HospitalInspections.org

Based on MR review and interview with staff (M), in 2 of 5 MR (1 and 2) the facility failed to ensure the Important Message (IM) from Medicare is given to the Pt within 48 hours of admission. This deficiency potentially affects all 11 inpatients Pts treated during survey.

Findings include:

Pt #1's MR review on 3/14/13 at 10:00 AM revealed he was admitted on 2/27/13. There is no copy of the IM in the MR indicating Pt #1 received the notice within 48 hours of admission. This is confirmed in interview with IRN M on 3/18/13 at 12:30 PM, adding an IM should be in the MR.

Pt #2's MR review on 3/14/13 at 12:42 PM revealed he was admitted on 2/27/13. There is no copy of the IM in the MR indicating Pt #2 received the notice within 48 hours of admission. This is confirmed in interview with IRN M on 3/18/13 at 12:40 PM, adding an IM should be in the MR.

Based on review of MR, and interview with staff (M), in 1 of 5 MR (4) the facility failed to ensure care plans are developed and based on the Pt's diagnosis. This deficiency potentially affects all 11 inpatients Pts treated during survey.

Findings include:

Pt #4's MR review on 3/18/13 at 1:05 PM revealed Pt #4 was admitted with pneumonia on 1/9/10. There is no nursing care plan related to pneumonia. This is confirmed in interview with IRN M on 3/18/13 at 1:20 PM, adding a care plan for pneumonia with related interventions should be in the MR.

Based on MR review, and interview with staff (M), in 1 of 5 MR (4) the facility failed to obtain a consent to treat upon admission. This deficiency potentially affects all 11 inpatients Pts treated during survey.

Findings include:

Pt #4's MR reviewed on 3/18/13 at 1:05 PM revealed there is no consent to treat in the MR for the admission date of 1/9/13. This is confirmed in interview with IRN M on 3/18/13 at 1:10 PM, adding there should be a consent to treat document on file for all admissions.