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Based on review of facility documentation and medical records (MR), and interview with staff (EMP), it was determined the facility failed to present a copy of "An Important Message from Medicare" for two of two medical records reviewed (MR12 and MR13).

Findings include:

Review of facility policy and procedure "Notification Of Discharge Appeal Rights/Important Message From Medicare (IMM)" revised May 2016, revealed "Follow Up Deliver Of The IMM Prior To Discharge The follow up delivery of the IMM should be given to the patient as early as possible so that the patient has adequate time to consider and act on the information. But the follow up IMM should not be delivered more than two calendar days before discharge."

Review of MR12 on February 22, 2019, revealed patient was admitted on January 7, 2019, and discharged on January 17, 2019. Further review of MR12 revealed the IMM was signed on January 7, 2019, with no further signature before discharge.

Review of MR13 on February 22, 2019, revealed patient was admitted on January 1, 2019, and discharged on January 12, 2019. Further review of MR13 revealed the IMM was signed on January 1, 2019, with no further signature before discharge.

Interview with EMP8 on February 22, 2019, at 1:30 PM confirmed the above findings and revealed "No, they [signatures] are not there."

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure each medical record include a clinical resume according the facility policy including documenting a discharge summary with the outcome of hospitalization, disposition of case, and provisions for follow-up care for two of four medical records reviewed (MR1 and MR3).

Findings include:

Review of facility Medical Staff Rules and Regulations, last revised June 2015, revealed, " ... 11D. Discharge Summary: (10 A concise, dictated discharge summary will be prepared by the practitioner discharging the patient ... and must be completed within 30 days of discharge: ...(a) reason for hospitalization; (b) significant findings; (c) procedures performed and care, treatment, and services provided; (d) condition and disposition at discharge; (e) information provided to the patient and family, as appropriate; (f) provisions for follow-up care; and (g) discharge medication reconciliation. ... "

Review of MR1 revealed a discharge date of October 10, 2019. Further review of MR1 on February 20, 2019, revealed no documentation of discharge disposition or follow up care.

Interview with EMP4 on February 21, 2019, at 2:00 PM confirmed the above findings and revealed "We have a program and some of the information is not mandatory. The physicians have the choice."

Review of MR3 revealed a discharge date of December 27, 2018. Further review of MR3 on February 21, 2019 revealed no documentation of a discharge summary in the medical record.

Interview with EMP4 on February 22, 2019 at 2:15 PM confirmed the above findings.

Based on a review of facility policy and medical records (MR), and interview with staff (EMP), it was determined the facility failed to dictate an operative report immediately following a procedure or surgery for two of four medical records reviewed (MR2 and MR3).

Findings include:

Review of facility Medical Staff Rules and Regulations, last revised June 2015, revealed, "... 6B Post-Procedure Protocol: (1) A procedure report must be dictated immediately after an operative or high-risk procedure and entered into the record. ..."

Review of MR2 revealed date of surgery December 27, 2018 and the operative report was dictated on December 31, 2018.

Review of MR3 revealed date of surgery December 17, 2018, and the operative report was dictated on January 7, 2019.

Interview with EMP4 on February 21, 2019 at 1:00 pm confirmed the above findings.