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Based on record review and interview, the facility failed to ensure 3 of 34 patients ( #2, 15, & 20) received the Important Message from Medicare letter (IM letter) within 2 days of admission.

Finding included:

Review of the facility policy- Patient Admission Discharges and Transfers, 2.6, unknown date, states-Explanation of additional forms required for Medicare patients: Inpatients-An Important Message from Medicare/Champus-This form shall be given to the patient within 2 calendar days of admission and be signed by the patient/representative. A follow-up copy of the form signed at admission shall be given to the patient within 2 calendar days of discharge. This form requires the address of the state Quality Improvement Organization (QIO) be pre-printed. It is the responsibility of the CFO/Controller to ensure this information is accurate. Use as a resource.

Review of the medical record for patient #2 showed he was admitted on 6/07/2013 for Osteomyelitis post hardware removal (laminectomy hardware). Review of the medical record on 6/10/2013 at approximately 10:36 a.m. showed the IM letter-was not signed by the patient, representative, or an explanation of the lack of notification was found.
During an interview on 6/10/2013 at 11:45 a.m. the chief clinical nurse said the form should have been signed at admission.

Review of the medical record for patient #15 showed he was admitted on 2/23/2013 for acute respiratory failure, pleural effusion, cardiac arrest, ventilator associated pneumonia, and Congestive Heart Failure (CHF) and expired on 3/04/2013. Review of the medical record on 6/10/2013 at approximately 12:36 p.m. showed the IM letter-was not signed by the patient, representative, or an explanation of the lack of notification was found.

Review of the medical record for patient #20 showed she was admitted on 2/21/2013 for acute respiratory failure, pleural effusion, cardiac arrest, ventilator associated pneumonia, and CHF and expired on 3/01/2013. Review of the medical record on 6/10/2013 at approximately 12:36 p.m. showed the IM letter-was not signed by the patient, representative, or an explanation of the lack of notification was found.

During an interview on 6/11/2013 at 11:35 a.m. the health information manager said patient #20's brother refused to sign the Medicare Important letter. She also said she does not remember if patient #15's family refused to sign or if they were given the IM letter and just did not return it as requested. She confirmed she is not able to locate the signed document and there was no documentation in the medical to explain why the form was not completed.

Based on record review and interview, the facility failed to ensure the blood bank courier log was consistently completed with the receipt of blood delivered from the local blood bank for 3 of 5 patients (#28, 29, & 31).

Findings included:

Patient #28-Received 2 units of packed red blood cells (PRBC) on 5/01/2013. The first unit #333413005950 was started on 5/01/2013 at 2:00 p.m. and completed at 2:30 p.m. The second unit #333413005961 was started at 2:30 p.m. and completed at 3:00 p.m. The Transfusion record showed the blood was released from the local hospital blood bank on 5/01/2013 at 9:43 a.m. No record was found on the blood bank courier log that the facility ever received the blood from the blood bank.

Closed patient #29-Received 2 units of PRBC on 5/03/2013. The first unit #333613027508 was started on 5/03/2013 at 11:15 a.m. and completed at 1:25 p.m. The second unit #38113008394 was started at 1:45 p.m. and completed at 4:00 p.m. The blood bank courier log has one time recorded on the log, but it was unknown if the time was the time the courier was called or if it was the time the blood arrived at the facility from the blood bank.

Closed patient #31-Received 1 unit of PRBC on 5/18/2013. Unit #03811310665 was started on 5/16/2013 at 4:30 a.m. and completed at 1:25 p.m. The Transfusion record showed the blood was released from the local hospital blood bank on 5/18/2013 at 2:08 a.m. No record was found on the blood bank courier log that the facility ever received the blood from the blood bank.

During an interview on 6/12/2013 at 9:30 a.m. the above patient records were reviewed with the chief clinical nurse and she confirmed the blood bank courier log was incomplete.

Based on observation, interview, and record review, the facility failed to ensure staff used sterile technique when performing tracheostomy care for 1 patient (#3) as per facility policy.

Findings included:

During an observation on 6/10/2013 at 10:45 a.m., trach care/dressing change/suctioning was observed on patient #3. Registered respiratory therapist (RRT), staff F, identified the patient, used alcohol gel, and donned clean gloves. She proceeded to remove the soiled dressing from the tracheostomy site and cleansed the area with clear solution. She then proceeded to open a sterile package containing sterile gloves and a sterile suction catheter. She used the sterile technique process and proceeded to don sterile gloves over the soiled clean non-sterile gloves. She then suctioned the patient. The nurse completed the procedure by applying a sterile dressing to the tracheostomy site.
The chief clinical nurse was present during the procedure and later confirmed this process is not the standard of practice according to facility policy.

Review or the policy-Tracheostomy and Endotracheal Tube Open Suctioning, dated as revised on 02/2012 states the policy is-Suctioning will be performing using sterile technique. The procedure states-Wash hands; Prepare equipment. Don sterile gloves. Remember, the hand that passes the catheter must remain sterile. The hand that holds the suction port and connecting tube is considered contaminated.