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Based on a review of 6 open and 4 closed medical records the hospital failed to provide 2 Medicare recipients with the standardized notice, "An Important Message from Medicare," (IMM) within the appropriate time frame.

A review of patient #7's closed medical record revealed no evidence or documentation of a second IMM given before discharge after a stay of 5 days. On review of an open record for patient #2, no initial IMM was found though the patient had been admitted for greater than a week's time.

Based on an onsite survey including a review of restraint training, it was determined that the hospital had failed to implement a corrective action arising from a citation related to staff training elements following a survey done in May, 2018. The hospital's current training curriculum for safe application of restraints remained deficient in that it did not specifically prohibit prone restraints, nor did it state that anyone being taken down in a forward position would immediately be turned supine.

The plan of correction (POC) from the May survey stated training instructions would be revised to state that anyone taken down in a prone position would be immediately turned on his or her back. The training was also to mandate that staff were never to use a prone position to restrain a patient. Additionally, instruction was to be revised to include training on the signs and symptoms of patient distress while in restraint. The POC further stated that security staff was educated of process changes via email and review during staff meetings and that the education was to continue through July 2018.

Interview with the Security Manager on 10/17/2018 at approximately 1030 revealed that retraining had been done with new hires, but not with existing staff who, contrary to the POC, would not be trained until Spring 2019 when annual restraint training was due. The hospital was again cited for the possibility of patients being placed and held in an unsafe prone position, and staff being unable to determined when a restrained patient is in distress.

Based on an onsite condition of participation survey, it was determined that, without appropriate training or oversight, the hospital allowed unit secretaries from a medical-surgical unit to access the pharmacy tube system, place incoming medications into the locked drawers of patients, and on discharge, remove remaining medications for transfer back to the pharmacy.

Review of a medical-surgical unit on 10/17/2018 included an interview with a nurse manager and an inquiry into the frequency of pharmacy staff coming to the unit to bring medications and review for expired medications. The RN stated that the unit used a tube system, and each morning, the Charge RN checked the tube for medications sent by the pharmacy. The RN then placed those medications into the combination-locked patient drawers. However, throughout the day, the unit secretary accessed the tube and placed incoming medications into the patient drawers. The secretaries had the combination to the patient medication drawers, which was confirmed by the RN, who further stated that all drawers have the same combination.

Review of the unit secretary job description revealed, "Assist nurse with delivery from Pharmacy of non-controlled medications to support patient care." A query for secretarial training related to this duty revealed a general medication safety training given to all employees at orientation, which contained nothing specific to accurately delivering medications into patient drawers. Further, no oversight of secretaries related to the handling of medications was found.

A review of the medication administration system revealed a bar-code system which could prevent a medication error if a secretary placed medication into the wrong drawer, but also revealed that RNs could override the barcode system at will. The hospital demonstrated multiple concerns for the safety of medication administration and the oversight of employees working outside their scope of training.

Based on review of 6 open and 4 closed medical records it was determined that the hospital's staff to document the patient's response to services throughout their admission after undergoing a hip repair surgery.

Patient #7 was an 85+ year old who presented to the hospital's emergency department (ED) after sustaining a fall. In the (ED) it was discovered patient had a left femoral neck fracture. Patient #7 was admitted to the hospital that same day and underwent a hip surgery to repair the fracture on the second day of admission. Per operative note, there were no complications. A post-surgery X-ray of the hip showed "No fracture or dislocation." Patient received Physical Therapy and Occupational Therapy following the hip surgery and was discharged in stable condition per hospital's hospitalist on the 5th day of admission to a rehabilitation facility.

The hospitalist's discharge summary stated "for orthopedic recommendation see orthopedic discharge recommendation" as well as "orthopedics cleared patient for discharge." A document titled "Discharge Instructions Orthopedics" was dated the day of surgery that provided discharge and follow up instructions. There was no evidence found in the chart that the orthopedic surgeon saw the patient after the day of surgery to assess patient.

Nursing staff also failed to document a motor strength assessment that assessed the strength of all extremities for the last three days of patient #7's admission.

The patient was found to have a dislocated hip shortly after discharge. While there were orthopedic discharge instructions, the lack of a documented orthopedic evaluation post-surgery coincident with the discharge, made it impossible to determine if the dislocation occurred in the hospital or at the post-acute location.