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Based on medical record review, policy and procedure review and interview, the facility failed to ensure that 2 of 6 patients (#13 and #15) received the Important Message from Medicare (IMM). Findings include:
During medical record review on 01/07/13 at approximately 1110 it was revealed that patient #13's medical record failed to have the required discharge IMM. During an interview with staff E on 01/07/13 at approximately 1115 it was confirmed that the IMM was not in the medical record.
During medical record review on 01/07/13 at approximately 1130 it was revealed that the patient #15's medical record failed to have the required discharge IMM. During an interview with staff E on 01/07/13 at approximately 1140 it was confirmed that the IMM was not in the medical record.
During policy and procedure review on 01/07/13 at approximately 1330 it was revealed in the policy titled, "Medicare Important Message Presentation Policy", states under #5, "CRM staff will present the second IMM within 2 days of discharge".




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Based on medical record review, interview, and policy review the facility failed to ensure restraint orders were ordered or authenticated by the attending physician for 5 out of 6 patients (#2,#6,#7,#10,and #12) resulting in the restraint of a patient without an order. Findings include:

During the medical record review of patient #2 on 01/07/13 at approximately 1100 it was revealed that the patient was put into bilateral soft restraints for medical necessity on 01/02/13 and had no initial restraint orders as of 01/07/13. These findings were confirmed during the medical record review by staff E.

During the medical record review of patient #6 on 01/07/13 at approximately 1120 it was revealed that the patient was in bilateral soft restraints for medical necessity and had no renewal restraint orders for 01/02/13 and 01/04/13. These findings were confirmed during the medical record review by staff E.

During the medical record review of patient #7 on 01/07/13 at approximately 1140 it was revealed that the patient was in bilateral soft restraints for medical necessity beginning on 12/31/12 to present and had no renewal restraint orders for 01/02/13. These findings were confirmed during the medical record review by staff E.

During the medical record review of patient #10 on 01/07/13 at approximately 1150 it was revealed that the patient was put into bilateral soft restraints for medical necessity on 12/25/12 thru 01/02/13, with a one day stop order on 12/27/12. There were no initial restraint orders for 12/25/12 or 12/28/12 and no renewal restraint order for 12/29/12. These findings were confirmed during the medical record review by staff E.

During the medical record review of patient #12 on 01/07/13 at approximately 1200 it was revealed that the patient was put into bilateral soft restraints for medical necessity on 01/02/13 to present and had no initial restraint orders for 01/02/13 and no renewal restraint orders for 01/03/13 or 01/07/13. These findings were confirmed during the medical record review by staff E.

According to Policy No. 1 CLN 008 "restraint use in the non-psychiatric, medical/surgical healthcare setting" (p.12) "the physician must be contacted prior to application or immediately following emergency application of restraints, face to face assessment by physician required, order good for a maximum of one calendar day". The attending physician failed to order initial and renewal restraint orders.



30988

Based upon on-site observation and document review by the Life Safety Code (LSC) surveyors, the facility did not comply with the applicable provisions of the 2000 edition of the Life Safety Code. See K-Tags on the 2567 dated November 21, 2012 Life Safety Code.

Based on medical record review, interview, and policy review the facility failed to identify patients at an early stage of hospitalization in need of discharge planning according to their policy in 4 of 18 patients (#5, #10, #11, and #13,).
Findings include:
During medical record review on 01/07/13 at approximately 1045 it was revealed that patient #5 was admitted on 12/12/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The initial discharge plan was not initiated by social work until 12/19/12 . These findings were confirmed at the time of the medical record review by staff E.
During medical record review on 01/07/13 at approximately 1105 it was revealed that patient #10 was admitted on 12/25/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The initial discharge plan was not initiated by social work until 01/03/13. These findings were confirmed at the time of the medical record review by staff E.
During medical record review on 01/07/13 at approximately 1125 it was revealed that patient #11 was admitted on 01/02/13 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The initial discharge plan was not initiated by social work until 01/07/13. These findings were confirmed at the time of the medical record review by staff E.
During medical record review on 01/07/13 at approximately 1145 it was revealed that patient #13 was admitted on 12/10/12 and had a health condition that would require a discharge plan assessment to be completed within 48 hours of admission per hospital policy. The initial discharge plan was not initiated by social work until 12/14/12 . These findings were confirmed at the time of the medical record review by staff E.
During policy and procedure review on 01/07/13 it was found in the facility ' s policy titled " Initial Social Work Assessment " dated 12/20/12, which was originally dated 01/01/10, revealed " It is the policy of the Clinical Resource Management Department Social Work staff to assess patient ' s needs for services, plans for discharge, and post acute setting health management services. Patients will be assessed based on the following trigger criteria for their need for services. The Social Work assessment form should be completed either after consultation or within 48 hours of admission. " Triggers include but are not limited to: Chronic disease/Complex needs with risk for readmission and history of falls, abnormal gait or unsteady gait. Each of the above listed patients had one or more triggers documented in their medical records.



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