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Based on clinical record reviews and interviews the facility failed to inform 2 of 5 sampled patients of their rights, in advance of furnishing or discontinuing care as evidenced by failure to provide Medicare notices as required.

The findings include:


Patient # 11, insured by Medicare, was admitted to the facility on 11/24/12. Document titled " The Important Message from Medicare About Your Rights " (IM) was presented and signed by the patient on 11/27/12. The facility did not present the copy of the IM within two calendar days before the patient's discharge on 12/04/12.

Patient # 12, insured by Medicare, was admitted to the facility on 11/02/12. The record failed to provide the evidence of the document titled "The Important Message from Medicare About Your Rights." The patient was discharged on 11/06/12.

Facility policy titled " Procedure for the Important Message From Medicare " effective 09/01/12 documents " In compliance with CMS regulations, all patients admitted as in patients will be requested to date and sign the Important Message from Medicare at or near admission, but not later than two calendar days following the date of admission to the hospital." The policy did not address that notices should be given within two calendar days prior to discharge.

Interview with the Case Manager (CM) was conducted on 12/13/12 at 8:48 AM. The CM explained it is the responsibility of the case manager to provide the Medicare Notices; the notices are given to patients every three days.

Subsequent interview with the Risk Manager (RM) and the Vice President of Quality was conducted on 12/13/12 at approximately 11:30 AM. The RM was not able to locate the notice pertaining to Patient # 12 and the Vice President of Quality acknowledged the notice given to Patient # 11 was not presented within two calendar days from discharge.

Based on clinical record review and interview the facility failed to arrange for post hospital services and care for 1 of 5 sampled patients (Patient # 1).

The findings include:

Clinical record review conducted on 12/12/12 revealed Patent # 1 was admitted to the facility on 11/03/12 with diagnosis of Rhabdomyolysis, Elevated Troponin and Leukocytosis. The past medical history includes alcohol use, malnutrition and abnormal liver function.
Emergency Department Record dated 11/03/12 documents the patient was laying on the floor for two days prior to the fire rescue arrival.

Initial Nursing Assessment dated 11/03/12 documents Patient # 1 was admitted with a decubitus ulcer to the buttocks, assessed as stage II.

Wound Care Note dated 11/12/12 documents "Patient noted to be saturated with clear yellowish exudate from buttocks. Soiled linens removed. Area cleansed and patient place on ultrasorb pad. Yellow slough area to buttock noted very thin with pink tissue noted. Blackened necrotic area noted at fleshy part of buttock, peri wound area noted to be red possibly due to moisture. "

Case Management Notes dated 11/12/12 document the case manager spoke to the physician, " patient can be discharged to rehab but patient does not have insurance. Unable to check with Veterans (VA) Hospital for placement in their rehab facility because they are closed for veterans day. "

Physician Progress Notes dated 11/13/12 document the patient has an appointment with primary care provider at the VA, so will discharge today and his primary care provider will arrange for further testing."

Physical Therapy Notes dated 11/13/12 documents "patient was seen today for continuation of physical therapy services. "I got a lot of stuff in my mind ". Patient was able to walk 100 feet with rolling walker but requested to go back to his bed, complained of dizziness. Discharge recommendations noted skilled nursing facility for placement and rolling walker.

Physician order dated 11/13/12 documents "Discharge patient to home", Case Management Consult for Durable Medical Equipment, rolling walker" and "Physical therapy for gait training and therapeutic exercises".

Case Management Notes dated 11/13/12 documents Patient to be discharged to rehabilitation center, spoke with representative at the Veterans (VA) transportation center for possible placement in the VA rehab. The representative stated "since the patient has been hospitalized for what appears to be several new medical conditions for which he has not received treatment previously at the VA, the patient would be better served if he is evaluated by his primary medical doctor. Patient will be given appointment at the VA where he will be seen immediately after discharge from hospital ... Spoke to physician regarding suggestion from VA for evaluation by his primary medical doctor upon discharge. After evaluation the VA physician will make arrangements for further care as needed and for rehab placement at the VA."


Case Management Notes dated 11/13/12 documents "Received order for discharge home, so patient will be able to keep his scheduled appointment at the VA with his primary care physician. Inform representative from the VA that the patient will be transported at the scheduled time. Faxed copies of discharge orders. Patient given discharge instructions, prescriptions and medication reconciliation sheet."

Discharge instructions date 11/13/12 documents Patient # 1 to be discharged home, has follow up appointment with the VA at 2 PM. The discharge instructions did not specify if any assistance was needed. No referrals to community resources, supplies, equipment or instructions for wound care were documented.

Interview with the Case Manager (CM) assigned to Patient # 1 was conducted on 12/12/12 at 12:26 PM. The CM explained Patient # 1 was originally to be transferred to the Veterans Hospital as an inpatient; during the course of the hospitalization the patient improved and it was then determined that he would be a good candidate for rehabilitation. The patient requested to be placed at the VA rehabilitation center. She then contacted the VA and was advised the best way to expedite the transfer to the rehabilitation unit, was for the patient to be assessed by a VA provider. The Case Manager stated she then arranged for a follow up appointment and the patient was transported from the facility to the doctor's office. The Case Manager was asked what was her intent upon discharge and she replied the patient was transferred to the VA rehabilitation unit, she followed the instructions given, but she acknowledged that she was never told the VA had rehabilitations beds available; the information given to her was the fact that the VA facility had no open beds for outside referrals at the time. The Case Manager was asked if she was aware of the patient's prior living arrangements and the fact that he was lying on the floor for two days prior to the paramedic's arrival; the case Manager stated she was not aware of the history, but the spouse visited frequently and appeared to be a willing participant in his care. The Case Manager was then asked if the physician order for durable medical equipment was implemented; and replied she did not see the order. In addition the case managers was not able to explain if the physical therapy orders written on the day of discharge were orders for post hospital care. Neither could she explain why wound care follow up was not addressed as part of the discharge. The Case Manager reiterated her intention was to discharge the patient to the VA rehabilitation unit. She expected the VA physician to complete the needed referrals and obtain immediate placement.

During interview with the Director of Case Management on 12/12/12 at 1:47 PM, the Director stated she recalled Patient # 1; the facility has a VA Liaison; most likely the Liaison is contacted for in patient to in patient transfers. The Director acknowledged the knowledge of the available veteran's services is limited, as they rarely have veterans in the facility. The Director was not aware the patient had a wound upon discharge, but explained the discharge plan was discussed during the care conference and the case manager followed instructions given by the VA representative. The Director acknowledged the Liaison was not contacted to arrange further services for Patient # 1 and her understanding was that the patient was discharged home with a follow up appointment with the VA physician.

Phone interview with the Health System Specialist Veterans Services was conducted on 12/14/12 at 9:48 AM. The Specialist explained the facility has a navigator, who should be notified of all admissions so they can facilitate transfer or assists with needed services if they have no capacity. Patient # 1 is one hundred percent covered for home health services, skilled nursing and palliative care. The VA Rehabilitation facility had no open beds at the time of discharge and if the facility would have asked for placement or other services, the patient could have been placed in any nursing facility of choice, home health services and equipment would be covered as well; the facility never requested any services. The only request made was for a follow up appointment. The clinical presentation provided by the case manager noted the patient was ambulatory, two hundred feet and needed additional rehabilitation services. The patient arrived with a prescription for wound care; the extent of wound was not provided prior to arrival. When the patient arrived to his appointment; the physician determined the patient ' s wound needed more than skilled nursing services or home health. The patient was admitted and diagnosed with Necrotic Fasciitis and underwent a deep debridement. The patient remains hospitalized.

Facility policy titled "Discharge Planning Assessment" documents "Discharge planning is a systematic coordinated program that is designed to bring about the timely discharge of a patient from a hospital to the next level of care or to return to his/her normal living situation. Based on information obtained during the initial evaluation, the Case Manager Coordinator will make recommendations for post hospital services or placement needed. Once a physician order is obtained, the case Manager Coordinator will arrange services and placement requested. Case Management Coordinator meets with patent, family and or significant other regarding requested equipment. If a patient does not have equipment at home they are asked if they have a preference to company used. Depending on insurance company, the Case Manager will inform patient/family of company supplying the equipment and when to expect delivery."

Based on clinical record review and interview the facility failed to arrange for post hospital services and care for 1 of 5 sampled patients (Patient # 1).

The findings include:

Clinical record review conducted on 12/12/12 revealed Patent # 1 was admitted to the facility on 11/03/12 with diagnosis of Rhabdomyolysis, Elevated Troponin and Leukocytosis. The past medical history includes alcohol use, malnutrition and abnormal liver function.
Emergency Department Record dated 11/03/12 documents the patient was laying on the floor for two days prior to the fire rescue arrival.

Initial Nursing Assessment dated 11/03/12 documents Patient # 1 was admitted with a decubitus ulcer to the buttocks, assessed as stage II.

Wound Care Note dated 11/12/12 documents "Patient noted to be saturated with clear yellowish exudate from buttocks. Soiled linens removed. Area cleansed and patient place on ultrasorb pad. Yellow slough area to buttock noted very thin with pink tissue noted. Blackened necrotic area noted at fleshy part of buttock, peri wound area noted to be red possibly due to moisture. "

Case Management Notes dated 11/12/12 document the case manager spoke to the physician, " patient can be discharged to rehab but patient does not have insurance. Unable to check with Veterans (VA) Hospital for placement in their rehab facility because they are closed for veterans day. "

Physician Progress Notes dated 11/13/12 document the patient has an appointment with primary care provider at the VA, so will discharge today and his primary care provider will arrange for further testing."

Physical Therapy Notes dated 11/13/12 documents "patient was seen today for continuation of physical therapy services. "I got a lot of stuff in my mind ". Patient was able to walk 100 feet with rolling walker but requested to go back to his bed, complained of dizziness. Discharge recommendations noted skilled nursing facility for placement and rolling walker.

Physician order dated 11/13/12 documents "Discharge patient to home", Case Management Consult for Durable Medical Equipment, rolling walker" and "Physical therapy for gait training and therapeutic exercises".

Case Management Notes dated 11/13/12 documents Patient to be discharged to rehabilitation center, spoke with representative at the Veterans (VA) transportation center for possible placement in the VA rehab. The representative stated "since the patient has been hospitalized for what appears to be several new medical conditions for which he has not received treatment previously at the VA, the patient would be better served if he is evaluated by his primary medical doctor. Patient will be given appointment at the VA where he will be seen immediately after discharge from hospital ... Spoke to physician regarding suggestion from VA for evaluation by his primary medical doctor upon discharge. After evaluation the VA physician will make arrangements for further care as needed and for rehab placement at the VA."


Case Management Notes dated 11/13/12 documents "Received order for discharge home, so patient will be able to keep his scheduled appointment at the VA with his primary care physician. Inform representative from the VA that the patient will be transported at the scheduled time. Faxed copies of discharge orders. Patient given discharge instructions, prescriptions and medication reconciliation sheet."

Discharge instructions date 11/13/12 documents Patient # 1 to be discharged home, has follow up appointment with the VA at 2 PM. The discharge instructions did not specify if any assistance was needed. No referrals to community resources, supplies, equipment or instructions for wound care were documented.

Interview with the Case Manager (CM) assigned to Patient # 1 was conducted on 12/12/12 at 12:26 PM. The CM explained Patient # 1 was originally to be transferred to the Veterans Hospital as an inpatient; during the course of the hospitalization the patient improved and it was then determined that he would be a good candidate for rehabilitation. The patient requested to be placed at the VA rehabilitation center. She then contacted the VA and was advised the best way to expedite the transfer to the rehabilitation unit, was for the patient to be assessed by a VA provider. The Case Manager stated she then arranged for a follow up appointment and the patient was transported from the facility to the doctor's office. The Case Manager was asked what was her intent upon discharge and she replied the patient was transferred to the VA rehabilitation unit, she followed the instructions given, but she acknowledged that she was never told the VA had rehabilitations beds available; the information given to her was the fact that the VA facility had no open beds for outside referrals at the time. The Case Manager was asked if she was aware of the patient's prior living arrangements and the fact that he was lying on the floor for two days prior to the paramedic's arrival; the case Manager stated she was not aware of the history, but the spouse visited frequently and appeared to be a willing participant in his care. The Case Manager was then asked if the physician order for durable medical equipment was implemented; and replied she did not see the order. In addition the case managers was not able to explain if the physical therapy orders written on the day of discharge were orders for post hospital care. Neither could she explain why wound care follow up was not addressed as part of the discharge. The Case Manager reiterated her intention was to discharge the patient to the VA rehabilitation unit. She expected the VA physician to complete the needed referrals and obtain immediate placement.

During interview with the Director of Case Management on 12/12/12 at 1:47 PM, the Director stated she recalled Patient # 1; the facility has a VA Liaison; most likely the Liaison is contacted for in patient to in patient transfers. The Director acknowledged the knowledge of the available veteran's services is limited, as they rarely have veterans in the facility. The Director was not aware the patient had a wound upon discharge, but explained the discharge plan was discussed during the care conference and the case manager followed instructions given by the VA representative. The Director acknowledged the Liaison was not contacted to arrange further services for Patient # 1 and her understanding was that the patient was discharged home with a follow up appointment with the VA physician.

Phone interview with the Health System Specialist Veterans Services was conducted on 12/14/12 at 9:48 AM. The Specialist explained the facility has a navigator, who should be notified of all admissions so they can facilitate transfer or assists with needed services if they have no capacity. Patient # 1 is one hundred percent covered for home health services, skilled nursing and palliative care. The VA Rehabilitation facility had no open beds at the time of discharge and if the facility would have asked for placement or other services, the patient could have been placed in any nursing facility of choice, home health services and equipment would be covered as well; the facility never requested any services. The only request made was for a follow up appointment. The clinical presentation provided by the case manager noted the patient was ambulatory, two hundred feet and needed additional rehabilitation services. The patient arrived with a prescription for wound care; the extent of wound was not provided prior to arrival. When the patient arrived to his appointment; the physician determined the patient ' s wound needed more than skilled nursing services or home health. The patient was admitted and diagnosed with Necrotic Fasciitis and underwent a deep debridement. The patient remains hospitalized.

Facility policy titled "Discharge Planning Assessment" documents "Discharge planning is a systematic coordinated program that is designed to bring about the timely discharge of a patient from a hospital to the next level of care or to return to his/her normal living situation. Based on information obtained during the initial evalua