HospitalInspections.org

Based on observations, records review and interviews, the hospital failed to meet the Condition of Participation for Special Requirements for Critical Access Hospital Providers of Long Term Care Services as evidenced by:


1) Failing to ensure that each patient was fully informed in a language that he/she could understand of his/her health status or medical condition.


The hospital failed to develop a policy and procedure for informing patients of their admission status of observation versus inpatient. This could affect all Medicare patients' ability to qualify for skilled services under Medicare (a 3 day qualifying inpatient stay was required to obtain services in a skilled nursing facility).


The hospital failed to inform 3 of 3 patients admitted for observation of their admission status from a total sample of 13 patients (#11, #12, #13).


See findings in tag CA0361).


2) Failing to develop a policy and procedure for the distribution of the form titled "An Important Message From Medicare About Your Rights" (provides information regarding Medicare covered services and Medicare discharge and appeal rights).


There were 3 of 3 patients (#11, #12, #13) from a total of 13 sampled patients having signed the form without knowledge of what they were signing.


The hospital failed to be inform the patients of their Medicare rights for discharge and the ability to appeal a discharge decision.


Ssee findings in tag C0379.

Based on observations, records review and interviews, the hospital failed to ensure that each patient was fully informed in a language that he/she could understand about his/her health status or medical condition.


The hospital failed to develop a policy and procedure for informing patients of their admission status of observation versus inpatient. This could affect all Medicare patients' ability to qualify for skilled services under Medicare (a 3 day qualifying inpatient stay was required to obtain services in a skilled nursing facility).


The hospital failed to inform 3 of 3 patients (#11, #12, #13) admitted for observation of their admission status from a total sample of 13 patients


Findings:


Patient #11


Review of Patient #11's medical record revealed that he was a 78 year old male admitted for observation on 01/02/13 at 4:30am. Further review revealed that his admission diagnosis was chest pain, rule out myocardial infarction.


Observation on 01/03/13 at 9:50am revealed that Patient #11 was asleep sitting in the chair at the bedside. Further observation revealed that Patient #11's wife, daughter, and son were present in Patient #11's room.


Review of Patient #11's medical record revealed no documented evidence that any staff member or physician had instructed Patient #11 and/or his family members that he was being admitted for observation and was not being admitted as an inpatient.


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #11's wife on 01/02/13 revealed information regarding Patient #11's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #11 was admitted for observation and not as an inpatient.


In a face-to-face interview on 01/03/13 at 9:50am, Patient #11's wife indicated that no staff member of the hospital had explained to her or her husband (Patient #11) what being admitted on observation meant versus being admitted as an inpatient. She further indicated that she didn't know whether he was admitted for observation or as an inpatient.



Patient #12


Review of Patient #12's medical record revealed that he was a 70 year old male admitted for observation on 01/02/13 (no documented evidence of the date or time that the physician's orders were received). Further review revealed that the admitting diagnoses were Chronic Obstructive Pulmonary Disease Exacerbation and Influenza.


Review of Patient #12's medical record revealed no documented evidence that any staff member or physician had instructed Patient #12 and his family members that he was being admitted for observation and was not being admitted as an inpatient.


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #12 on 01/02/13 at 3:43pm revealed information regarding Patient #12's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #12 was admitted for observation and not as an inpatient.


Observation on 01/03/13 at 10:25am revealed Patient #12 sitting up in bed with his daughter at his bedside.


In a face-to-face interview on 01/03/13 at 10:25am, Patient #12 indicated that no staff member had explained to him the difference between being admitted for observation and being admitted as an inpatient. He further indicated that he was not aware that he was admitted for observation and not as an inpatient. During the interview Patient #12's daughter indicated that she was present during her father's admission and confirmed the above information.


Patient #13


Review of Patient #13's medical record revealed that she was an 84 year old female admitted for observation on 01/02/13 at 3:10pm with the diagnosis of Syncope.


Review of Patient #13's medical record revealed no documented evidence that any staff member or physician had documented that they had instructed Patient #13 that she was being admitted for observation and was not being admitted as an inpatient.


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #13 on 01/02/13 at 3:25pm revealed information regarding Patient #13's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #13 was admitted for observation and not as an inpatient.


Observation on 01/03/13 at 10:05am revealed that Patient #13 was sitting up in bed with her eyes closed.


In a face-to-face interview on 01/03/13 at 10:05am, Patient #13 indicated that no staff member had explained to her the difference between being admitted for observation and being admitted as an inpatient. When asked if she was aware that she had been admitted for observation and not as an inpatient, Patient #13 did not answer and appeared to have fallen asleep.


In a face-to-face interview on 01/02/13 at 4:10pm, DONS2 indicated that the hospital did not have a policy and procedure for the use of "An Important Message From Medicare About Your Rights" form. She further indicated that the form was included in the patient admission packet, and the admission personnel get it signed.


In a face-to-face interview on 01/03/13 at 11:10am, Business Office DirectorS9 indicated that "An Important Message From Medicare About Your Rights" addressed the patient as an "hospital inpatient", and the patient could assume when they read the form that they were an inpatient when actually they were admitted for observation.


In a face-to-face interview on 01/03/13 at 11:25am, LPNS10 indicated that she was the hospital's Utilization Review nurse. She further indicated that usually the emergency department physician or the admit department staff notified the patient that they were being admitted for observation. LPNS10 indicated that she "assumed" that the patient's admit status of observation was addressed in the emergency department or admit, because she didn't usually go in the patient's room to discuss anything with the patient about their admit status.


In a face-to-face interview on 01/03/13 at 1:05pm, PhysicianS11 indicated that the physician decided whether a patient would be admitted for observation or as an inpatient. He further indicated that he did not discuss this with the patient or their family, because the patient would be treated the same whether they were admitted for observation or as an inpatient.


In a face-to-face interview on 01/03/13 at 1:40pm, LMSWS12 indicated that she did not speak with patients or their families about their admit status of observation versus inpatient, because she was more concerned with discharge planning. When asked about patients needing to have a 3 day inpatient stay to qualify for skilled nursing facility coverage under Medicare, LMSWS12 indicated that she was not "completely aware of the requirements for skilled nursing coverage in the nursing home".


Review of the hospital policy titled "Observation Procedure", presented by DONS2 as the current policy on 01/02/13 at 1:15pm, revealed the following:


1. Observation services are used for the ongoing short-term treatment, assessment and reassessment of the patient to determine whether the patient will need further treatment as an inpatient or can be safely discharged to home.


2. Placement in observation begins with the order from the physician or other qualified licensed provider.


3. Observation services end when the physician or other qualified licensed provider writes the order to either admit the patient to inpatient, transfer to another facility, or discharge the patient.


4. Progress notes should indicate the physician's documentation of the evaluation and treatment that resulted in the clinical decision to either admit to inpatient or documentation to support the clinical decision to transfer or discharge the patient.


There was no documented evidence in the policy that addressed that the patient would be informed of the admit status and whose responsibility it was to inform the patient.

Based on records review and interviews, the hospital failed to develop a policy and procedure for the use of the form titled "An Important Message From Medicare About Your Rights" (provides information regarding Medicare covered services and Medicare discharge and appeal rights). This resulted in 3 of 3 inpatients (#11, #12, #13) from a total of 13 sampled patients having signed the form without knowledge of what they were signing and failing to be informed of their Medicare rights for discharge and the ability to appeal a discharge decision.


Findings:


Review of the form titled "An Important Message From Medicare About Your Rights" that was presented to each Medicare patient revealed, in part, "As a Hospital Inpatient, you have the right to: Receive Medicare covered services. ... Be involved in any decisions about your hospital stay, and know who will pay for it. Report any concerns you have about the quality of care you receive to the Quality Improvement Organization... Your Medicare Discharge Rights... Please sign and date here to show you received this notice and understand your rights..." Further review revealed the end of the form had a line for initials and a date after the statement "I acknowledge follow-up receipt of this notice and understand my discharge appeal rights."


Patient #11


Review of Patient #11's medical record revealed that he was a 78 year old male admitted for observation on 01/02/13 at 4:30am. Further review revealed that his admission diagnosis was chest pain rule, out myocardial infarction.


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #11's wife on 01/02/13 revealed information regarding Patient #11's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #11 was admitted for observation and not as an inpatient.


In a face-to-face interview on 01/03/13 at 9:50am, Patient #11's wife indicated that a staff member asked her to sign the form, and she told them "wait, I have to read it first". She further indicated that they did not explain the information contained in the form to her. When asked if she could explain to the surveyor what information was contained in the notice, Patient #11's wife could not explain what the information meant. During the interview, Patient #11's son was present, and he indicated that the receptionist handed the paper to his mother and said "here, sign this".


Patient #12


Review of Patient #12's medical record revealed that he was a 70 year old male admitted for observation on 01/02/13 (no documented evidence of the date or time that the physician's orders were received). Further review revealed that the admitting diagnoses were Chronic Obstructive Pulmonary Disease Exacerbation and Influenza.


Review of the "Adult Admission Assessment" completed on 01/02/13 at 3:00pm revealed a note that "pt. (patient) unable to read & (and) write."


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #12 on 01/02/13 at 3:43pm revealed information regarding Patient #12's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #12 was admitted for observation and not as an inpatient.


In a face-to-face interview on 01/03/13 at 10:25am, Patient #12 indicated he could only sign his name, and he could not read or write. He further indicated that he was sent from the physician's office and signed the Medicare form in the admit department. Patient #12 indicated that no one explained what was contained in the Medicare form. This information was confirmed during the interview by Patient #12's daughter who was present and indicated that she was also present during his admission.


Patient #13


Review of Patient #13's medical record revealed that she was an 84 year old female admitted for observation on 01/02/13 at 3:10pm with the diagnosis of Syncope.


Review of the form "An Important Message From Medicare About Your Rights" signed by Patient #13 on 01/02/13 at 3:25pm revealed information regarding Patient #13's rights as a "hospital inpatient". Further review revealed no documented evidence that Patient #13 was admitted for observation and not as an inpatient.


In a face-to-face interview on 01/03/13 at 10:05am, Patient #13 indicated that she was handed the Medicare form to sign, and no one explained what was contained in the form.


In a face-to-face interview on 01/02/13 at 4:10pm, DONS2 indicated that the hospital did not have a policy and procedure for the use of "An Important Message From Medicare About Your Rights" form. She further indicated that the form was included in the patient admit packet, and the admit personnel get it signed.


In a face-to-face interview on 01/03/13 at 10:35am, RNS6 indicated when she did a patient's discharge paperwork, she would have the patient initial the Medicare form. When asked what she would tell the patient about the form that they were initialing as evidence of their understanding, RNS6 indicated she would tell the patient that it was "so we can file with Medicare, it's their Medicare rights". When questioned further about what the form contained, RNS6 indicated "it's about all their rights, anything they have a question about".. RNS6 did not verbalize that the form included information about the patient's discharge rights and how to file an appeal of their discharge.


In a face-to-face interview on 01/03/13 at 10:40am, RNS7 indicated that she had never had a patient initial a Medicare notice at discharge, and she had only been working at the hospital for a week. When asked if she knew what information was included in the form, RNS7 indicated that she did not, since she had never completed a form with a patient.


In a face-to-face interview on 01/03/13 at 11:00am, Business Office ClerkS8 indicated that part of her job was to have "An Important Message From Medicare About Your Rights" signed by the patient or their family member. She further indicated that she knew that the form included information about discharge and the patient's ability to appeal their discharge, but she did not explain the form to the patient when she had the patient sign it. She further indicated that if a patient asked about the form or stated that they didn't understand the form, she would explain the form to them.


In a face-to-face interview on 01/03/13 at 11:10am, Business Office DirectorS9 indicated that the business office staff were supposed to be explaining the Medicare form to the patients.