HospitalInspections.org

Based on review of facility documents, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to inform patients, or when appropriate, the patient ' s representative of their rights in advance of furnishing patient care by failing to provide the Important Message from Medicare (IMM) when appropriate for four of 14 medical records (MR5, MR7, MR9, and MR14).
Findings include:
On December 6, 2022, review of facility policy titled, "Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal," dated October 27, 2022, revealed, "...The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative...Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge..."
On December 6, 2022, MR5, MR7, MR9, and MR14 were reviewed and revealed that the facility failed to provide the IMM to patients or their representatives within two calendar days of their admission.
On December 6, 2022, at 1:30pm EMP3 confirmed the above findings.

Based upon a review of facility policies and procedures, facility documents, and staff interview (EMP), it was determined that the facility failed to ensure patients received an initial written response to grievances in a timely manner for three of five patient grievances reviewed (MR 11, MR13, and MR16).

Findings include:

A review of the facility ' s complaint and grievance log from August 2022, through December 6, 2022, was completed on December 6, 2022.

On December 6, 2022, a review of the facility ' s Patient Complaint Management and Grievance Process, dated April 28, 2022, revealed, "On average, a written response addressing resolution of the grievance will be sent to the patient/family within 7 business days of receipt of a grievance ... There are occasions when a grievance is complicated and may require an extensive investigation. If a grievance will not be resolved or if the investigation will not be completed within 7 days, the [Patient Representative] should inform the patient or the patient ' s representative of the need for additional time. Ideally, the grievance will be resolved in twenty-one (21) business days. However, there may be times when a longer response period is appropriate. "

On December 6, 2022, review of a grievance by MR11 was received by the patient representative (PR) on 09/24/2022. The initial letter to the patient, acknowledging the grievance and need for additional time, was sent on 10/10/2022; 11 business days after receipt of the formal grievance. Thus, exceeding the 7-day requirement outlined in the facility policy.

On December 6, 2022, review of a grievance by MR13 was received by the PR on 09/22/2022. The initial letter to the patient, acknowledging the grievance and need for additional time, was sent on 10/09/2022; 12 business days after receipt of the formal grievance. Thus, exceeding the 7-day requirement as outlined in the facility policy.

During an interview on December 6, 2022 at 02:45pm, EMP2 and EMP3 confirmed the above findings.

On December 6, 2022, review of a grievance by MR16 was received by the PR on 10/31/2022. There was no initial letter acknowledging the grievance, or final letter resolving the grievance.

During an interview on December 6, 2022, at 12:50 PM, EMP2 confirmed that the PR failed to send a letter to the patient, as per facility policy.

Based upon a review of facility policy and procedure, medical records (MR), and staff interview (EMP), the facility failed to obtain an order for the initiation of a vest restraint for two of three medical records revewed (MR5 and MR6).

Findings include:

On December 6, 2022, a review of the facility's policy Restraint and Seclusion, last reviewed July 1, 2022, revealed, "...A physician order, order of a CRNP or order of a PA is required for restraint use..... Verbal orders may be accepted for the initiation of a restraint order, and then followed by physician, CRNP or PA authentication according to institutional policy..... The RN may initiate the use of restraint in an emergent situation before a physician's, CRNP or PA order is obtained. The patient is to be seen by a physician and an order obtained for the restraint interventions when practical."

On December 6, 2022, a review of MR5 revealed that a vest restraint was initiated by the RN on 12/02/2022, at 7:33pm as the patient was, "trying to get OOB [out of bed], uncooperative." A physician's order for the vest restraint was obtained on 12/03/2022, at 00:32am, 5 hours after restraint initiation. There was no evidence of a verbal order in the medical record.

On December 6, 2022, a review of MR6 revealed that a vest restraint was initiated by the RN on 12/5/2022, at 11:00pm as, "Patient verbally aggressive, physical with wife and threatening. Pt. [patient] disoriented. Only oriented to self." A physician's order for the vest restraint was obtained on 12/6/2022, at 07:00am, 8 hours after the restraint initiation. There was no evidence of a verbal order in the medical record.

The above findings were validated and confirmed by EMP3 on December 6, 2022, at 1:12pm.