HospitalInspections.org

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to inform each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for four out of five Medicare patients records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

1) A review of facility policy "Registration," dated April, 2009, revealed " ... Procedure: It is the responsibility of the Patient Interviewer at each campus to: ... If the patient has Medicare or a Medicare HMO, the Patient Interviewer should provide the "Important Message form Medicare" document at time of registration. ... " A further review of the policy revealed no requirement that the hospital present a copy of the signed Important Message from Medicare (IMM) in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

An interview with EMP1 on October 20, 2014, at 1:15 PM confirmed that the facility's policy nor did the facility have a process in place to address the requirement that the hospital present a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

2) A review of MR1 revealed the patient was a Medicare Beneficiary who was admitted on July 30, 2014. A further review of MR1 revealed one IMM form which stated "Pt unable to sign" and was not dated, timed, or initialed.

An interview on October 20, 2014, at 1:30 PM, with EMP2 confirmed that MR1 contained one IMM form which stated "Pt unable to sign" and was not dated, timed, or initialed. Further, EMP2 stated that staff attempt three attempts to obtain the the patient's signature and upon each attempt, staff are supposed to document the date, time and initial the blank form.

3) A review of MR2 revealed the patient was a Medicare Beneficiary who was admitted on September 2, 2014, and was discharged on September 7, 2014. A further review of MR2 revealed no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

An interview on October 20, 2014, at 1:40 PM, with EMP1 confirmed that MR2 contained no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

4) A review of MR3 revealed the patient was a Medicare Beneficiary who was admitted on September 16, 2014, and was discharged on September 26, 2014. A further review of MR3 revealed no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

An interview on October 20, 2014, at 1:50 PM, with EMP1 confirmed that MR3 contained no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

5) A review of MR4 revealed the patient was a Medicare Beneficiary who was admitted on September 22, 2014, and was discharged on September 29, 2014. A further review of MR4 revealed no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

An interview on October 20, 2014, at 2:00 PM, with EMP1 confirmed that MR4 contained no documented evidence that the hospital presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.