HospitalInspections.org

Based on medical record review and interview the facility failed to provide the "Important Message from Medicare" to Medicare patients admitted as in-patient in the facility within the 48 hour period and prior to discharge resulting in denying Medicare patients the right to appeal discharge and denying Medicare patients the information to start the discharge appeal process.

On 2/9/2012 at approximately 1000 during medical record review it was revealed the facility failed to provide the important message from medicare (IMM) to 2 of 2 patients (#4 and #15). An interview with staff #A confirmed the IMM was not located in the patient chart.

On 2/9/2012 at approximately 1600 during and interview with staff #B it was revealed the facility failed to provide the IMM to Medicare patients upon admission to the hospital and prior to discharge from the facility. Staff #B stated she had spoke to staff members responsible for providing the IMM and it had been revealed no staff member had provided the IMM to Medicare patients. Staff #B could not determine how many patients had not been provided the IMM or when the process of providing the IMM had ceased.

Based on record review, policy review, and interview the facility failed to implement established policies for responding to patient complaints resulting in the potential for failure to take corrective measures to address patient needs and concerns. Findings include:

On 2/9/2012 at approximately 1500 during and interview with the patient liaison it was revealed the staff assigned to supervision after business hours and on weekends had failed to forward complaints to the patient liaison and the patient advocate. During the interview with the patient liaison it was revealed the facility's service recovery program issued gas cards and meal vouchers for individuals when a patient's family complained about inconveniences of costs associated with canceled surgeries, procedures, or diagnostic exams. A log of issuance of gas cards and meal vouchers was obtained with identification of the date, patient, department, reason or nature of need and what was needed to prevent the situation from reoccurring.

According to the policy titled "patient complaint - grievance process", policy # 108840-00-66, under procedure "complaint investigation, resolution, and documentation, #2, "all associates are expected to attempt to resolve an issue at the time it is identified." Unresolved grievances are to be forwarded to the patient liaison.

The review of the service recovery log revealed 5 of 16 listed encounters were considered grievances and were not forwarded to the patient liaison. Two of five of the occurrences lacked the patient information, nature of the complaint, or resolve to situation.

Based on interview and record review the facility failed to ensure that the patient or his or her representative are being informed of his or her health status, and being involved in care planning and treatment. Findings include:

On 2/9/2012 at approximately 1020 during medical record review it was revealed that 3 of 5 patients (#4, #5, and #10) did not have the general consent for treatment signed by the patient or patient's guardian. An interview with staff #A confirmed the patients medical records did not have the general consent signed by the patient or the patient's guardians.

Based on observation and interview, it was determined that the facilty was not taking sufficient steps to promote patient privacy, which had the potential to affect all in patients. Findings include:

On 2/9/2012 at approximately 0920 during the initial tour of the facility it was revealed patient information was displayed on large screens visible by the public which included last name first initial, age, and gender. Staff #A was queried if this was a practice throughout the hospital and he confirmed that most of the floors contained this information but was unaware it was a violation because the date of birth was not listed.

Further tour of the facility revealed the hospital's telemetry floor contained the first and last name of the patients being monitored on telemetry and a listing of the patients according to last names both being capable of being viewed from the corridor for visitors and staff. Staff #A confirmed the patient names contained both the first and last names of patients on the telemetry screens and could be cross referenced by using the patient list screen.

Based on record review, interview, and policy review the facility failed to ensure restraint orders were renewed within a 24 hour period for 9 out of 10 orders reviewed, resulting in the potential for violation of a patient's right to restrained longer than medically necessary. Findings include:

On 2/9/2012 at approximately 920 during medical record review it was revealed physician #F had not dated and timed the restraint order for patient #15 on 1/12/2012, 1/13/2012, 1/15/2012, 1/16/2012, 1/18/2012, and 1/21/2012 failing to authenticate the time of the renewal of the restraints within the 24 hour period. Physician #F was queried as to why he did not date and time his signature. Physician #F responded "I am not the primary physician of that patient and I do not have to date and time my orders! I will no longer be signing orders for patients that I am not the primary." Staff #A was asked is it was the policy of the hospital for consults to not date and time restraint orders and he stated "that is not the accepted practice of the facility".

On 2/9/2012 at approximately 1015 during medical record review it was revealed patient #16's renewal of restraint orders had not been signed by the physician on 2/4/2012, 2/5/2012, and 2/6/2012. During an interview with staff #A it was confirmed the renewal orders for restraints had not be signed by the physician.

On 2/9/2012 at approximately 1040 during medical record review it was revealed patient #1's renewal of restraint orders failed to contain the date and time of the physician's signature failing to authenticate the time of the renewal of the restraints within the 24 hour period. An interview with staff #A confirmed the restraint orders did not contain the date and time of the physician's signature and could not verify if the physician had signed the orders within the required time.

Based on observation, policy review, records review, and interview the facility failed to insure that patients were repositioned every 2 hours as ordered, resulting in the potential for facility acquired pressure wounds in all bedridden patients.

On 02/09/2012 at approximately 1100 during observation in the CCU, staff J was interviewed about repositioning of bedridden patients and the subsequent documentation. Staff J turned to the document "24 hr Medical Surgical Patient Care Summary" and demonstrated where she documents the repositioning with initials when it is completed.

Review of medical records revealed failure to document repositioning of bedridden patients, in 4/4 charts (patients #13, #14, #17, #18) this finding was verified with staff A.

During review of policys and procedures, policy 106370-1-04 confirmed that bedridden patients are to be turned every 2 hours, and policy 106370-1-25 confirmed that documentation should reflect the care given "If it is not documented it is perceived as not done". This finding was verified with staff A.



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On 2/9/2012 at approximately 1540 during a tour of the medical/surgical unit it was revealed during review of medical document review 2 of 2 patients (#17 and #18) failed to have documentation in the patients chart that showed the patients had been repositioned every two hours as needed. An interview with staff #A confirmed the documentation was blank and considered to be not done if not charted.