HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the protection of patient rights when:

1. Nine of 23 sampled patients (Patients 3, 4, 5, 14, 23, 24, 26, 27, and 28) with Medicare benefits (a federal health insurance program) did not receive, within the required timeframes, the "Important Message from Medicare" notice informing them of their rights as patients to appeal a hospital's decision to discharge and express concerns about completeness their care (refer to A-0117), and

2. Two of 5 (Patients 9 and 25) sampled patients who were in restraints (physical devices used to limit a patient's movement or behavior for medical purposes to prevent injury or harm) did not have documentation of restraint use included in their plan of care (refer to A-0166).

These failures had the potential for patients and providers not to effectively communicate about patients' care putting patients at risk for harm and care not consistent with their wishes.

The cumulative effects of these failures resulted in the inability of the hospital to comply with the statutory mandated Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to inform patients of their rights as Medicare beneficiaries (federal health insurance program) to appeal hospital discharge when:

1. Two of 23 patients with Medicare benefits (Patient 3 and Patient 24) did not receive the "Important Message from Medicare" (IMM- an appeal process where you can dispute a hospital's decision to discharge from the hospital) within two days of admission, and

2. Seven of 23 Medicare patients (Patients 4, 5, 14, 23, 26, 27, and 28) did not receive IMM within two days of discharge.

These failures resulted in Medicare beneficiaries not receiving timely information of their rights as hospital in-patients and their right to appeal hospital discharge and had the potential to result in delay in reporting their concerns about the quality and completeness of their care while hospitalized.

Findings:

1. During a review of Patient 3's History and Physical (H&P), dated 2/11/25, the H&P indicated Patient 3 was admitted to the hospital on 2/11/25 with syncope (sudden, temporary loss of consciousness caused by insufficient blood flow to the brain). The H&P indicated Patient 3's medical history included alcohol use disorder (pattern of alcohol use that involves problems controlling drinking or continuing to use alcohol even when it causes problems).

In a concurrent interview and record review, on 4/16/25, at 1:50 p.m., with Revenue Cycle Manager (RCM), Patient 3's admission documents were reviewed. RCM stated Patient 3 had admission orders written 2/11/25 and had no record of receipt of IMM until 2/14/25. RCM stated Patient 3 "did not receive IMM within two days of admission as required."

A record review of Patient 24's H&P, dated 3/13/25, indicated this patient had a diagnosis of dementia (progressive loss of brain functions including memory, language, problem-solving and changes in mood, behavior including increased irritability, agitation, or withdrawal) and arrived at the emergency department for evaluation of an unwitnessed fall. According to the H&P, Patient 24 was not able to provide history, was mumbling and crying. An x-ray was done and noted a broken hip bone.

In a concurrent interview and record review, on 4/17/25, at 9:17 a.m., with the Coordination of Care Service Director (CCSD), the CCSD could not locate evidence that Patient 24 was provided with the IMM notice at time of admission. CCSD stated despite being a short admission, an initial IMM notice is required; however, it appeared to be missing.

2. During a review of Patient 4's H&P, dated 3/3/25, H&P indicated Patient 4 presented to the hospital on 3/3/25 with confusion and disorientation. The H&P indicated Patient 4's medical history included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), and a previous cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). Patient 4's medical record (MR) indicated, after a period of observation, Patient 4 was admitted as an in-patient to the hospital on 3/4/25.

In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 4's MR was reviewed. CCSD stated care coordination staff needed to deliver an additional IMM to Medicare patients within two days of discharge if discharge was greater than two days after receiving the initial message. CCSD confirmed the physician placed an order to discharge Patient 4 on 3/8/25 and stated there was no evidence in the MR that Patient 4 received the IMM within two days of the discharge order as required.

During a review of Patient 5's H&P, dated 3/11/25, the H&P indicated Patient 5 presented to the hospital on 3/11/25 with progressive fatigue and shortness of breath. H&P indicated Patient 5's medical history included COPD, CHF, and peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs). Patient 5's MR indicated, after a period of observation, Patient 5 was admitted as an inpatient to the hospital on 3/14/25.

In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 5's MR was reviewed. CCSD stated the physician placed an order to discharge Patient 5 on 3/25/25 and stated there was no evidence in the MR that Patient 5 received the IMM within two days of the discharge order.

During a review of Patient 14's H&P, dated 2/11/25, the H&P indicated Patient 14 presented to the hospital on 2/11/25 with leg pain after a fall. The H&P indicated Patient 14's medical history included kidney failure (body organ that filters waste and extra fluid from your blood no longer works). Patient 14's MR indicated, after a period of observation, Patient 14 was admitted as an inpatient to the hospital on 2/12/25.

In a concurrent interview and record review, on 4/16/25, at 2:10 p.m., with CCSD, Patient 14's MR was reviewed. CCSD stated the physician placed an order to discharge Patient 14 on 2/18/25 and stated there was no evidence in the MR that Patient 14 received the IMM within two days of the discharge order.

A record review of Patient 23's H&P, dated 3/8/25, noted Patient 23 had stomach cancer and was on chemotherapy (medication used to treat cancer)> Patient 23 was evaluated in the emergency department and noted to have an inflamed lower gut and a hole in the stomach.

During concurrent record review and interview with Quality Nurse Consultant (QNC), on 4/16/25, at 11:12 a.m., QNC stated the physician discharge order for Patient 23 was written for 3/16/25 at 1:30 p.m. and no follow-up IMM notice was found in Patient 23's medical records.

On 4/17/25 at 9:17 a.m., concurrent interview and record review of Patient 23's scanned medical documents with CCSD verified the follow-up IMM notice was not present. CCSD stated the follow-up IMM should be given to patients at time of discharge.

A record review of Patient 26's H&P, dated 3/12/25, noted Patient 26 arrived at the emergency department on 3/12/25, at 6:06 a.m., due to a fall and loss of consciousness. This patient had a history of diabetes, (a disorder characterized by difficulty in blood sugar control and poor wound healing), CVA, multiple cancers, and high blood pressure. Patient 26 was diagnosed and treated for a urinary tract infection (bacteria enters the opening to the body's drainage system for removing urine). A physician discharge order for Patient 26 was written for 3/16/25, at 2:45 p.m.

On 4/17/25, at 9:41 a.m., during a concurrent record review of Patient 26's MR and interview with CCSD, no follow-up IMM notice was found. CCSD stated patients should receive a follow-up IMM notice prior to discharge; however, no IMM can be found for Patient 26.

A record review of Patient 27's discharge summary physician note, dated 3/23/25, indicated Patient 27 had previous tobacco smoking and unhealthy alcohol drinking. Patient 27 reportedly slipped off her wheelchair and fell on her left side. Patient 27 was admitted on 3/18/25 as an in-patient for a hip and leg bone breaks in three or more pieces.

On 4/17/25, at 9:17 a.m., during a concurrent record review of Patient 27's MR and interview with CCSD, the record indicated a physician discharge order was written for 3/23/25, at 1:00 p.m. The CCSD confirmed the record only contained a receipt of the IMM at time of admission on 3/19/25, and there was not a receipt of a follow-up IMM notice given within two days of discharge. CCSD confirmed this notice was required.

A record review of Patient 28's H&P, dated 3/18/25, noted Patient 28 was brought to the emergency department after he was found unconscious. In the emergency department, he was found to have low levels of oxygen and an irregular heartbeat.

On 4/17/25, at 9:41 a.m. during concurrent record review of Patient 28's MR and interview with CCSD, the physician discharge order indicated to discharge patient home on 3/22/25 at 11:30 a.m. CCSD stated there was no follow-up IMM notice in the MR. CCSD stated patients should receive a follow-up IMM notice prior to discharge; however, no IMM can be found for Patient 28.

In a review of facility policy and procedure (P&P) titled, "CMS [Center for Medicare Services] Important Message NCAL [Northern California] Regional Policy", dated 1/8/25, P&P indicated "When a Medicare patient presents at the hospital for inpatient admission, the Admitting Department will provide the patient with a copy of the 'Important Message'. ...The 'Important Message' can be completed at the time of admission or ...if no one is available at the time of admission, the Admitting Staff will continue to try and obtain a signature within 2 calendar days of admission. ...Follow-up copy of the Important Message: If the patient is in the hospital for more than 2 calendar days after receiving the notice, the patient must again be presented with the notice as far as possible but no more than 2 calendar days prior to discharge."

Based on interview and record review, the facility failed to follow its policy and procedures to initiate and document restraint use (physical devices used to limit a patient's movement or behavior for medical purposes) in patient care plans for two of five sampled patients in restraints, (Patient 25 and Patient 9).

This failure precluded members of the healthcare team from having necessary information on which to base clinical decisions in a timely manner and had potential to put Patient 25 and 9 at risk for errors and harm made by providers who relied on the content of these records for care decisions.

Findings:

In a review of Patient 25's History and Physical (H&P), dated 4/7/25, the H&P indicated Patient 25 arrived at the emergency department with altered mental status (confusion), generalized weakness after falling in the bathroom, and unknown head trauma (injury to scalp, skull, or brain caused by an external force). Patient 25 was unable to recall the reason he was brought to the hospital. Patient 25 was admitted to the Intensive Care Unit (ICU).

In a review of an ICU RN (Registered Nurse) End-of-Shift Team Note, dated 4/7/25, the Note indicated as day progressed, Patient 25 became more confused, attempting to climb out of bed, and staff was unable to re-direct patient.

Review of physician order, dated 4/9/25, indicated mitten restraints ( a glove-like device used to cover the hand to prevent patient's from dislodging medical equipment) ordered to both hands due to Patient 25 pulling out intravenous (IV) line (tubing inserted to the patient's in which fluids and medications are administered to patient via their blood vessels) and dressings (gauze material to cover up wounds and/or IV lines).

On 4/17/25, at 8:56 a.m., during concurrent interview and record review of Patient 25's care plan records, the Quality Nurse Consultant (QNC) was unable to locate documentation for use of restraints in Patient 25's care plan records. QNC confirmed restraint usage was not documented in the care plan and should be according to policy and procedure.

In a review of Patient 9's H&P physician progress record, dated 2/2/25, H&P indicated Patient 9 was injured in a boating accident resulting in a cervical-7 fracture (broken neck bone) and a subarachnoid hemorrhage (a brain injury associated with bleeding in the spaces between the brain and the tissue surrounding the brain).

On 2/2/25, a physician's order was written for right wrist soft limb restraint (a cuff and strap device used to restrict the movement of the patient's arm) due to pulling at IV line and pulling at dressings.

On 4/17/25, at 8:56 a.m., during concurrent interview and record review of Patient 9's care plan records with QNC, QNC was unable to locate documentation for use of restraints in Patient 9's care plan records. QNC confirmed restraint usage was not documented in the care plan and should be according to policy and procedure.

A review of the facility policy and procedure (P&P) titled, "Restraints NCAL [Northern California] Regional Policy," dated 12/6/23, indicated, "Documentation Requirements: When restraint is used, there must be documentation in the patient's medical record of the following:... The use of a restraint shall be reflected in the patient's plan of care or treatment plan ..."