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Based on hospital policy and procedure review, medical record reviews and staff interviews, the hospital staff failed to provide the patient and/or the patient's representative with the Medicare Important Message (IM) form within two days of admission for 2 of 8 Medicare patients sampled (#3 and #6)

The findings include:

Review on 11/26/2013 of the hospital policy, "Medicare Discharge Appeal Rights", dated 11/2011 revealed "Every Medicare beneficiary admitted to or discharged from an inpatient status will be provided their Discharge Appeal Rights. The Important Message must be signed, dated and timed within two calendar days of admission by the beneficiary or appropriate representative defined by CMS (Centers for Medicare Services). The beneficiary or representative must also receive a follow up notice of their Discharge Appeal Rights no more than two days prior, but no less than four hours prior to discharge...The Case Manager will run the Medicare Important Message not Signed report from Bed Board in Meditech to identify and contact the appropriate representative and provide the: a. name and telephone number of contacting case manager, b. the anticipated date of discharge c. the beneficiary's right to appeal a discharge decision d. when (by what date/time) the appeal must be filed to take advantage of the liability protections e. mail notification of issuance to representative on same day via certified mail. 3. Case Manager will then provide documentation to demonstrate the: a. name and relationship of the representative to the beneficiary contacted, b. the date and time of the call, c. the information provided to the representative. 4. Every Monday, Wednesday and Friday a case manager will notify appropriate Medicare beneficiary or representative of the follow up Important Message and obtain their signature, date and time on the originial form. When direct contact cannot be made via telephone or in person to the represenatative of a beneficiary that is not able to sign the follow up Important Message, the case manager will certify mail the notification to the representative the same day..."

1. Closed record review on 11/26/2013 of Patient #3 revealed an 87 year-old female presented to the Emergency Department on 09/11/2013 and placed in observation status on 09/11/2013 at 1242. Continued review revealed the patient was admitted to an inpatient status on 09/12/2013 at 1050 with diagnosis of Pneumonia, Dehydration, Diabetes, and Weakness. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed an IM (Important Message from Medicare) form CMS-R-193 (approved 05/07) included in the patient's medical record. Review of the IM form revealed the section "Please sign and date here to show you received this notice and understand your rights" revealed "Pt (patient) unable to sign (secondary) confusion (without) family present. Copy left in room for family" signed by RN (registered nurse) dated 09/16/2013 (4 days after admission).

Further review revealed the patient was discharged from the hospital on 09/19/2013 at 1415. Review revealed no documentation of the IM form being delivered and signed 2 days prior to the discharge date.

Interview on 11/26/2013 at 1400 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview further revealed that the discharge planning staff were responsible for providing IM discharge appeal rights information to patients or patients' representative on Monday, Wednesday and Friday and obtaining a signed copy of the IM form for the patient's medical record. The staff member reviewed the IM form and confirmed the form was not signed and dated by the patient or the patient's representative. Interview confirmed the staff failed to follow the policy to provide the IM notice within two days of admission.




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2. Open record review on 11/26/2013 of Patient #6 revealed an 80 year-old female admitted 11/22/2013 at 2315 with syncope episodes. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed an IM (Important Message from Medicare) form CMS-R-193 (approved 05/07) included in the patient's medical record. Review of the IM form revealed the section "Please sign and date here to show you received this notice and understand your rights" was blank. Further review of the IM form revealed "Additional review of IMM with patient" was signed by a staff member on 11/25/2013 (three days after admission).

Interview on 11/26/2013 at 1735 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview further revealed that the discharge planning staff were responsible for providing IM discharge appeal rights information to patients or patients' representative on Monday, Wednesday and Friday and obtaining a signed copy of the IM form for the patient's medical record. The staff member reviewed the IM form and confirmed there was no signature of the patient or patient's representative. Interview confirmed the IM information was documented as being provided to the patient three days after admission. Interview confirmed the staff failed to follow the policy to provide the IM notice within two days.

Based on hospital policy and procedure review, grievance file review and staff interview, the hospital staff failed to provide written notice of the resolution of a grievance in 1 of 1 grievance files reviewed (Patient #3).

The findings include:

Review on 11/26/2013 of the hospital's policy and procedure,"Resolution of Patient & Customer Complaints and Concerns/Grievance Process", last revised date of 11/2013 revealed "...the source of complaints and grievances may include but are not limited to the patient, family members, and an employee or a visitor. The complaint/grievance may be issued verbally, by phone, in written form, via email...b. Grievance: 1. a patient grievance is a formal or informal written or verbal complaint that is made to the hospital by patient, or the patient's representative, regarding the patient's care that can not be resolved promptly upon the spot by staff present or 2. a complaint involving or alleging a violation of a patient's rights...Examples of grievances could be (but not limited to) the following:...lack of family involvement in care planning and treatment ...C. Grievances: 5. The department Manager/Director will document investigative findings and actions taken on the complaint thru the Meditech Risk Management System ...D. Response: 2. Grievances: the patient/customer will be notified of grievance closure/resolution in the form of a written letter by the Patient Advocate to the patient/customer filing the complaint within 10 days. For more complicated grievances requiring extensive investigation and analysis, the Patient Advocate will send a written interim response stating that the hospital is still working on the response, which they should expect within 30 days if at all possible ..."


1. Review of grievance file for Patient #3 revealed a family member reported a grievance on 09/12/2013 at 1600 regarding an allegation of "...communication that was shared was frustrating and confusing...questions the policy on releasing patient to (nursing homes) without consent...feels that her mother was rushed out due to the length of stay she had to be moved that day...she was not notified that her mother (#3) was placed in (name of Nursing Home) without permission, and they were not allowed to look into other options. They (the family) had asked when her mother (#3) was moved they wanted to be with her and they were not notified. They feel this was very traumatic to their mother not having anyone with her or anyone present when she arrived." The review revealed a verbal discussion by the Case Management Director with the family member regarding her complaint. Review of the file revealed an investigation was conducted and documented in the system on 10/18/2013 at 1316. File review revealed no documentation of a written notice of the resolution.

The customer service representation receiving the complaint was not available for interview.

Interview with 11/26/2013 at 1540 with Customer Service supervisor revealed there was no written notice of the resolution. The staff member stated "the daughter came into our office and spoke with (name) regarding her concerns and complaint...the 'complaint' was received on 09/12/2013 at 1600 but was not entered into the computer system until 10/18/2013 because the person taking the complaint was on a leave of absence and entered it in the system upon her return. (Name) thought the complaint had been resolved prior to the patient leaving the hospital so we would not have sent a resolution letter." Interview confirmed there was no documentation of the resolution of the grievance. Interview confirmed no letter of resolution sent to the complainant. Interview confirmed the staff did not follow the hospital's grievance policy.

NC00092055