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Based on review of facility documents, medical records, (MR) and a staff interview (EMP), it was determined the facility failed to provide evidence that Medicare patients were informed of their rights regarding the Important Message From Medicare (IMM) within two calendar days of admission for five of five Medicare medical records reviewed (MR1, MR2, MR3, MR4, and MR5) and 48 hours prior to discharge from the facility as required per facility policy and regulation for three of five Medicare medical records reviewed (MR2, MR3, and MR5).

Findings include:

Review of facility policy " Notification of Discharge Appeal Rights/Important Message from Medicare (IMM) (CMS 10065-IM), last approved 10/2021, revealed: " ... INITIAL DELIVERY OF THE IMM: The initial IMM should be delivered to the patient on the day of admission, but no later than 2 calendar days after the admission date. The signature along with the date and time of the patient or his representative is required to verify that the notice was received. This document is to be placed in the front of the chart. ... FOLLOW UP DELIVER [sic] OF THE IMM PRIOR TO DISCHARGE The follow up delivery of the IMM should be given to the patient as early as possible so that the patient has adequate time to consider and act on the information. But the follow up IMM should not be delivered more than two calendar days before discharge. The signature along with the date and time of the patient or his representative is required to verify that the notice was received. This second signed document is to be placed in the front of the chart behind the first signed document. ... OTHER CONSIDERATIONS: The IMM is not applicable in the following situations: Observation level patients. Acute to Acute transfers. Acute to Acute Inpatient Rehabilitation transfers, Acute to Inpatient Psychiatric transfers, and Acute to Long Term Acute (LTAC) transfers. ... " .

1. Review of MR1 revealed that the patient was admitted to the facility on January 4, 2022 and transferred to hospice on January 7, 2022. There was no documentation that the patient or the patient's representative was provided an Important Message from Medicare to Medicare (IMM) on admission.

2. Review of MR2 revealed the patient was admitted to the facility on January 7, 2022 and was discharged on January 14, 2022. There was no documentation that the patient or the patient's representative was provided an IMM on admission or on discharge.

3. Review of MR3 revealed the patient was admitted to the facility on January 5, 2022 and was discharged on January 9, 2022. There was no documentation that the patient or the patient's representative was provided an IMM on admission or on discharge.

4. Review of MR4 revealed the patient was admitted to the facility on January 2, 2022 and was discharged to a rehabilitation facility on January 8, 2022. There was no documentation that the patient or the patient's representative was provided an IMM on admission.

5. Review of MR5 revealed the patient was admitted to the facility on January 2, 2022 and was discharged on January 10, 2022. There was no documentation that the patient or the patient's representative was provided an IMM on admission or on discharge.

On February 16, 2022, at approximately 11:45 AM EMP2 confirmed the above findings for MR1, MR2, MR3, MR4 and MR5, and confirmed that the patients were Medicare patients.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure each order for restraint used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others was renewed within 4 hours for adults 18 years of age or older for 1 of 1 medical records reviewed (MR1),

Review of facility's "Restraints/Seclusion, E-13 " policy, last revised 11/2020, revealed: " ... BEHAVIOR MANAGEMENT INDICATIONS FOR RESTRAINTS (FOR THE VIOLENT/SELF-DESTRUCTIVE PATIENT) a. Orders ... 4. The restraint order is not to exceed 4 hours for adults (ages 18 and above) ... " .
Review of MR1 revealed that the patient was a 91 year old man who was placed in 4 point soft restraints for self-destructive behavior and violent/aggressive behavior towards others continuously between January 5, 2022 at 18:45 through January 7, 2022 at 19:30. Further review of MR1 revealed two occurrences where the order for restraints exceeded 4 hours:
1) On January 6, 2022, MR1's restraint order was documented at 10:45. The next order was dated January 6, 2022 at 17:25. Therefore the restraint order exceeded 4 hours by 2 hours and 40 minutes.
2) On January 7, 2022, MR1's restraint order was documented at 05:25. The next order was dated January 7, 2022 at 10:00. Therefore the restraint order exceeded 4 hours by 35 minutes.
During an interview with EMP2 on February 15, 2022 at approximately 2:30 PM, EMP2 confirmed the above stating that " there was a gap without a renewal order " .