dated the same day as the anesthesia consent, did not contain the patient's signature but had a note that the patient verbally consented. It was not documented as to why the patient could not sign their surgical procedure consent.

Based on review of eight closed records and seven open records it was determined the hospital failed to have a completed medical record within 30 days after patient # 9 expired.


Patient # 9 was an elderly patient who went into cardiac shock after one week in the hospital. Patient # 9 expired on 12/1/17. Their discharge summary was entered into the medical record over 30 days later, on 1/24/17, and signed the following day.

Based on review of hospital bylaws and eight closed records and seven open records it was determined the hospital failed to ensure the surgeons wrote or dictated an operative report immediately following surgery for two of four surgery cases reviewed.
Per hospital Medical Bylaws, Appendix 1.1.10-D, "Section 3. Surgical Procedures," "All operations shall be described using the electronic brief operative note immediately on arrival to the recovery area. The attending surgeon or his/her assistant will dictate the detailed operative report, which should be authenticated within 48 hours. "


Patient # 2 was out of surgery and in the Post Anesthesia Care Unit (PACU) at 09:04. The "Brief OpNote" was completed at 11:43.
Patient # 8 was out of surgery and in the PACU at 14:59. The "Operative Note" was signed five days after surgery. No brief operative note was found in the chart.