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Based on record review and interview, facility staff failed to inform patients of their Medicare discharge rights upon admission for 1 of 7 Medicare-eligible inpatients (Patient #1) and failed to inform patients of their rights upon discharge for 3 of 7 discharged patients reviewed (Patients #2 , #4, and #9), in a total sample of 10.

Findings include:

Review of the facility's policy "Important Message from Medicare (IM) And Inpatient Discharge Appeal Process" last revised 4/2021 under Procedure revealed "Hospital personnel must provide the IM at or near admission but no later than 48 hours from the day of admission... The follow-up IM must be provided to the patient as soon as possible prior to discharge."

Per medical record review, Patient #1 was a 72-year-old admitted to the facility on 5/30/2021 with the diagnosis of respiratory distress, pneumonia and sepsis and discharged 6/06/2021. There was no follow-up IM provided prior to discharge.

On 9/23/2021 at 3:11 PM during interview with Acute Care Coordinator Manager F, Manager F confirmed there was no Important Message from Medicare notice given to Patient #1 or their activated Power of Attorney on discharge.

Per medical record review, Patient #2 was a 74-year-old admitted to the facility on 6/03/2021 at 6:16 PM with the diagnosis of dyspnea and acute kidney failure and discharged 6/06/2021. Patient #2's Important Message from Medicare was signed on 6/06/2021 at 10:50 AM, more than 48 hours after admission. There was no Important Message provided on admission.

During interview on 9/23/2021 at 4:12 PM with Informatics Nurse Specialist E, E stated there was no Important Message from Medicare notice provided to Patient #2 within 48 hours after admission.

Per medical record review, Patient #4 was a 77-year-old admitted to the facility on 9/08/2021 with the diagnosis of obstructing nephrolithiasis, urinary tract infection and septic shock and discharged 9/13/2021. Patient #4's verbal consent for the Important Message from Medicare was given 9/13/2021, more than 48 hours after admission. There was no Important Message provided on admission.

During interview on 9/24/2021 at 12:35 PM with Informatics Nurse Specialist R, R stated there was no Important Message from Medicare notice given to Patient #4 within 48 hours after admission.



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Per medical record review, Patient #9 was a 78-year-old admitted to the facility on 09/03/2021 with the diagnosis of altered mental status due to a urinary tract infection and discharged on 09/09/2021. There was no follow-up IMM provided prior to discharge.

During an interview with RN Supervisor O on 09/24/2021 at 1:12 PM, when asked to confirm that there no documentation found of an IMM being provided prior to discharge, O stated, "Correct."

Based on record review and interview, the facility failed to address or provide information on Advance Directives in 1 of 10 (Patient #2) inpatient record reviewed, in a total sample of 10.

Findings include:

Record review of policy "Advance Care Planning (ACP) System" last revised 11/2020 under Assessment revealed "Upon admission in a hospital setting... nursing staff will assess adult patients for Advance Care Planning needs." Under Implementation revealed "If the patient or family member wishes to complete or change an Advance Directive, the patient should be referred to a social worker." Under Addendum: Advance Care Planning Roles and Responsibilities, Care Coordination or Social Worker revealed "Provide information and assist in completion of document, and Document as needed in the... electronic or paper medical record."

Per medical record review, Patient #2 was admitted 6/03/2021. Nursing admission assessment dated 6/04/21 at 1:13 PM revealed patient #2 requested information on advanced directives. No follow-up of request for information on advanced directive documented in the medical record.

During interview on 9/23/2021 at 3:38 PM with Acute Care Coordinator Manager F, Manager F confirmed there was no assistance with completion of an advanced directive documented in Patient #2's medical record.

Based on record review and interview, facility staff failed to perform and document interventions prior to discharge (intravenous [IV] catheter removal) for 1 of 10 patients (Patient #6) and failed to document a nursing note upon discharge for 1 of 10 patients (Patient #7) out of a total of 10 medical records reviewed.

Findings include:

A review of the facility's policy titled, "Nursing Clinical Documentation Guidelines (System)," last revised 04/2021 revealed, " ...I. Documentation will be patient-centered and interdisciplinary, showing the care and treatment delivered and the patients' progress related to nursing interventions, nursing outcomes and nursing diagnosis in meeting expected outcomes ...Clinicians are accountable to document diagnoses, patient care data, information related to admissions, assessments, evaluations, interventions, plan of care, education, and the patient's response to treatment ...Interdisciplinary team members are accountable to document patient care data ...education/interventions/services provided ..."

A review of the facility's document titled, "OCU (Oncology Care Unit) Documentation Reminder" revealed a checklist for, "Discharge to Home." Items on the checklist include, " ...Remove IV ...Review and educate patient on AVS (After Visit Summary; Discharge Instructions) ...Remove IV/lines from [electronic health record] ...Fastnote on discharge ..."

A review of Patient #6's medical record was conducted on 09/23/2021 at 11:31 AM with Informatics Nurse Specialist E who confirmed the following per interview:

Patient #6 was a 27-year old admitted to the facility on 09/05/2021 with a diagnosis of acute encephalopathy (altered brain function) following a fall at home and severe anorexia (an eating disorder characterized by low weight, food restriction, and fear of gaining weight). The documentation revealed that Patient #6 had a 22 gauge peripheral IV catheter in place in the left forearm and an 18 gauge peripheral IV catheter in place in the right forearm on admission from the Emergency Department.

Discharge was ordered by the physician on 09/07/2021 at 3:49 PM.

Patient #6 was discharged to home on 09/07/2021 at 5:15 PM.

A review of the nursing flowsheets titled, "Daily Cares/Safety," "Head to Toe," or the "LDA (Lines, Drains, Airway) Avatar" revealed no evidence that the IVs were documented as removed prior to discharge.

Patient #6 presented to another acute care facility at 7:15 PM, 2 hours later, with bilateral arm IVs noted still in place.

When asked if it was expected that nursing staff document IV removal, E stated, "I would say yes."

During a telephone interview with Registered Nurse G on 09/23/2021 at 2:09 PM, when asked if s/he recalled whether or not #6 had IVs in place or whether s/he had removed any IVs prior to discharge, G stated, "I don't recall. It would be documented in the LDAs (Lines, Drains, Airways flowsheet)."

A review of Patient #7's medical record was conducted on 09/24/2021 at 10:50 AM with Registered Nurse Supervisor O who confirmed the following per interview:

Patient #7 was admitted to the facility on 09/01/2021 with a diagnosis of alcohol withdrawal.

Patient #7 was discharged from the facility on 09/04/2021. There was no evidence found that a nursing discharge note was documented indicating that discharge instructions were reviewed with Patient #7, the discharge disposition, the mode of transport, or the time of discharge.

When asked for nursing documentation regarding #7's discharge, O stated, "I'm not seeing anything." When asked if s/he would expect to see a note regarding discharge, O stated, "I would expect to see something in the Transfer/Discharge area or a nursing note."