HospitalInspections.org

Based on record review and interview, the facility staff failed to issue a second notice of the Important Message from Medicare for 4 out of 4 medicare eligible patients (Patient #'s 1, 3, 6 & 7) out of a total universe of 10.

Findings include:

During a review of facility policy titled, "Important Message from Medicare (IMM)" #7984504, last reviewed 04/28/2020 revealed, "The IM shall be delivered to inpatients within two (2) calendar days of admission or at preadmission, but not more that seven (7) calendar days before admission. The follow-up copy of the IM shall be delivered as far in advance as possible before discharge, but no more than two (2) calendar days before the day of discharge. Retained copies must be placed in the patients' medical record."

Patient #1's medical record was reviewed. Patient #1 was originally an inpatient 11/24-12/24/2020 and on that admission Patient #1 was deemed incapacitated and spouse was appointed as legal guardian for health care decision making. Patient #1 was readmitted to the hospital on 1/4/2021 and expired at facility on 1/11/2021. Patient #1 was issued the first copy of the Important Message from Medicare on 1/4/2021 it documented "Verbal" consent related to "COVID" by Patient #1 even though patient was incapacitated. There was no documentation of the second copy being issued to the patient.

During an interview with Registered Nurse (RN) K on 5/10/2021 at 2:00 PM RN K was asked the expectation of consent on IMM for an incapacitated patient, RN K replied "Yeah they should have contacted her husband and got his verbal approval since she was incapacitated."

Patient #3's medical record was reviewed. Patient #3 was admitted to the hospital on 11/04/2020 and was discharged on 11/12/2020. Patient #3 was issued the first copy of the Important Message from Medicare on 11/4/2020. There was no documentation of the second copy being issued to the patient.

Patient #6's medical record was reviewed. Patient #6 was admitted to the hospital on 12/06/2020 and was discharged on 12/14/2020. Patient #6 was issued the first copy of the Important Message from Medicare on 12/7/2020. There was no documentation of the second copy being issued to the patient.

Patient #7's medical record was reviewed. Patient #7 was admitted to the hospital on 12/27/2020 and was discharged on 1/03/2020. Patient #7 was issued the first copy of the Important Message from Medicare on 12/27/2020. There was no documentation of the second copy being issued to the patient.

During an interview on 05/10/2021 at 1:45 PM, Manager E stated a second copy of the Important Message of Medicare should be distributed to the patient by case management and it appears that was not done because there is not a copy in the medical records."