HospitalInspections.org

Based on MR review and interview with staff, in 2 out of 5 MR reviewed of Medicare beneficiaries (Pt. #3 and 9 ) out of a total of 16 MR reviewed, the facility failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility according to the guidelines set by the Centers for Medicare and Medicaid Services (within 48 hours of admission and 48 hours of discharge). Failure to notify Medicare beneficiaries of their discharge appeal rights has the potential to affect all inpatient Medicare beneficiaries who receive services in this facility.

Findings include:

A MR review was completed on Pt. #3's closed MR on 7/30/2012 at 2:06 p.m. Pt. #3, a 83 year old, was admitted on 7//2012 and discharged on 7/12/2012. A Medicare Discharge Appeal (MDA) form was signed by the patient on 7/12/2012, the day of discharge. There is no evidence that a MDA was provided within 48 hours of admission.

This finding was verified by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review was completed on Pt. #9's closed MR on 7/30/2012 at 3:25 p.m. Pt. #9, a 95 year old, was admitted on 7/19/2012 and discharged on 7/23/2012. A MDA form was signed by the patient on 7/19/2012 and there are two copies in the MR with this date. There is no evidence that a MDA was provided within 48 hours of discharge.

This finding was verified by Mgr A on 7/30/2012 at 4:15 p.m.

In an interview with Mgr B on 7/30/2012 at 3:43 p.m., Mgr B stated that Admission personnel are responsible for providing the MDA information and obtaining a signature on the MDA form at the initial time frame of 48 hours from admission and nursing/case management personnel are responsible to do the same within 48 hours of discharge.

Based on Medical Staff rules and regulations, MR review, and staff interview, this facility failed to obtain properly authenticated verbal/telephone (TO/VO) orders from a physician with date, time and/or signature within 48 hours in 8 out of 16 MR reviewed (Pt. #2, 3, 4, 8, 9, 10, 12, and 13). Failure to have properly authenticated orders in MRs has the potential to affect all patients who receive services in the facility.

Findings include:

Per previously reviewed Medical Staff Rules and Regulations, dated 8/2/05, (reviewed on 6/14/2012), related to TO/VO, the rules and regulations state, "C. General Conduct of Care: 2. These orders shall be authenticated by the responsible practitioner within 48 hours of their writing."

Per interview on 7/30/2012 with Mgr C at 12:38 p.m., Mgr C stated that the time frame for physicians to sign verbal/telephone orders is still 48 hours and the timeframe for chart completion after discharge remains 30 days.

A MR review for Pt. #2 was completed on 7/30/2012 at 1:55 p.m. Pt. #2 was admitted through the ED on 7/19/2012. ED orders written by a RN do not indicate the time medications were ordered, and do not indicate a date or time the physician signed the orders. On 7/19/2012 there are also two verbal orders written after Pt. #2 was admitted as an inpatient that were not signed until 7/23/2012, a time period greater than 48 hours.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #3 was completed on 7/30/2012 at 2:06 p.m. Pt. #3 was admitted on 7/9/2012. Pt. #3 has TOs/VOs written on 7/9/2012 and 7/12/2012 that are not signed, dated, or timed by a physician and 1 TO written 7/9/2012 that was signed by the physician on 7/19/2012, a time period greater than 48 hours.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #4 was completed on 7/30/2012 at 2:18 p.m. Pt. #4 came to the ED on 7/19/2012. ED orders written by a RN do not indicate a date or time the physician signed the orders.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #8 was completed on 7/30/2012 at 3:20 p.m. Pt. #8 came to the ED on 7/7/2012. ED orders written by a RN do not indicate the time medications were ordered, and do not indicate a date or time the physician signed the orders.

These findings were confirmed by Mgr A on 7/30/2012 at 4:15 p.m.

A MR review for Pt. #9 was completed on 7/30/2012 at 3:25 p.m. Pt. #9 was admitted through the ED on 7/19/2012. ED orders written by a RN do not indicate the time medications were ordered, and do not indicate a date or time the physician signed the orders.

These findings were confirmed by Mgr A on 7/30/2012 at 4:15 p.m.

A MR review for Pt. #10 was completed on 7/30/2012 at 3:35 p.m. Pt. #10 was admitted on 7/16/2012. Pt. #10 has a TO written on 7/16/2012 that does not indicate a time or date the physician signed the order, and another TO written on 7/16/2012 that was signed by the physician on 7/25/20102, a time period greater than 48 hours.

These findings were confirmed by Mgr A on 7/30/2012 at 4:15 p.m.

A MR review for Pt. #12 was completed on 7/30/2012 at 3:35 p.m. Pt. #12 was admitted on 7/9/2012. Pt. #12 has a TO written on 7/9/2012 that was signed by the physician on 7/12/2012, and another TO written on 7/17/2012 that was signed by the physician on 7/23/20102. Both have time periods greater than 48 hours.

These findings were confirmed by Mgr A on 7/30/2012 at 5:00 p.m.

A MR review for Pt. #13 was completed on 7/30/20112 at 4:25 p.m. Pt. #25 was admitted to Swing Bed on 7/12/2012. There are 3 orders from 7/13/2012 that were not signed until 7/17/2012, a time period greater than 48 hours.

These findings were confirmed by Mgr A on 7/30/2012 at 5:00 p.m.

Based on MR review and staff interview, this facility failed to ensure that documentation in the MR is complete and accurate in 7 out of 16 MR reviewed (Pt. #3, 4, 5, 6, 10, 11 and 12). Failure to have complete and accurate documentation in the MR has the potential to affect all patients receiving services in the facility.

Findings include:

In an interview with Mgr A on 7/30/2012 at 11:00 a.m. during an observation of a surgical procedure where DuraPrep, an alcohol based skin preparation (ABSP), was being used to cleanse the surgical site, Mgr A stated that staff are now documenting that the ABSPs are dry prior to draping of the surgical site and that the dry time for DuraPrep is 3 minutes.

A MR review for Pt. #3 was completed on 7/30/2012 at 2:06 p.m. Pt. #3 was admitted on 7/9/2012 and discharged on 7/12/2012. The discharge order sheet and medication discharge order sheet do not indicate the time the physician completed these forms.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #4 was completed on 7/30/2012 at 2:18 p.m. Pt. #4 came in to the ED at 4:55 p.m. and was discharged to home, however the MR does not indicate the time Pt. #4 was discharged from the ED.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #5 was completed on 7/30/2012 at 4:25 p.m. Pt. #5 had gallbladder surgery on 7/10/2012 for which anesthesia was started at 1:02 p.m. The update to the History and Physical, done by the physician on 7/10/2012 does not indicate the time it was signed, thereby not defining a chronological time line.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #6 was completed on 7/30/2012 at 2:57 p.m. Pt. #6 came to the ED on 7/23/2012 and had a Cat Scan of the abdomen and was sent home with prescriptions for pain medication and an antibiotic. Page 1 of the ED orders do not reflect a date, time or signature from the physician, and page 2 does not indicate a time the orders were signed.

These findings were confirmed by Mgr A on 7/30/2012 between 3:12 p.m. and 3:17 p.m.

A MR review for Pt. #10 was completed on 7/30/2012 at 3:35 p.m. Pt. #10 had a total hip replacement on 7/16/2012 and DuraPrep was used to clean the skin. There is no documentation to indicate the skin preparation was dry prior to surgery starting.

These findings were confirmed by Mgr A on 7/30/2012 at 4:15 p.m.

A MR review for Pt. #11 was completed on 7/30/2012 at 4:03 p.m. Pt. #11 had a total hip replacement on 7/16/2012 and DuraPrep was used to clean the skin. There is no documentation to indicate the skin preparation was dry prior to surgery starting.

These findings were confirmed by Mgr A on 7/30/2012 at 5:00 p.m.

A MR review for Pt. #12 was completed on 7/30/2012 at 3:35 p.m. Pt. #12 was admitted on 7/9/2012 and discharged on 7/23/2012 from the Swing Bed program. There is no time indicating when the physician signed the discharge orders.

These finding were confirmed by Mgr A on 7/30/2012 at 5:00 p.m.