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Based on record review and interview the facility staff failed to follow their policy and procedures by failing to inform patients of their Medicare discharge rights upon admission for 3 of 6 Medicare-eligible inpatients (Patient #1, #2 & #4) and failed to inform patients of their rights upon discharge for 3 of 6 discharged patients reviewed (Patients #1, #3, and #9), in a total sample of 10 medical records reviewed.

Findings include:

Record review of policy 'Medicare Beneficiary Notification of Discharge Appeal Rights (Important Message from Medicare - IMM)" #10969861 last reviewed 9/13/2021 under Procedure revealed "The patient access department or hospital designee is responsible for the delivery of the Important Message from Medicare to all Medicare patients registered through admissions or the emergency department." Under Notice delivery and retention revealed "The patient receives the original copy of the signed document. The signed notice is then scanned into the patient's registration records in the electronic medical record." Under Second Notice "The second Important Message from Medicare notice is documented in the case management documentation system and a copy is scanned into the electronic medical record,"

Patient #1's closed medical record was reviewed on 1/26/2021 at 3:25 PM and revealed Patient #1 was a 77-year-old admitted to the Medical Surgical floor 7-14-2021 at 11:15 PM through the Emergency Department with abdominal pain, urinary tract infection and obstructive uropathy (blockage of the urinary tract). The Important Message from Medicare (IMM) notice was dated 7/14/2021 at 11:15 PM on the patient signature line "COVID verbal Consent" was written in. There is no indication who verbal consent was obtained from, there was no initial signed notice scanned into the medical record. On 7/27/2021 Patient #1's Power of Attorney was activated. Case Management note dated 8/10/2021 at 3:15 PM revealed "imm completed" and did not indicate who it was discussed with. Patient #1 was discharged on 8/10/2021 at 4:00 PM. There was no second IMM scanned into the electronic medical record.

Patient #2's inpatient medical record was reviewed on 1/26/2021 at 11:12 AM revealed Patient #2 was a 69-year-old admitted to the Medical Surgical floor on 1/22/22 at 7:45 AM through the Emergency Department with alcohol hepatitis. An IMM notice in English was dated 1/22/2022 at 7:45 AM, the patient signature line "Verbal Consent" was written in. There is no indication who verbal consent was obtained from. Interpreter service was used on 1/23/2022, 1/24/2022 and 1/26/2022 as Patient #1's language was Spanish. There was no signed IMM notice in Spanish in Patient #2's medical record.

Patient #3's closed medical record was reviewed on 1/26/2022 at 12:10 PM and revealed Patient #3 was a 65-year-old with advanced vascular dementia (activated Power of Attorney for healthcare), schizophrenia, hypertension and type 2 diabetes who was admitted 8/10/2021 after a fall and discharged 8/19/21. There was no IMM notice in Patient #3's medical record on discharge.

Patient #4's inpatient medical record was reviewed on 1/26/2021 at 1:12 PM revealed Patient #4 was a 94-year-old admitted to the Medical Surgical floor on 1/22/22 at 1:02 PM through the Emergency Department with an altered mental status. Ischemic stroke was diagnosed pending speech therapy for difficulty swallowing.There was no IMM notice in Patient #4's medical record.

Patient #9's closed medical record was reviewed on 1/28/2021 at 2:52 PM revealed Patient #9 was an 81-year-old who presented to the Emergency Department 12/30/2022 at 9:51 PM with a urinary tract infection and was admitted to the Medical Surgical floor on 1/03/22 at 9:16 PM. Patient #9 was discharged 1/04/2022. There was no IMM notice on discharge in Patient #9's medical record.

On 1/26/2022 and 1/28/2022 interview with Clinical Nurse Leader (CNL) E, during medical record review of Patient #1, #2, #3, #4 and #9's medical records, CNL E stated "I don't see" an IMM for these patients.

On 1/28/2022 at 3:08 PM during interview with Quality Coordinator (QC) B, QC B stated since COVID, verbal IMM notice is given to patients by the patient access staff on admission, the patient is given a copy to sign, and the signed copy is scanned into the medical record. QC B stated "we have not been able to locate the others."

Based on record review and interviews, the facility failed to provide a timely comprehensive dietary assessment of the patients nutritional needs according to their policies and procedures by failing to complete admission evaluations in 3 of 10 inpatients (Patient #2, #4, & #9) in a total of 10 medical record reviewed.

Findings include:

Record review of policy "Inpatient Nutrition Assessment Policy" #10934968, last revised 12/28/2021 under Procedure initial screening Nursing revealed "Gathers information from patients withing 24 hours of admission... Based on results of initial screening, notifies the dietitian." Under Prioritization table for assessment column titled Within 2 days revealed "1. Nutrition Consult. 2. Nutrition Screen with results of 2 or greater."

Patient #2's inpatient medical record review on 1/26/2022 at 11:12 AM revealed Patient #2 was a 69-year-old admitted to the medical surgical floor on 1/22/22 at 7:45 AM through the Emergency Department with alcohol hepatitis. There was no nutritional screening done by nursing. A diet consult was ordered and completed on 1/25/2022, 3 days after admission.

Patient #4's inpatient medical record review on 1/26/2021 at 1:12 PM revealed Patient #4 was a 94-year-old admitted to the medical surgical floor on 1/22/22 at 1:02 PM through the Emergency Department with an altered mental status. There was no nutritional screening done by nursing or a dietary assessment documented in the medical record.

Patient #9's closed medical record review on 1/28/2021 at 2:52 PM revealed Patient #9 was an 81-year-old who presented to the Emergency Department 12/30/2022 at 9:51 PM with a urinary tract infection and was held in the Emergency Department until admitted to the medical surgical floor on 1/03/22 at 9:16 PM. There was no nursing nutritional screen completed until 1/03/2022 at 9:54 PM, which scored as a 2, qualifying for a dietary consult within 2 days of admission. A dietary consult was completed 1/04/2022 at 11:29 AM, greater than 4 days after presentation to the Emergency Department.

On 1/26/2022 and 1/28/2022 interview with Clinical Nurse Leader (CNL) E, during medical record review of Patient #2, #4, & #9's medical records, CNL E confirmed a nutritional assessment was not completed according to their policy and procedures and stated patients holding for a bed in the Emergency Department are expected to have the same nutritional screening completed.