HospitalInspections.org

Based on review closed medical records, the hospital failed to provide 1 patient with the second Important Message to Medicare and failed to provide an initial or second Important Message to Medicare to another patient.
Patient #11 was admitted 9/22/2016 an initial Important Message from Medicare was presented to the patient 9/23/2016. No second Important Message from Medicare was presented to the patient #11 within 2 days of discharge.
Patient # 10 was admitted 9/23/2016 no initial Important Message from Medicare was presented to the patient within 2 days of admission. No second Important Message from Medicare was presented to the patient #10 within 2 days of discharge.

Based on review of open and closed medical records, the hospital failed to provide informed consent to 1 patient.
Patient #12 was given a consent for cardiac surgery. The form was pre-filled by a person other than the physician who signed the form. The dates and times were both pre-filled on the form. With this information being pre-filled one is unable to determine who presented the form and explained the information to the patient, and if the patient and physician signed the form at the same time. The consent that was signed by the patient also states that all procedures may be done by a member of the treatment team. Without specifying which procedures this includes one is unable to determine if the members of the treatment team are qualified to perform the established procedures.

Based on review of open and closed medical records, the hospital failed to determine if 1 behavioral health patient had a behavioral health directive.
Patient #7 was admitted to an inpatient behavioral health unit on 9/23/2016. Patient #7 was asked if they had a medical advanced directive. There was no indication that patient #7 was asked if they had a behavioral health directive.

Based on the review of open and closed medical records, the hospital failed to document time accurately.
The medical record documenting system EPIC that is used by the hospital documents time in both military and standard methods. By using two different time methods there is no baseline for future actions or assessments.