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Based on interview, policy review and record review, the facility failed to ensure that Medicare Beneficiary's received the Important Message From Medicare (IM) for one current patient (#20) and three discharged patients (#45, #46 and #47) of four patients that were discharged from the Behavior Health Unit (BHU) and re-admitted to an inpatient unit. This failed practice had the potential to affect any patients discharged from the BHU and then admitted to a medical unit from receiving their discharge or discharge appeal options as a Medicare Beneficiary. The facility census was 571.

Findings included:

1. Record review of the Management Policy and Procedure Manual titled, "Important Message From Medicare - June 2011," revised 01/2014, showed the following direction:
- Designated hospital co-workers must deliver a valid, written notice of a Medicare beneficiary's rights as an inpatient, including discharge appeal rights. Designated hospital co-workers will use the IM, a statutorily required notice to explain these rights.
- The IM is required for beneficiaries enrolled in traditional Medicare . . . entitled to benefits under Medicare Part A.
- Designated co-workers are responsible for the delivery of the IM to the beneficiary.
- The original copy of the signed IM is given to the beneficiary and a copy is placed in the medical record.

Record review of the Admitting Policy and Procedure titled, "Important Message From Medicare/Tricare," reviewed 04/2011, showed the following direction:
- All patients presenting for services in which they may be admitted will receive and be asked to sign the IM.
- The Admitting Department will be responsible for explaining the IM to all patients presenting for services which may result in admission to a bedded unit.
- The IM must be issued to enrollees within 24 hours of their admission.

2. Record review of Patient #20's face sheet showed that he had been admitted to the Medical/Surgical Intensive Care Unit (MS ICU, a special department of a hospital that provides specialized care by specially trained staff for seriously ill patients) on 07/09/16. The record showed that he was a Medicare Beneficiary but a copy of his signed and dated IM for that admission was not evidenced in his medical record. Record review showed that he had received an IM upon admission to the Behavioral Health Adult Unit (BHAU) on 06/29/16 but not for his discharge on 07/09/16.

During an interview on 07/12/16 at 1:00 PM, Staff N, Registered Nurse (RN), Case Manager, stated that Patient Administration should have delivered the first IM and then Case Management should have delivered the discharge and/or transfer IM. She stated that Staff O was the Manager of Patient Access and the designated co-worker in charge of the process.

During an interview on 07/12/16 at 2:30 PM, Staff O, Manager of Patient Access, stated that the patient was 'transferred' from the BHAU to the MS ICU but that it required the patient to be discharged from the BHAU and admitted as an inpatient to the MS ICU and would have required three IM's to be delivered to the patient:
- An IM upon admission to the BHAU;
- An IM upon discharge to the BHAU; and
- An IM upon admission to the MS ICU.

During an interview on 07/12/16 at 3:15 PM, Staff Q, Executive Director of Patient Access, who had signed the final review and approval for the Management Policy and Procedure Manual titled, "Important Message From Medicare - June 2011," stated that evidently there were gaps in the process. She stated that in the case of Patient #20 that he should have received an admission and discharge IM for each and every admission.

3. Record review of Medicare Beneficiary 'transfers' from the BHAU to other facility medical units from 04/01/16 to 07/12/16 showed the following:
- Patient #45 was admitted to the BHAU on 04/24/16 and discharged to the MS ICU on 04/27/16. The medical record showed an admission IM on 04/24/16 but did not have evidence of a discharge IM or another admission IM to the MS ICU for the date of 04/27/16.
- Patient #46 was admitted to the BHAU on 03/29/16 and discharged to the MS ICU on 05/05/16. The medical record showed an admission IM on 03/29/16 but did not have evidence of a discharge IM or another admission IM to the MS ICU for the date of 05/05/16.
- Patient #47 was admitted to the BHAU on 06/02/16 and discharged to the Trauma/Neurology ICU (intensive care unit for serious head/brain injuries) on 06/05/16. The medical record showed an admission IM on 06/02/16 but did not have evidence of a discharge IM or another admission IM to the MS ICU for the date of 06/05/16.

Based on interview, record review and policy review, the facility failed to question any of the adult female inpatients on the mother/baby, obstetric units (OB), including labor and delivery (fifth, sixth and seventh floors, capacity of 141, current census of 73), and antepartum units (a pre-birth unit on the seventh floor, capacity of 16, current census of nine) if they had an advance directive (a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) and/or wanted to formulate one. They also failed to locate an advance directive for one patient (#38) of two patient records reviewed and to retrieve the document when it was identified as received.
This had the potential to affect all patients who have the right to formulate an advance directive. The facility census was 571.

Findings included:

1. Record review of the facility's policy titled, "Basic Statement of Rights and Responsibilities of Patients," revised 05/2014, showed patients have a right to formulate advance directives and have hospital staff comply.

Record review of the facility's policy titled, "Advance Directive Policy," dated 09/05/12, showed the following:
- All individuals receiving care have the right to formulate advance directives.
- Staff will have a conversation with patients regarding advance directives at or near the time of admission.
- If the patient has an advance directive, confirm it is still in effect and ask for a copy for the record.
- Follow-up to obtain a copy of the signed advance directive.

2. Record review of the facility's educational content (provided to staff in orientation and annually) showed the following:
- Staff must offer information to patients or representatives on the right to formulate written advance directives.
- Having an advance directive is important for everyone, young or old, since accidents and illness can strike at any age.
- The hospital can't honor the advance directive if it is not in the record.

3. During an interview on 07/12/16 at 10:00 AM, Staff K, Manager of the sixth floor mother/baby unit stated that staff did not ask patients on this unit if they had, or wanted to formulate, an advance directive. Staff K stated that this was true for all the mother/baby units, including antepartum.

During an interview on 07/13/16 at 10:10 AM, Patient #41, a patient admitted to the fifth floor mother/baby unit on 07/11/16, stated that staff had not asked her if she had, or wanted to formulate an advance directive.

During an interview on 07/13/16 at 10:18 AM, Patient #42, a patient admitted to the fifth floor mother/baby unit on 07/12/16, stated that staff had not asked her if she had, or wanted to formulate an advance directive.

During an interview on 07/13/16 at 12:45 PM, Staff BB, Director of Pastoral Services, (department that coordinates advance directive process in this hospital) stated that he would expect the mothers on the OB units to be asked about an advance directive like any other patient.

4. Record review of Physician History and Physical (H&P- document created by the physician to outline the patient's condition upon admission) showed Patient #38 was transferred from another hospital for admission to facility's Intensive Care Unit (ICU) on 07/04/16 for treatment and further evaluation of a subdural head bleed (collection of blood on the surface of the brain).

Record review of Patient #38's Electronic Medical Record (EMR) on 07/12/16 at 2:30 PM, in a section identified as "Demographics," (area where specific personal patient information is stored) showed a line item of, "Advance Directive, Living Will," marked as "received" on 07/04/16.

During a concurrent interview and review of Patient #38's medical record on 07/12/16 at 2:45 PM, Staff S, Registered Nurse (RN), Third Floor Supervisor, stated that he could not locate the advance directive in the record. Staff S also reviewed the "paper lite chart," (patient specific binder that holds non electronic documents until they can be scanned into system) but the advance directive was not located. Staff S stated that he could not explain why the document could not be located.

During an interview on 07/12/16 at 3:00 PM, Staff X, RN, Third Floor Nurse Manager stated that she did not know why the document was not found. Staff X stated that advance directives were not currently monitored to ensure they are available if they would be needed. Staff X stated that they used to have a process but was not sure why it stopped.

During an interview on 07/13/16 at 12:45 PM, Staff BB, Director of Pastoral Services, stated that the registration staff has the ability to, and should, scan the document into the system when they mark it "received."

During an interview on 07/13/16 at 1:15 PM, Staff D, RN, Patient Safety Manager, stated that Medical Records could not locate Patient #38's advance directive in the patient's record and that she has not been able to contact the registration staff member to discuss what may have happened to this document.

Neither Patient #38, or the family, was interviewable during the survey.





29511

Based on observation, interview, policy review and record review, the facility failed to ensure that all 4,843 appropriate (physicians, nurse practitioners, nurses, patient care technicians, medical assistants and security) staff who apply restraint or seclusion, monitor, access or provide care for a patient in restraint or seclusion were educated on first aid response techniques related to restrained patients. This failure had the potential for serious injury or death to any patients that required restraints in the facility. The facility census was 571.

Findings included:

1. Record review of the administrative policy and procedure manual titled, "Restraints, Seclusion, Protective/Assistive Devices," revised 01/2014, failed to show any provision for First Aid in Restraint Training for staff as required by the Centers of Medicare & Medicaid Services (CMS).

2. Record review of the facility document titled, "Restraint Competency," dated 12/2012, failed to show any evidence that specialized training or demonstrated knowledge of competency for First Aid in Restraint Training was required to be completed.

3. Record review of the facility document titled, "Annual Regulatory Education for Co-Workers in Hospitals with Patient Contact 2016," showed pictures of the on-line (electronic) version of the education required for staff to complete. The educational training did not contain the specialized training for immediate interventions and demonstrated knowledge required by CMS for patients in restraints.

4. Observations on 07/12/16 showed 17 patients currently in restraints on the following hospital units:
- Medical/Surgical Intensive Care Unit (MS ICU, an ICU is a special department of a hospital that provides specialized care by specially trained staff for seriously ill patients);
- Burn ICU;
- Trauma/Neurological (Trauma/Neuro ICU, intensive care unit for serious head/brain injuries);
- Behavioral Health (BHU) Adult 5 West;
- Pediatric ICU Unit 3; and
- Orthopedics (prevention and correction of injuries or disorders of the skeletal system and associated muscles, joints, and ligaments).

5. Record review of the personnel file for Staff P, Registered Nurse (RN), Emergency Department (ED), showed no evidence for First Aid in Restraint Training.

During an interview on 07/12/16 at 4:00 PM, Staff R, Senior Human Relations Manager, stated that he was not aware that any of the personnel files contained evidence of any specialized First Aid in Restraint Training.

During an interview on 07/13/16 at 10:40 AM, Staff Y, RN, Nurse Manager, ED, Nurse Educator, stated that the ED staff did not receive any specific First Aid in Restraint Training.