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Based on clinical record review and staff interview, the facility staff failed to ensure two (two) of 5 (five) patients who were eligible to receive the "Important Message from Medicare" (IM) were provided with this notice. Patient's # 6 and #2.

The findings included:

1. Patient #6 was admitted to the facility on 9/20/12 with the diagnoses of, but not limited to: right femoral hip fracture, dementia, and hypertension. Patient #6 was discharged on 9/22/12. The surveyor was unable to locate the IMM within the closed clinical record.

On 5/21/13 at 9:20 a.m., the surveyor requested the assistance of Employee #10 in locating the IM. Employee #10 stated, "I don't see one....I do not know how that was missed..."


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2. Patient # 2 was not presented an Important Message from Medicare (IMM) regarding pending discharge and the patient's right to appeal discharge. Patient # 2 was admitted to the hospital on 5/15/13 through the Emergency Department. The patient's clinical record was reviewed on 5/20/13, it did not include evidence the patient or her family were presented an IMM upon admission or through 5/20/13. The patient was transferred to the hospital's Hospice services on 5/19/14 and discharged from the hospital the afternoon of 5/20/13 and her clinical record was reviewed on 5/21/13. The record did not evidence the patient/family was presented an IMM prior to discharge. Employee # 3 was interviewed on 5/21/13 at 9:30 a.m. and she stated the Social Worker/Discharge planners or the Registered nurse caring for the patient were responsible for the presentation of the IMM to patients/families. Employee # 3 stated compliance with presenting patients with the IMM was monitored through chart reviews and office of Regulatory Affairs department. Employee # 3 stated the second IMM would be presented by care management if the patient's stay was longer.

No further evidence or information was presented during the survey to evidence each eligible patient received the IMM, or information why Patient # 6 or 2 did not receive the IMM.

Based on observation, patient interview, clinical record review, staff interview and facility document review, the facility staff failed to ensure a care plan was developed and kept current for 4 (four) of 7 (seven) patients of the survey sample. Patient #'s 4, 6, 2, and #5.

1. Patient #4 did not have a current care plan developed to include interventions for the identified problems and outcomes and did not have a care plan developed to address pain or a diagnoses of diabetes.

2. Patient #6 did not have a care plan update when the diagnosis of MRSA (Methicillin Resistant Staphylococcus Aureus) was made including the patient being placed on isolation. There were also numerous areas of the care plan which were not updated/individualized for Patient #6's care needs.

3. Patient #2's plan of care was not revised when she experienced pain and when transferred to hospice services.

4. Patient #5 did not have comprehensive plan of care developed to direct the patient's care, diagnosis or treatments.


The findings included:

1. Patient #4 was admitted to the facility on 5/17/13 with the diagnoses of, but not limited to: right hip fracture, stroke and diabetes. Patient #4 was observed in bed on 5/20/13 at 2:00 p.m. The patient stated he had fallen. "The nurse fell on me and I broke my hip... I have had surgery and it is still painful sometimes...yes, I am getting medicine for pain when I need it."

Review of the current "care plan" for Patient #4 revealed the following "problems: fracture of bone, altered bowel function, impaired gas exchange, impaired urinary elimination, impaired skin integrity, risk of venous thrombosis, risk of infection, risk of impaired skin integrity, falls, and complication of medical care. There were "expected outcomes" listed on the document, however, there were no interventions for any of the identified problems. There was no care plan developed for pain and diabetes for which Patient #6 was receiving treatment.

On 5/21/13 at 11:15 a.m., Employee #14 assisted the surveyor to navigate the care plan section of the electronic medical record for Patient #4. Employee #14 stated, "There should be interventions listed. I think whomever did this care plan left out a step in the process and did not put in the interventions and make adjustments to individualize the plan for this patient. We have just changed to a new system and everyone has been educated, but someone did not complete the steps..."

On 5/21/13 at 1:15 p.m., Employee #17 stated, "We went live with the new system last Thursday. Our education has been nearly one hundred percent except for a few employees who are on leave. I wouldn't be a bit surprised if there was still a learning curve..." Employee #18 stated, "We have had one audit so far but have not had the opportunity to review the results..."

2. Patient #6 was admitted to the facility on 9/20/12 with the diagnoses of, but not limited to: right femoral hip fracture, dementia, and hypertension. Patient #6 was discharged on 9/22/12.

Patient #6 had a lab report dated 9/20/12 which evidenced the Patient tested positive for "MRSA". A Nurse's note on 9/20/12 documented the patient was placed in isolation.

The "care plan" for Patient #6 was reviewed and did not evidence any revision/update to include the diagnosis of MRSA or that the patient had been placed on isolation. Further review of the care plan evidenced areas such as treatments, diagnostic procedures, nutrition, and activity which had not been completed/individualized to reflect the care needs of Patient #6.

Employee #11 stated on 5/21/13 at 11:25 a.m. that there should have been dates and initials in the areas which were pertinent for Patient #6 and other areas should have "been lined out as not applicable with the nurse's initials, date and time..."

On 5/21/13 at 1:15 p.m., Employee # 17 stated, "The care plan we were using at that time (for Patient #6) was a paper care plan. We went live with the new system last Thursday. Our education has been nearly one hundred percent except for a few employees who are off on leave. I wouldn't be a bit surprised if there was still a learning curve..." Employee # 18 stated, "We have had one audit so far but have not had the opportunity to review the results..."

The policy "Interdisciplinary Care Coordination and Discharge Planning" was reviewed and contained the following information regarding care planning: "Interdisciplinary Care Planning Process- (2) The admission assessment, physician's plan of care, physician orders, progress notes, and interdisciplinary components of care for a patient with the diagnosis, are reviewed by the RN (Registered Nurse) and provide a framework for the development and initiation of the Interdisciplinary Plan of Care...(4) The RN caring for the patient is responsible for reviewing the established plan of care with the patient and responsible party as soon as possible after admission...(5) The Interdisciplinary Plan of Care is updated continuously throughout the patient's hospital stay and is used as a component of Interdisciplinary rounds/Grand Rounds...(10) The Plan of Care serves as a guide toward accomplishing the interventions and identified goals..."


3. Patient # 2 was admitted to the hospital through the emergency department on 515/13 with an altered mental status. The patient also had the diagnosis of sepsis, diabetes type II, urinary tract infection, pneumonia, hypertension and a urinary tract infection. After admission, the patient experienced pain requiring morphine (narcotic pain medication intervention). The plan of care did not include specific interventions for the included problems. The problem/care plan did not include pain or hospice services. These problems/interventions were not an issue upon admission, but manifested after admission to the unit.
Employee # 11, the Registered Nurse Unit Manager was interviewed on 5/21/13 at 10:15 a.m. The RN stated the patient's problem of pain should be included on the plan of care: "I don't' know why there is not a pain plan of care for this patient, but there should be." Employee # 11 stated that once a patient arrived to the assigned unit and the physical assessment was completed and admission data reviewed the "plan of care is populated automatically" by the computerized system. In reference to the process for modifying the plan of care for new, additional or changed problems-Employee # 11 stated "I should be able to add a problem to the POC-for some reason it's not adding or showing this." Employee # 3 was reviewing the real time/live electronic patient record.

4. Patient # 5 was admitted to the hospital on 5/18/13 with the diagnosis of cancer, congestive heart failure, dementia, gastroesophageal reflux disease, hypertension, acute pulmonary emboli, urinary tract infection. The clinical record was reviewed with Employee # 11, the Unit Manager. The plan of care contained only the problem of "heart failure." The POC did not include any interventions for this problem, and did not include any other problem to include the intravenous heparin (blood thinner) treatment or any other problem for which the patient was receiving medications or treatment/interventions. Employee # 11 stated the primary nurse should have ensured a complete plan of care, and reviewed at least each shift for completeness and accuracy.

Based on clinical record review and staff interview, the facility staff failed to ensure a complete clinical record was maintained for one (1) of seven (7) patients of the survey sample, Patient #6.

Patient #6 did not have a case management document and a physician's discharge summary on the closed record.

The findings included:

Patient #6 was admitted to the facility on 9/20/12 with the diagnoses of, but not limited to: right femoral hip fracture, dementia, and hypertension. Patient #6 was discharged on 9/22/12.

The closed clinical record for Patient #6 was reviewed on 5/21/13. The surveyor was unable to locate information pertaining to discharge for Patient #6 in the closed clinical record including the physician's discharge summary.

On 5/21/13 at 9:20 a.m., the surveyor interviewed Employee #'s 9 and 10 regarding further information relating to the discharge of Patient #6. Employee #9 stated there should be a note in the clinical record for Patient #6 but "I don't see one". At 10:15 a.m., Employee #9 was able to locate a document "Case Management Support Services" dated 9/22/12 at 1000 (10:00 a.m.)

The surveyor inquired as to why this document was not present in the clinical record. Employee #10 stated, "During that time (September) we were using a different system to log case management information. We found it was not getting scanned into the patient's record. This is an example of that...since that time we no longer use this system for documentation..."

On 5/21/13 at 12:45 p.m., Employee #9 presented the surveyor with a document "Discharge Summary" for Patient #6 dated 9/22/12. Employee #9 stated the document was not in the clinical record but was found "in the physicians dictation system". Employee #9 further stated this particular physician group had been "difficult" to get their charts completed.