HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure the following: 1. The patient or patient's representative is informed in advance of discontinuing care; 2. A Medicare beneficiary inpatient is provided the standardized notice, "An Important Message from Medicare"(IM), within 2 days of admission; and 3. The hospital has policies and procedures developed and implemented on determination of a patient's authorized representative. Six of six patients' records reviewed did not have evidence of meeting patient rights requirements.

Findings:

1. The hospital's medical records are partially electronic and partially paper. All documents that are to be signed by the patient or their representative are paper documents according to hospital staff. Five (#'s 1,2,3,4&5) of the six patient records reviewed did not have evidence of notification to the patient or patient's representative in advance of discharge.

2. Five (#'s 1,3,4,5 & 6) of six patient records reviewed did not evidence of the standardized notice, "An Important Message from Medicare"(IM), within 2 days of admission.

3. Hospital staff stated on 09/16/13 in the afternoon that the hospital did not have policies and procedures developed and implemented on determination of patient's authorized representative.

4. One (#3) of two patient records reviewed of two different hospital visits for the same patient did not have evidence in the record of the patient's Power of Attorney and Health Care Proxy. The records' facesheets documented there was no Power of Attorney and Health Care Proxy.

Based on policy and procedure review, medical record review and interview it was determined the hospital failed to prepare the patient or the patient ' s representative for post hospital care. This occurred in 5 of 6 (#1, 2, 3, 4 & #5) medical records reviewed.
Findings:
1. A Policy titled, " Discharge Planning " was provided to the surveyors on the afternoon of 09/16/2013. This policy documents " A registered nurse or social work will arrange for initial implementation of the discharge plan including ...written discharge instructions that are legible and use non-technical language ... " The hospital utilizes an electronic print out for discharge instructions. Although a copy of these instructions was found on the medical records reviewed, the instructions were not signed by the patient or patient ' s representative in 5 of 6 medical records reviewed. (#1, 2, 3, 4, & #5).

2. On the afternoon of 09/16/2013 Staff I stated that each patient receives discharge instructions that are printed out from the computer and a signed copy is placed into the medical record. 5 of 6 medical records (#1, 2, 3, 4, & #5) showed no evidence that the patient had received the discharge instructions. There was no documentation in the nurses notes that the patient had received any discharge instructions.

Based on medical record review, policy and procedure review and interview it was determined the hospital failed to send necessary medical information to appropriate facilities upon transfer of a patient. This occurred in 2 of 2 medical records reviewed. (#3 & #5)
Findings:
1. A policy titled " Discharge Policy " , dated, 07/2011 documented " ... a patient being discharged to a nursing home will have the transfer to nursing home form on the chart... " 2 of 2 medical records reviewed ( #3 & #5) where a patient was transferred to a nursing home did not contain this form.
2. A policy titled " Discharge Policy " , dated, 07/2011 documented " ... report will be called to the nursing home and charted in the record ... " 2 of 2 medical records reviewed (#3 & #5) where a patient was transferred to a nursing home did not contain evidence that report was given to the receiving facility.
3. On the afternoon of 09/16/2013 Staff I stated that a patient being discharged to a nursing home should have a " Nursing Home Transfer Record " included on the chart. 2 of 2 medical records reviewed (#3 & # 5) where a patient was transferred to a nursing home did not contain this form; this was verified at time of record review.