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Based on hospital policy review, medical record review and staff interviews, the hospital staff failed to inform patients who were Medicare beneficiaries of notification of rights regarding the discharge appeal process within two days of admission and no more than two calendar days before the patients' discharge for 2 of 5 Medicare beneficiary patients admitted for inpatient hospital services. (Patient #6, and Patient #9)

Findings included:

Review of the hospital policy titled "Issuing the Important Message (IM) from Medicare" revised April 09., 2020 revealed, " Policy....4. When the beneficiary is unable to comprehend the notice, the IM must be delivered to the beneficiary's representative utilizing the same process as when providing the IM notice to the beneficiary...It is someone authorized under state law to make decisions on the beneficiary's behalf (i.e. legal guardian...)"

1. Closed medical record review on 04/06/2021of Patient #6, a 69-year-old male patient admitted to the hospital on 02/19/2021 at 1059 for respiratory distress, hypoxia (low oxygen), and altered mental status (AMS). Review revealed Patient #6 had a legal guardian, and the hospital had received verification of guardianship and was flagged by the electronic record. Record review revealed that Patient #6 signed his initial Important Message notification on 02/19/2021 at 1431. On 02/20/2021 at 1628, Case Manager (CM) #1 assessed Patient #6 while sister (legal guardian) was present at bedside and documented he was independent, wheelchair manual, and had PT (physical therapy) and OT (Occupational therapy) at the ALF (assisted living facility). "Anticipate discharge back to ALF pending confirmation from (named) facility and medical clearance for discharge... If SNF (skilled nursing facility) is recommended he would like to look for a facility in (named city) and has a positive history with (named health care facility). CM following for additional needs." On 2/22/2021 at 1347, CM #2 wrote a follow up note, "spoke to ALF (named) and the plan was to return there when medically stable." Review of Nurse Practitioner #1 (NP) progress note dated 02/23/2021 at 0850 revealed "...Patient is sitting up in bed. No acute changes overnight. Denies any CP (chest pain) or SOB (shortness of breath). Family is present..." Review of the Important Message from Medicare dated 02/24/2021 at 1220 revealed a notation "verbal consent, (named) Patient #6/ (named) CM #2 signature, dated 02/20/2021 at 1220 pm signature of CM #2." Review of Discharge Summary dated 02/26/2021 at 1038 by NP #1 revealed "...Patient is medically stable for discharge today as he felt to be back at baseline. Will continue PT (physical therapy)/OT (occupational therapy) to help continue increase strength and endurance." Review revealed Patient #6 was discharged to the ALF where he previously lived on 02/26/2021 at 1655 via EMS (emergency services) transport with discharge orders for PT/OT services. Review revealed no documentation of discharge IM or communication of discharge to the legal guardian.

CM #2 was unavailable for interview.

Interview on 04/07/2021 at 1130 with CM #1 revealed "At a minimum the CM should be reaching out to the patient and care team every 3 days. The legal guardian is the decision maker and primary contact. The discharge IM and discharge arrangements and decisions would be discussed with the guardian."

Interview on 04/07/2021 at 1400 with the Director of CM revealed the expectation was for the CM to do the discharge IM and discharge arrangements with the legal guardian before discharge. Interview revealed that the hospital policy to include the legal guardian in the discharge IM was not followed.

Interview on 04/08/2021 at 1430 with the Senior Director of CM revealed "the expectation was to make a minimum of 2 attempts to communicate to the legal guardian the discharge plan, and to document all communication with family/and or legal guardian in the patient's record."

2. Closed medical review on 04/07/2021 of Patient #9 revealed a 60-year-old male patient admitted to the hospital 03/12/2021 at 1812 for fever and chills from a skilled nursing facility (SNF). Review revealed Patient #9 had a legal guardian, and the hospital had received verification of guardianship and was flagged by the electronic record. Record review revealed that Patient #9 signed his initial important message notification on 03/12/2021 at 1038. On 03/14/2021 at 1244 the initial Case Management Assessment was completed by CM #2 with the recommendation to return to SNF. Review of the discharge IM dated 03/16/2021 at 1000 by CM #2 revealed "verbal consent (named) Patient #9/ (named) CM #2 dated 03/16/2021 at 1000 with signature of (named) CM #2." Review of the discharge summary dated 03/16/2021 at 1010 by MD #2 revealed "...Patient is discharged back to SNF with improved symptoms..." Review revealed Patient #9 was discharged to the SNF where he previously lived on 03/16/2021 at 1337 via EMS transport with discharge orders. Review of the CM Progress Note dated 03/16/2021 at 1500 revealed that CM #2 had left a voice mail on the legal guardian's phone of discharge. Review revealed no documentation of the discharge IM presented to the legal guardian prior to hospital discharge. Review revealed one phone call attempt with voice mail was relayed to the Legal Guardian prior to patient discharge.

CM #2 was unavailable for interview.

Interview on 04/07/2021 at 1130 with CM #1 revealed "At a minimum the CM should be reaching out to the patient and care team every 3 days. The guardian is the decision maker and primary contact. The discharge IM and discharge arrangements decisions would be discussed with the guardian.

Interview on 04/07/2021 at 1400 with Director of CM #1 revealed the expectation was for the CM to discuss the discharge IM and discharge arrangements with the legal guardian before discharge. Interview revealed that the hospital policy to include the legal guardian in the discharge IM was not followed.

Interview on 04/08/2021 at 1430 with the Senior Director of CM #1 revealed "the expectation was to make a minimum of 2 attempts to communicate to the legal guardian the discharge plan, and to document all communication with family/and or legal guardian in the patient's record."

Based on hospital policy review, grievance review, medical record review, and staff interviews, the hospital staff failed to provide written response to a grievance for 1 of 2 grievance files reviewed. (Patient #6)

Findings included:

Review of the hospital policy titled Complaints and Grievances from Patients, last revised October 09, 2020 revealed, "Scope/Purpose, this policy explains how patients' complaints and grievances are handled...B. Complaints and grievances will be resolved promptly....3. Patients or their legal representative who filed a grievance will receive a written response that includes a contact person, the steps taken to investigate the grievance, the results of the grievance process and the date of completion..."

Review on 04/07/2021 of the grievance for Patient #6 revealed the hospital was notified of the grievance in person by the legal guardian on 03/01/2021. The event date was 02/28/2021, the legal guardian came to the hospital to visit her brother and was told that Patient #6 had been discharged on 02/26/2021 to an Assisted Living Facility (ALF). The hospital acknowledgement letter went out to Patient #6 on 03/05/2021 addressed at the Assisted Living Facility. The hospital investigation was completed, and final responses received 03/22/2021. The final grievance letter was seen on 03/22/2021 by Patient Partnership Specialist #1 and addressed to Patient #6 at the Assisted Living Facility (ALF). Review of the hospital grievance documentation did not reveal correspondence with the legal guardian.

Closed medical record review on 04/06/2021of Patient #6, a 69-year-old male patient admitted to the hospital 02/19/2021 at 1059 for respiratory distress, hypoxia (low oxygen), and altered mental status (AMS). Review of the record revealed Patient #6 had a legal guardian, and the hospital had received verification of guardianship timestamped 03/17/2020 at 1503 and was flagged by the electronic record. Review revealed Patient #6 was discharged to the ALF where he previously lived on 02/26/2021 at 1655 via EMS (emergency services) transport with discharge orders for PT (physical therapy)/OT (occupational therapy) services.

Patient Partnership Specialist #1 was not available for interview.

Interview on 04/07/2021 at 1220 with the Manager of Patient Services #1 revealed, "So we identified opportunities, there was an oversight with follow up for this grievance. They should have conversed with the legal guardian, and both the patient and legal guardian should have received grievance resolution letters. My expectation was that the legal guardian should have received the resolution letter."

Interview on 04/07/2021 at 1235 with the Senior Director of Professional and Support Services #1 revealed, "After it was identified that the legal guardian had not received notification, we did call the legal guardian/sister together and update her. This has left an opportunity for all of us." Interview revealed education was completed for the Patient Services department in April 2021.

NC00175468