HospitalInspections.org

Based on review of policy and medical record review, the facility failed to document an acknowledgment of receipt of patient's rights information for 1 of 5 (N1) patients and failed to document the Important Message from Medicare upon admission and discharge for 2 of 5 (N1 and N5) patients whose medical records were reviewed.

Findings included:

1. Facility policy "Completion of Miscellaneous Page", last reviewed/revised 3-31-2010, provided on page 1 "The purpose of this policy is to outline the process of accessing patient records for documenting vital information pertinent to the patient's visit concerning important notifications that cover patients' rights and privacy while they are in Community Health Network facilities" and on page 5 part 4 "Complete the following fields if applicable...Patient Rights Info Given--Required for every patient".

2. Facility policy "Medicare Beneficiaries (Important Message)", last reviewed/revised 12-2010, provided on page 1 "Federal Law (PL97-218) requires that Medicare beneficiaries be notified at the time of their admission to the hospital that the instituional care provided through Medicare will be reviewed to ensure that patients are receiving adequate and appropriate health care services.... The HCFA mandated notification letter regarding the rights of the Medicare patient and review by the designated Indiana Peer Review Organization will be given to each Medicare patient (spouse or next of kin) at the time of their admission... In the event a Medicare patient (spouse or next of kin) is not seen at admission, the notification letter is to be delivered and explained at the patient's bedside to either the patient (spouse or next of kin) by a Patient Financial Counselor".

3. During review of medical record of N1 on 11-19-12 at 2:30 P.M. the following were noted:
a. N1 was a Medicare in-patient.
b. N1 had a medical power of attorney in the medical record exercised by the designated person during admission at the facility from 10-14-12 to 10-25-12 until N1 was transferred to a skilled nursing facility.
c. On 10-14-12 at 12:57 an entry attached to the notification of the Important Message from Medicare by S8 "Patient unable to sign" but contained no further entries on attempts to deliver the message and obtain signature of N1's representative within 2 days of admission.
d. the medical record contained two scanned "Important Message from Medicare" forms which lacked date and signature of patient or representative on the lines indicated near the bottom of the form.

4. During review of medical record of N5 on 11-19-12 at 3:30 P.M. the following were noted:
a. N5 was a Medicare in-patient.
b. the medical record contained two Important Message from Medicare which were blank other than the pre-printed notice of rights; neither had a patient label or other patient identification; neither were signed by the patient or the patient's representative; neither had any notation from staff of delivery of the Important Message either upon admission (10-18-12) and no more than 2 days prior to discharge to a long term acute care hospital (10-27-12).

5. During interview with S2 on 11-19-12 at 5:00 PM, S2 indicated:
a. facility policy requires an acknowledgment of receipt of patient's rights by patient or their representative which is to be documented in the medical record.
b. N1's was a Medicare patient whose medical record lacked acknowledgement of receipt of patient's rights to N1's representative during N1's admission from 10-14-12 to 10-25-12.
c. facility policy requires that upon admission of Medicare patients, the "Important Message from Medicare" (IM) be obtained by staff and that it be signed and dated by the patient or patient's representative and that a copy of the Important Message is to given to the patient or representative and a copy is to be retained in the medical record.
d. after extensive searching in the computer and calls to other staff including case management staff, could not produce a policy addressing the requirement to deliver an Important Message from Medicare to the patient or patient's representative not more than 2 days prior to planned discharge.
e. N1's medical record contained two scanned Important Messages from Medicare. Neither IM was signed or dated by N1's representative as required by facility policy, and it could not therefore be reliably determined that N1's representive had received the Important Message upon or soon after N1's admission as required by facility policy, and it could not be reliably determined that N1's representative received, not more than 2 days prior to discharge, an Important Message notice.
f. N5 was a Medicare patient whose medical record contained 2 blank Important Messages from Medicare which had been scanned into the medical record. Neither Important Message had any documentation of attempts to deliver the Important Messages to N5 within 2 days of admission on 10-18-12 or not more than 2 days prior to discharge to a long term acute care hospital on 10-29-12. Neither of the Important Messages in the medical record were signed or dated by patient or patient's representative.