HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 3 of 7 (Patients #2 - #4) MRs reviewed for Medicare beneficiary patients, the hospital did not ensure the required form titled "The Important Message From Medicare" (IM) was provided to the patients within two days of admission as required. This could cause patients and/or their representatives to be unaware of their patient rights.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Important Message From Medicare," dated 1/2018, indicated all Medicare beneficiaries should be provided the IM. The hospital should explain and obtain the signature from the patient or their representative on the IM form on admission or within 2 days of admission. If the form is not signed on admission, patient access staff should communicate to clinical staff that the form needs to be signed by the patient or representative.

-- Review of Patient #2's MR revealed, he was admitted on 10/30/19. There was no signed IM form as of 11/5/19 (6 days after admission).

-- Review of Patient #3's MR revealed, she was admitted on 10/31/19. There was no signed IM form as of 11/5/19 (5 days after admission).

-- Review of Patient #4's MR revealed, she was admitted on 10/24/19. The IM form was completed on 10/29/19 (5 days after admission).

-- During interview of Staff K, Registered Nurse (RN) on 11/6/19 at 9:00 am, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, 1) in 6 of 10 MRs (Patients #1 - #6 ) reviewed, there was no documentation indicating, that at the time of the patient's admission to the hospital, the patient was asked whether he/she wanted his/her own physician notified of admission to the hospital. 2) In 1 of 10 MRs (Patient #7) reviewed, there was no documentation indicating the patient's physician was notified after he/she made the request. This could impact continuity of patient care.

Findings regarding (1) include:

-- Review of the hospital's policy and procedure (P&P) titled "Patient Rights and Responsibilities," dated 1/2018, indicated during the inpatient admission process, the patient registration representative will present the form titled "Provider and Family Notification" to the patient/legal representative to document their wishes to have their provider notified of their admission. If notification is requested, the registration staff should print the face sheet from the MR and fax to the providers office. The completed document should be scanned into the MR.

-- Review of Patient #1 - Patient #6 MRs, each lacked documentation the patients were asked whether they wanted their own physician notified of admission to the hospital.

-- Review of Patient #7's MR revealed she requested her own physician be notified of her admission. The form titled "Provider and Family Notification," dated 1/2018, lacked documentation that the information had been faxed to her provider.

-- During interview of Staff K, Registered Nurse (RN), on 11/6/19 at 9:00 am, he/she acknowledged the above findings.