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Based on review of facility policies and procedures, medical records, and staff interview, it was determined that the facility lacked policies and procedures regarding the notification of Medicare beneficiaries of their hospital discharge appeal rights for eleven (11) of twenty (20) (#2, 3, 4, 7, 8, 10, 14, 15, 17, 18, and 20) sampled inpatient medical records.

Findings were:

Review of facility policies and procedures failed to reveal evidence that the facility had developed policies and procedures to address the Medicare requirements at 42 CFR Part 405.1205, Notifying Beneficiaries of Hospital Discharge Appeal Rights, by providing inpatients who were Medicare beneficiaries with the Important Message (IM) from Medicare, which informed Medicare beneficiaries and/or their representatives of the beneficiaries' rights as a hospital inpatient.

Eleven (11) of twenty (20) medical records reviewed (#s 2, 3, 4, 7, 8, 10, 14, 15, 17, 18, and 20) lacked documentation that the facility had provided Medicare inpatients with the Important Message from Medicare.

During an interview at 4:30 p.m. on 02/23/10 in the Education Building, the interim Director of Nursing stated that the facility was unaware that they were to provide Medicare inpatients with a copy of the Important Message from Medicare.

Based on review of facility policies and procedures, pharmacy tour, and staff interview, it was determined that the facility failed to ensure that outdated drugs were not available for patient use.

Findings were:

Review of facility policy, entitled Department of Pharmacy, Expiration Date Procedure, no number, no effective date, revealed that drugs were to be placed in a box marked "Out Of Date Drugs" and returned to the proper drug company for credit if possible. The policy required that controlled substances be marked, separated from general stock, and arrangements made with the company for return credit. The policy also required that if credit would not be issued, the drugs would be held in a separate, locked cabinet to be destroyed by the drug inspector.

Observations during a tour of the pharmacy with the Pharmacy Director at 3:20 p.m. on 2/23/2010 revealed that all medications requiring refrigeration were stored in the medication refrigerator, which also contained outdated medications that were not marked as expired or outdated in the bottom drawer of the same refrigerator. Observation of the narcotic cabinet revealed that the cabinet contained narcotics currently in date for use and also outdated narcotics that were not marked as expired or outdated on the bottom shelf of the same cabinet. During an interview at the time and date of the tour, the Pharmacy Director confirmed that there were outdated medications in the medication refrigerator and in the narcotics cabinet that had not been removed, even though the expired medications had been moved to the bottom drawer of the refrigerator and bottom shelf of the narcotics cabinet.