HospitalInspections.org

Based on record review and interview, staff at this facility failed to ensure that the Important Message from Medicare (IMM) informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 5 of 5 Medicare eligible medical records reviewed out of a total of 10 records reviewed (Patient #1, 4, 5, 6, & 8).

Findings include:

Patient #1's closed medical record was reviewed and revealed that Patient #1 was admitted on 04/28/2018 and the Important Message from Medicare was signed on 05/02/2018.

Patient's #4, #5, #6, & #8 closed medical records were reviewed and revealed no signed Important Message from Medicare forms in their records.

On 12/05/2018 at 2:00 p.m. an interview was conducted with Quality Director A who stated "I would expect all elibible patients to have a signed IMM in their record."

Based on record review and interview the facility failed to follow their policy for completion of History and Physical (H&P) prior to surgery or invasive procedures in 1 of 8 eligible patients (patient #7) out of a total of 10.

Findings:

Review of facility policy titled "Med Records-CSM Doc Requirements-Med Staff-Allied Health Prof-Residents" dated 06/2017 revealed "Section 8. History and physical examination. 5. It is the responsibility of the operating surgeon/physician to complete or delegate completion of an appropriate history and physical examination prior to surgery or potential high risk procedure, except in emergencies."

Record review of Patient #7 revealed admitted on 09/18/2018 for an interventional radiology procedure. The procedure began at 10:42 a.m. The H&P was completed at 11:35 a.m.

On 12/05/2018 at 11:25 a.m. an interview was conducted with Quality Director A who confirmed that the H&P for Patient #7 was conducted after the procedure.

Based on record review and interview, the facility staff failed to obtain accurate and complete consent forms for invasive procedures or treatments in 3 of 6 patients who required consent forms out of a total of 10 records reviewed. (Patients #1, #2, #4)


Findings include:

Review of the facility policy titled "Informed Consent, AW" dated 04/2018 revealed "C. Permit: The permit must contain the following elements: 6. Date and time the permit is signed by the patient."

Patient #1's closed medical record revealed the consent for Emergency Coronary artery bypass surgery on 04/28/2018 was not timed.

Patient #2's closed medical record revealed the consent to treat on 04/14/2018 was not dated or timed nor was there a consent for a paracentesis (remove fluid from the abdomen) in the medical record.

Patient #4's closed medical record revealed the consent for a paracentesis on 08/21/2018 was not dated or timed.

On 12/05/2018 at 9:15 a.m. during the record review. Quality Director A stated "the expectation is to have the consent form signed, dated and timed."