HospitalInspections.org

Based on interview and record review the facility found to provide notices of patient rights, including notices from Medicare pertaining to observation status or discharge rates, as applicable, to 6 of 11 sampled patients (Patients# 6, 15, 17, 21, 23 and 1).

The facility's Policy and Procedure titled Medicare Outpatient Observation Notice (MOON) & Hospital Outpatient Observation Notice (HOON) documents, "The MOON must be delivered to beneficiaries in Traditional Medicare (fee-for-service) and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours, and must be delivered not later than 36 hours after observation services begin."

1) During interview on 02/10/25 at 12:17 PM, Patient# 6 reported she did not get a notice of her rights as a patient, but stated she knows her rights and that she could leave against medical advice.
Review of the record with the Risk Manager on 02/10/25 reveals Patient# 6 was admitted on 2/7/25 but no evidence of notice of her rights as a patient.

2) During interview on 02/10/25 at 12:23 PM, Patient# 15 reported she was not offered a notice of her rights as a patient, has received no papers and denied finding a folder in her room on admission, and that she signed for something about releasing records but nothing for notice of her rights, not even electronically.

During interview on 2/10/25 at 12:35 PM, the Unit Manager of the 5th floor stated patients do not get folders in their rooms with notices of their rights and said, "ED does that."

Review of the record with the Risk Manager on 02/10/25 reveals Patient #15 was admitted to the hospital on 01/23/25 but there is no evidence Patient #7 was offered a copy of Patient's Rights or provided notice of her rights under Medicare to appeal a discharge.
During interview on 2/10/25 at 2:33 PM, the Risk Manager stated Patients# 6 and 15 should have received folders with Patient Rights in their room when they were admitted; the Risk Manager made a call in front of the surveyor and immediately afterwards reported he spoke to the Nurse Manager of that floor who reported she just checked and verified these patients did not have admission folders, which she then provided to them.

3) Review of the record with the Risk Manager on 02/06/25 reveals Patient# 17's order to admit her to observation status was dated/timed 01/25/25 at 6:33 PM; however, Patient 17's Medicare notice of observation status was signed by the patient and dated 1/27/25 at 10:15 AM (over 36 hours after admission) and not within 36 hours. The Risk Manager verified the findings at 02/06/25 at 1:45 PM.

4) Review of the record with the Risk Manager reveals Patient #21 had Medicare and was admitted to observation status on 01/27/25 and discharged on 01/30/25 but the notice of observation status was not given and was documented as "not received" although the patient did sign their own general consent to treatment.

5) Review of the record with the Risk Manager reveals Patient #23 had Medicare and was admitted on 01/28/25 at 8:15 PM; however, Patient 23's Medicare notice of observation status was signed by the patient and dated 1/30/25 at 3:35 PM (over 36 hours after admission) and not within 36 hours.

6) Review of the record reveals Patient# 1 was admitted to the facility on 01/17/25, their primary payer was Medicare, and their spouse made their medical decisions and consented to care; however their "CMS IM" (Important Message from Medicare, per Center for Medicare and Medicaid Services) was documented on Patient Demographics as "not received."

Based on record review and interview the facility failed to ensure patients' own physician and family member or representative were notified of their admission as per the patient's choice for 3 out of 6 patients (Patients# 7, 17, 18 ).

The findings include:

1) Review of the record reveals Patient #7 was admitted on 01/23/25 with femur fracture but no answer to the question of whether she wanted a family member or representative notified of her admission and no evidence family was notified of her admission before they called the next day to obtain information, after she had surgery.

During interview on 02/06/25 at 12:07 PM the director of patient access confirmed there was no answer to the question of whether Patient# 7 wanted family notified of admission although there was contact information on file and explained these are not "hard stop" questions, meaning they do not have to be answered in order to continue with the admission process and the emergency department is often busy with a lot of patients and activity, so her staff focus on the hard stop questions and may not ask if they want their provider or family notified of admission.

2) Review of the record reveals Patient# 17 was admitted 01/17/25 and responded yes to wanting their primary care provider notified of their admission but no answer for the question of whether they wanted a family member or representative notified of their admission.

3) Review of the record reveals Patient# 18 was admitted 01/16/25 and had a family member with contact information on file and responded yes to wanting that person notified of their admission, but no documentation that staff notified them Patient #18 was in the hospital. Patient# 18 signed consents for surgery on 01/17/25 and 01/20/25.

During simultaneous record review on 02/06/25 at 2:15 PM the Risk Manager confirmed there was no evidence of contact with the patients family member until documentation that the family member called the hospital on 01/22/25.