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Based on observation, review of records and interview, the hospital failed to provide complete and correct information to patients or patient representatives of their rights (including State required notices) prior to admission, at time of admission and prior to discharge as follows:

A. An Important Message From Medicare About Your Rights for 3 patients (Patient #s 31, 33, and 34) of 4 patients (Patient #s 31, 32, 33, and 34) was not delivered at admission and/or discharge. The facility failed to follow its own policy.

B. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/Emergency Room Waiting)

C. Provided the incorrect phone number to all patients for making a Health Facility Complaint at time of admission, creating a barrier to patients from exercising their right to make a complaint.

Findings include:

A. Four patient charts (Patient #s 31, 32, 33, and 34) were selected from the Complaints and Grievances Log to be reviewed. Three of the patients (Patient #s 31, 33, and 34) did not receive proper notification.

Patient #31 was admitted on 8-11-2016. The patient was discharged to hospice on 8-12-2016. Review of records showed that the form, An Important Message From Medicare About Your Rights (IM) had notation in the "Signature of Patient or Representative" block "pt cannot sign". This was dated and time 8/11/16 1017 (10:17 A.M.). There was no signature of the person delivering the IM or explanation of why the patient could not sign. The chart did not contain documentation of follow-up action with a patient representative or the patient to provide them with the patient rights information. A second delivery of the IM was not necessary.

Patient #33 was admitted on 8-8-2016. The patient was discharged to home with home health on 8-29-2016. Review of records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was not dated or timed. There was no IM form found in the chart with signature, date, or time of the second delivery of the IM prior to discharge.

Patient #34 was admitted on 6-13-2016. The patient left the hospital against medical advice on 6-19-2016. Review of the records showed that the IM form had a patient representative's signature in the "Signature of Patient or Representative" block. It was dated and timed "6 13 1900" (7:00 P.M.) There was no IM form with a signature, date, or time from the patient to show he had received a second delivery at time of discharge when he signed himself out of the hospital against medical advice.

Review of Community Health Systems Professional Services Corporation Policy Title: Important Message from Medicare Policy was completed. "Section II. Procedure" stated the following:

"Registration personnel are responsible for the following:

A. Delivery of the Important Message from Medicare (IM) at or near admission, but no later than 2 calendar days following the date of admission.

B. If the Medicare patient is admitted and/or transferred to a Distinct Part Unit within the hospital (e.g., Rehab or Psych unit), the IM specific to that Unit, which includes the DPU's Medicare provider number, should be delivered to the patient instead of the acute care IM.

C. When the IM is issued, obtain the signature of the patient or his/her representative on the IM to indicate that he/she received and understood the notice. This includes explaining the notice to the patient if necessary and providing an opportunity to ask questions ...

G. Regardless of the competency of a patient, if it is not possible to personally deliver a notice (initial IM or follow-up IM) to a representative, the attempts should be made to contact the representative by telephone to advise him or her of the patient's rights as a hospital patient, including the right to appeal a discharge decision ...

J. Place a dated copy of the notice in the patient's medical file, and document the telephone contact with the patient's representative (as in #8 above) on either the notice itself, or in a separate entry in the patient's fil or attachment to the notice...

L. If the patient refuses to sign the IM, indicate in writing on the IM the refusal. The date of refusal is considered the date of receipt of notice.

M. It is the ultimate responsibility of Registration personnel to ensure the initial IM is delivered to appropriate patients and/or their representatives, appropriate signature(s) is obtained, the original IM is given to the patient or his/her representative, and a signed and dated copy of the IM is placed in the medical record. A tracking system should be developed whereby there is certainty that the IM is delivered, as per Policy.

III. Delivery of the Follow-up IM Prior to Discharge
The Case Manager is responsible for the delivery and obtaining the patient's or the patient's representative's signature on the follow-up IM prior to discharge. When the CM is not available, the nurse manager, charge nurse or nurse assigned to patient is responsible for this process.

A. Provide the patient or his/her representative a new IM within 2 calendar days of the day of discharge. Obtain the patient's or patient's representative's signature and date on the new IM. Give the patient or the patient's representative the second signed and dated IM and place a copy of the second IM in the medical record."

Interview was conducted with Staff #51 on 9-21-2016. Staff #51 confirmed that it was the Case Management Department's responsibility along with nursing to ensure the second delivery of the IM. Staff #51 was unable to find the second delivery of the IM for Patient #33 and Patient #34.

Interview was conducted with Staff #54 on 9-22-2016. Staff #54 confirmed that registration staff was responsible for the initial delivery of the IM. Staff #54 stated the errors on the initial delivery of the IM on Patient #s 31, 33, and 34 had all been processed by the same person. Staff #54 stated the staff member that had made the mistakes was new and was to be re-educated on the process.

B. Tour of the facility was conducted on 9-19-2016 with Staff #7. State required posting to notify patients or patient representatives of the statement of duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in English and a second language with their right to contact the appropriate complaint line number was not posted at 3 of 3 entrances/waiting areas (Entrance/Main Lobby Gaslight Boulevard, Entrance/Lobby Loop 287, and Ambulance Entrance/Emergency Room Waiting). Staff #7 confirmed that the postings were missing.

C. Review of Patient Admission Forms was conducted. The "Patient Rights and Responsibilities ADM-1901 GHMS-TX" on page 2 of 2 stated:

"You also have the right to:

Lodge a concern with the state, whether you have used the hospital's grievance process or not. If you have concerns regarding the quality of your care, coverage decisions or want to appeal a premature discharge, contact the State Quality Improvement Organization (QIO) ....

If you have a Medicare complaint you may contact

Texas Department of State Health Services

Phone: (512) 834-6700"

Review of the Patient Guide, given to patients upon admission, contained the following information on page 24:
"Regarding Problem Resolution, You Have the Right To:

Express your concerns about patient care and safety to hospital personnel and/or management without being subject to coercion, discrimination, reprisal or unreasonable interruption of care; and to be informed of the resolution process for your concerns. If your concerns and questions cannot be resolved at this level, contact the accrediting agencies indicated below:"

This also lists the phone number for the Texas Department of State Health Services as (512) 834-6700.

An attempt to call the number provider was made with Staff #3 present. The phone number provided was for the Emergency Medical Services (EMS) group. There was an automated response that provided different options to contact various EMS related services. The only option for filing a complaint was for EMS services and not hospital provided care. Staff #3 confirmed this.

Based on review of documents and interview, the director of nursing service failed to ensure non-employee licensed nurses providing care in the emergency department to sexual assault victims were properly contracted, credentialed and supervised.

Review of the Sexual Assault Nurse Examination (SANE) program revealed that no hospital nursing staff were certified as SANE nurses.

Interview was conducted with Staff #44 revealed that SANE examinations were provided by nurses employed with an outside provider. Sometimes the nurses came to the emergency department to complete the examination. Sometimes the nurses requested the patient be sent to outside provider location.

Interview with Staff # 7 was conducted. Staff #7 stated there was not a contract with the outside provider for these services. Staff #7 stated that there were no policies concerning SANE exams since the hospital did not conduct the exam. Staff #7 stated there were no credentialing files on the nurses who came in to the hospital to examine the sexual assault patients.