HospitalInspections.org

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare no more than 2 days prior to discharge for three of five Medicare patient records reviewed (MR9, MR10 and MR11).

Findings include:

A review of facility policy "Important Message from Medicare" (IMM) last revised September 2013, revealed, "...The first IMM is issued by the admission staff (no more than 7 days prior), must be signed/dated by the patient or representative, and provided a signed copy at that time. The second IMM is presented to the patient or representative by admission staff at least 72 hours following admission but no more than 48 hours prior to discharge. The second IMM must be signed/dated by the patient or representative, and the patient is provided a signed copy at that time. ..."

A review of MR9 on November 9, 2016, revealed the patient was admitted on October 6, 2016, and discharged on October 9, 2016. The first IMM was given to the patient, but the second IMM was not given to the patient.

A review of MR10 revealed the patient was admitted on October 18, 2016, and discharged on October 21, 2016. The first IMM was given to the patient, but the second IMM was not given to the patient.

A review of MR11 revealed the patient was admitted on September 28, 2016, and discharged on October 5, 2016. The first IMM was given to the patient, but the second IMM was not given to the patient.

An interview conducted on November 9, 2016, at 11:00 am with EMP1 confirmed there was no documentation in MR9, MR10, and MR11 regarding the second IMM.

Based on a review of facility policy, medical records (MR), and staff interview (EMP), it was determined that the facility failed to fully implement the patient's discharge plan by not providing a list of all medications the patient should be taking after discharge and with clear indication of changes from the patient's pre-admission medications for three of five medical records (MR 1, MR2, and MR3) reviewed.

Findings Include:

A review of facility policy "Medication Reconciliation" effective July 2016, revealed, "...Updates and modifications to the list shall be made as appropriate at any point of clinical contact throughout the continuum of care. ...D. The updated medication list is provided to the patient/caregiver and other healthcare providers by the physician/prescriber or other healthcare professionals upon discharge as appropriate."

A review of MR1 on November 9, 2016, revealed the patient was discharged with discharge instructions. The instructions did not list all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications.

A review of MR2 on November 9, 2016, revealed the patient was discharged with discharge instructions. The instructions did not list all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications.

A review of MR3 on November 9, 2016, revealed the patient was discharged with discharge instructions. The instructions did not list all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications.

An interview conducted on November 9, 2016, at 11:00 am with EMP5 confirmed the instructions did not list all medications the patient (MR1, MR2, and MR3) should be taking after discharge with clear indication of changes from the patient's pre-admission medications. EMP5 further revealed that "Staff are supposed to free text changes and put it in the discharge instructions."