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Based on interview and record review, the facility failed to provide 2 of 5 Medicare patients the Important Message letter from Medicare (IM) within 48 hours of admission (#1 & 4).

Findings:

Review of the facility policy-Medicare Beneficiary Notice, dated as revised 11/2011 states-the procedure is-Obtain signature, date and time on "Important Message from Medicare" letter from patient/agent within 48 hours of admission as an inpatient.

During an interview on 1/28/2013 at 11 a.m., the registration manager said the first IM notice is given to the Medicare patients in registration and documented in the business office software called Infinity, and any other would be provided by the case management tech assigned.

1. Review of the medical record for patient #1 showed he was admitted on 1/22/2013 to the psychiatric unit post brain injury with seizure disorder. During an observation on 1/28/2013 at 2:45 p.m., the patient was observed on the medical psychiatric unit in the day room. He consented to an interview. The patient was alert and oriented and knew he was in a facility. He said he was being discharged today to another facility. He said he did not receive a copy of the Medicare important message at admission. During an interview on 1/29/2013 at 9:30 a.m., the risk manager said patient #1 received his Medicare letter on 1/28/2013. This was 6 days after admission.

2. Review of the closed medical record for patient #4 showed she was admitted on 12/06/2012 and discharged on 12/11/2012. The medical record did not have documentation the patient or her representative received the Important Message from Medicare letter during the hospital stay.

During an interview on 1/29/2013, the Manager of the Transition department (discharge planning) said the patient was initially an observation patient and was converted on 12/10/2012 to an in-patient. She said the patient should have received a letter related to the IM document on the day she was converted to in-patient. The Transition Manager provided documentation dated 12/11/2012 with an unknown time in the business office software documenting the patient needed an IM letter. The risk manager was also present.

Based on record review and interview, the facility failed to provide 3 of 5 sampled patients with written notice of information related to advanced directives (#2, 3 & 4), and failed to provide a copy of patient rights information to 5 of 5 sampled patients at admission (#1, 2, 3, 4 & 5).

Findings:

Review of the facility policies "Withholding and withdrawal of life Prolonging Procedures: Adults, dated as revised 1/2011" and policy "Patients' Rights and Responsibilities", dated as revised 3/2011, did not include any provision of providing patients with information related to patient rights while in the hospital or providing patients with information related to defining or formulating an advanced directive if they do not have one.

1. Review of the open medical record for patient #1 showed he was admitted on 1/22/2013 to the psychiatric unit post brain injury with seizure disorder. During an observation on 1/28/2013 at 2:45 p.m., the patient was observed on the medical psychiatric unit in the day room. He consented to an interview. The patient was alert and oriented and knew he was in a facility. He told me he was being discharged today to another facility. He said he did not receive a copy of his patient rights when he was admitted. Review of the business office software called Infinity showed the Consent to Treat as signed on 8/14/2012. Review of the same business office software showed the no information given to the patient at the time of admission related to patient rights.

2. Review of the open medical record for patient #2 showed she was admitted on 1/22/2013 for respiratory failure. During an interview on 1/28/2013 at 11:10 a.m., she said she did not receive a copy of his patient rights or a copy of "Health Care Advance Directives-The Patient's Right to Decide," when she was admitted. Review of the business office software called Infinity showed the no information given to the patient at the time of admission related to patient rights or advanced directives.

3. Review of the open medical record for patient #3 showed she was admitted on 1/24/2013 for pneumonia. During an interview on 1/28/2013 at 1 p.m., she said she did not receive a copy of his patient rights or a copy of "Health Care Advance Directives-The Patient's Right to Decide," when she was admitted. Review of the business office software showed the no information given to the patient at the time of admission related to patient rights or advanced directives.

Review of the open medical record for patient #4 showed she was admitted on 12/06/2012 for a fractured hip. Review of the business office software showed the no information given to the patient or her representative at the time of admission related to patient rights or advanced directives.
Review of the closed medical record for patient #5 showed he was admitted on 9/13/2012 and discharged on 10/19/2012 for a fractured right hip. Review of the business office software showed neither the patient nor the representative received a copy of the patient rights information.

During an interview on 1/28/2013 at 3:20 p.m., the registration manager said the facility did not give copies of advanced directive information and patient rights information to op or inpatients unless the patient would request because it is displayed on the wall in the registration areas and only printed copies would be given to the in-patients. The documentation of advanced directive information is found in the business office software called Infinity. This was confirmed by the registration manager on 1/29/2013 at 5 p.m.

During an interview on 1/28/2013 at 2:25 p.m., the risk manager said there was no policy related to advanced directives and patient rights for staff responsibility on providing a copy. Confirmed by the risk manager on 1/29/2013 at 2 p.m.

During an interview on 1/29/2013 at 4:15 p.m., the risk manager confirmed the admission packet "Road to Recovery" provided to the patients at admission as an in-patient does not contain any documents related and explanation of advanced directives and patient rights information. She said the packets are customized by each of the hospital units.

During an interview on 1/28/2013 at 2:40 p.m., the chaplain said he is often called to help patients with advanced directives and when he is called he would then provide a copy of advanced directive explanations to the patient. This was confirmed by the risk manager on 1/29/2013 at 2 p.m.

Based on interview and record review, the facility failed to have a policy addressing time frames for reporting deaths of patients while in restraints to Centers for Medicare and Medicaid Services (CMS), and failed to report 2 of 6 patients reviewed for restraint use, who died in restraints, to CMS (#12 & 14).

Findings:

Review of policy "Restraint Use in Acute Care Settings", with revised date of 6/2012, does not specify any facility specific requirements for reporting patient deaths while in restraints, reporting patient deaths within 24 hours of restraint use, or patient deaths within seven days of restraint use.

On 01/29/2013 at 3:30 p.m., the Risk Manager said there have been no patient deaths while in restraints during the year 2012 (this is date range requested for survey purposes).

1. Review of the closed medical record for patient #12- age 94, showed she was admitted on 11/12/2012 and expired on 11/13/2012 at 12:58 a.m. Review of the medical record showed the patient had bilateral soft wrist restraints beginning on 11/12/2012 at 12:24 p.m. per physician order because she was pulling at her Foley catheter, IV tubing and endotracheal tube. The wrist restraints were removed on 11/12/2012 at 8 p.m. The patient died approximately 5 hours later. There was no documentation the event was reported to Centers for Medicare and Medicaid Services (CMS).

2. Review of the closed medical record for patient #14, age 86, showed he was admitted on 12/16/2012 for general weakness, weight loss, and failure to thrive and expired on 12/18/2012 at 5:56 p.m. The medical record showed an order for bilateral soft wrist restraints beginning on 12/17/2012 at 4:50 p.m. There was no documentation as to whether or not the restraints were every used. The patient died on 12/18/2012 at 5:56 p.m. It was not known whether or not the patient had restraints because there was no documentation of the application or removal of the restraints in the nurses' notes.

Based on observation, interview, and record review, the facility failed to ensure staff provided daily care for 2 of 2 sampled patients with indwelling Foley catheters (a tube in the bladder to drain urine) following surgical procedures (#4 & 5), failed to have a physician order for the insertion of an indwelling Foley catheter for 1 of 2 sampled patients (#5), failed to obtain physician orders to continue ongoing use of indwelling Foley catheter use for 2 of 2 sampled patients (#4 & 5), and failed to discontinue a physician order for oxygen by nasal cannula for 1 of 3 sampled patients (#4).

Findings:

1. An observation of patient #4 on 12/10/2012 at 3:05 p.m. showed a female patient in bed, head of bed elevated with oxygen nasal cannula in place, and an indwelling Foley catheter to continuous drainage. She was admitted on 12/06/2012 for a fractured hip and arm, and is a current patient.

Review of the medical record showed no catheter care documented during the entire hospital stay, from 12/06/2012 to 12/11/2012. Additionally, there was a physician's order for insertion of the Foley catheter on 12/06/2012. However, the order was not renewed every 48 hours as the facility policy requires. The risk manager confirmed the lack of documented catheter care and continued orders on 12/11/2012 12:10 p.m. The order for the use of the oxygen, dated 12/7/2012 at 7:10 p.m., read "Keep O2 (oxygen) sat (saturation) greater than 92% then continue nasal cannula at 2-6 L min. Recheck O2 sat in the AM and if greater than 92% on room air then discontinue."

Review of the medical record showed the oxygen saturation on room on 12/08/2012 at 7:39 p.m. the O2 sat was 98%. The O2 sat on room air on 12/09/2012 at 4:47 a.m. was 96%. The O2 sat on room on 12/10/2012 at 2:45 p.m. was 99%. The record of the oxygen saturations showed the patient was receiving oxygen at 2 liters per minute by nasal cannula. The risk manager confirmed the order for the discontinuation of the oxygen and provided information saying nursing was responsible for the discontinuation of the oxygen on 12/11/2012 12:10 p.m.

2. Review of the closed medical record for patient #5 showed an admission on 9/13/2012 and discharge on 10/19/2012 for a fractured right hip. Review of the operative notes dated 9/14/2012 showed the patient went to surgery for the hip fracture repair. A Foley catheter was placed in the OR (according to the PACU, a #16 French catheter). There was no physician order found for the placement of the Foley catheter, and there was no renewal physician every 48 hours as the facility policy requires.

Review of the nursing assessment on return from the operating room on 9/14/2012 at 11 p.m. a.m. showed "Foley catheter in place, pain assessment - no pain, skin clear, and son at bedside." The medical record showed evidence of a Foley catheter from 9/14/2012 to 10/06/2012 at 7:50 p.m. with no mention of leaking. On 12/11/2012 at 11:35 p.m., the risk manager confirmed there was no documentation of the catheter care from 9/14/2012 to October 6, 2012.

3. Review of the patient #5's task list (where nursing tasks are documented) showed the section for catheter care was blank from 9/14/2012 to October 6, 2012 when apparently the catheter was removed. However, there was no order for the removal of the catheter found.

Review of the policy "Care of the Patient with indwelling urinary Catheters", dated as issued 12/11, read, "The catheter re-ordered if necessary every 48 hours for the duration of the catheter; and in the procedure-B. Routine care shall consist of cleansing the perineal area with soap and water only on a daily basis."