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Based on record review and interview, the facility failed to deliver the Important Message from Medicare (IMM) on discharge to 1 of 5 patients on Medicare (Patient #6) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Medicare Forms Delivery", #26, last revised 04/2022, revealed hospitals must notify Medicare beneficiaries about their hospital discharge appeal rights... "deliver a copy of the notice at least four hours before discharge, but not more than 2 calendar days before discharge."

Review of Patient #6's medical record revealed Patient #6 was an 82-year-old admitted 07/28/2022 after a fall and discharged 08/04/2022. There was no Important Message from Medicare (IMM) given to Patient #6 prior to discharge.

On 08-17-2022 at 4:40 PM during interview with Cardiac & Pulmonary Director E, Director E confirmed there was no documentation that Patient #6 was given the IMM prior to discharge.

Based on record review and interview, the facility failed to provide assistance with formulating an advanced directive in 1 of 10 inpatient admissions (Patient #6) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Advance Directives," #500, revised last 10/2020 under Policy Statement revealed "Patients without an advance directive are provided information about how to develop one. Under Formulating an Advance Directive revealed "The unit Social Worker (SW) or Care Coordination Department should be contacted if an inpatient requests assistance in formulating an advance directive."

Review of Patient #6's medical record revealed Patient #6 was an 82-year-old admitted 07/28/2022 after a fall. On 7/28/22 at 7:51 AM nursing assessment under advanced directives, requests information, revealed "yes". Care Coordination Initial Consult dated 7/29/2022 at 2:01 PM under Patient had Advanced Medical Directives, revealed "(!) No, patient does not have an advance directive for healthcare treatment." There was no documentation that the care coordinator provided Patient #6 assistance with formulating an advanced directive.

On 8/17/2022 at 4:40 PM during interview with Cardiac & Pulmonary Director E, Director E stated "I can't say" Patient #6 was provided assistance formulating an advanced directive and confirmed it was not documented.

Based on record review and interview, the facility failed to complete the annual performance evaluations on staff, according to their policies and procedures, in 2 of 10 staff performance evaluations reviewed (Nursing Assistant G and Registered Nurse H) in a total of 10 staff files reviewed.

Findings include:

Record review of policy "Performance Evaluations" #HR-2, last reviewed 01/2021 revealed "Performance evaluations for all team members are conducted annually." Under Implementation revealed "evaluations are typically due at the end of the month, annually, in which the team member was hired, beginning one year from date of hire. c. When a team member transfers from a position with a different evaluation period, ... 90 day orientation review shall be completed in its place."

Record review of Nursing Assistant G, date of hire 4/18/2022, most recent performance evaluation was due 7/18/2022. Form titled "RN and Service & Support Orientation Period Review (initial 90-Day Review)" with due date 7/18/2022, check in front of "Employee has successfully completed the orientation period," was not dated or signed.

Record review of Registered Nurse (RN) H, revealed a date of hire 6/10/2011. Her/his most recent performance evaluation form titled "RN Performance Evaluation" was dated 3/23/2021, greater than 4 months past due.

On 8/18/2022 at 10:00 AM during interview with Chief Nursing Executive (CNE) D, CNE D confirmed, after review of the employee files 8/18/2022, the Cardiac & Pulmonary Director E sent the most recent performance evaluations requested. The peer evaluations of Nursing Assistant G and Registered Nurse H were noted to be late.