HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 4 of 14 (Patient #2, Patient #4, Patient #5, and Patient #6) 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 2 days of admission and/or not more than 2 days before the patient's discharge.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Important Message From Medicare," published 11/2019, indicated to inform Medicare inpatients of their Patient Rights upon admission and upon discharge following an inpatient admission. Hospitals must deliver the "Important Message from Medicare" within 2 calendar days of admission and must obtain the signature of the beneficiary or their patient representative. Hospitals must provide a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days prior to discharge. Should the notice be delivered on the day of discharge, the patient/patient representative has up to four hours to consider their right to request a discharge review by the Quality Improvement Organization (QIO).

-- Review of Patient #2's MR revealed they were admitted on 5/21/2025. There was no signed IM form as of 6/17/2025 (28 days after admission).

-- Review of Patient #4's MR revealed they were admitted on 6/14/2025. There was no signed IM form as of 6/17/2025 (3 days after admission).

-- Review of Patient #5's MR revealed they were admitted on 3/4/2025. There was no signed IM form as of 6/17/2025 (105 days after admission).

-- Review of Patient #6's MR revealed they were admitted on 4/4/2025 and discharged on 4/7/2025. There was no signed IM form.

-- During interview of Staff A, Program Manager, Clinical Regulatory and Policy Management on 6/18/2025 at 1:45 pm, they acknowledged the above findings.

Based on medical record (MR) review and interview, a patient, (Patient #1) while inpatient, reported a sexual assault to hospital staff. The MR lacked documentation that the patient was offered a Sexual Assault Nurse Exam (SANE) examination or that a physical exam was performed.

Findings include:

-- Per MR review, on 6/2/2025, Patient #1 reported to staff that they were a victim of sexual assault by Patient #2 while inpatient on the Behavioral Services Unit (BSU). There is no documentation in the MR that a physical examination was performed or that a SANE examination was offered by staff to Patient #1 following the report of sexual assault.

-- Per interview of Staff B, Clinical Staff, on 6/16/2025 at 11:15 am, a SANE examination was not brought up to Patient #1 following report of the sexual assault.

-- Per interview of Staff C, Clinical Staff, on 6/16/2025 at 12:15 pm, Patient #1 had not complained of any injuries or trauma following the reported sexual assault. Staff B did not feel that a SANE examination was necessary.

On 6/2/2025, after Patient #1's hospital discharge, they presented to the ED with police requesting a SANE examination, which was performed.