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Based on review of medical records and interview, the facility did not ensure distribution of required notices to patients or their representatives upon admission and prior to discharge in 2 of 7 patients. (Patients #4 and #7)

Findings include:

Review of the medical record for Patient #4 indicated the patient was admitted to the hospital on 9/23/11 with altered mental status. A family member signed the "Important Message from Medicare" (IMM) form on 9/28/11. On 10/5/11 the patient was discharged, however, there is no evidence that a copy of the notice was provided no more than 2 days prior to discharge.

Review of the medical record for Patient #7 indicated the patient was admitted to the hospital on 8/27/11 with a GI bleed. On 8/31/11 the patient was transferred to a tertiary care facility. There is no evidence the patient or his representative was provided with the IMM within 48 hours of admission, as required.

Interview on 11/29/11 with Staff #7 at 2:40pm revealed that the goal is to provide a copy of the IMM upon admission and prior to discharge. Staff# 7 stated that some patients have been missed because the staff that distributes the IMM notice do not work on weekends.

Based on medical record review and independent physician review the medical care provided to 2 of 26 patients did not meet the standard of care (Patient # 1 and 7).

Findings Include:

Patient #1:

Review of the medical record indicated the following:
- On 6/19/10 at 2214 the patient presented to the Emergency Department (ED) with the complaint of severe cramping abdominal pain and vomiting for approximately 24 hours. CT scan of abdomen showed inflammation of the small bowel. The patient was admitted for acute abdominal pain.
- On 6/21/10 the patient complained of severe abdominal pain out of proportion to the abdominal findings. A surgical consult was ordered. On 6/21/10 at 6:00pm the patient underwent surgery for removal of approximately 8 feet of ischemic small bowel.

The independent physician reviews indicated surgical consultation should have been obtained in the ED or immediately after admission.

Patient #7:

Review of the medical record indicated the patient presented to the ED on 8/27/11 at 07:39 with complaint of black, tarry stools for 2 days. Hemoglobin and hematocrit were low at 5.8 and 17 (normal 13.5-17.5 and 40-54). The patient was admitted for GI bleeding. The patient was transfused and on 8/30/11 a colonoscopy and esophagogastroduodenoscopy (EGD) was performed. Bleeding continued and the patient was transferred to a tertiary care facility on 8/31/11.

The independent physician reviews indicated the patient should have had an immediate EGD or be transferred to a tertiary care facility rather than wait until two days later given the continued rectal bleeding and low hemoglobin and hematocrit despite multiple units of packed red blood cells.

Based on document review and interview medical staff failed to perform consults within 24 hours as required by the facility's Bylaws for 3 of 9 patients (Patient # 5, 18, and 19).

Findings include:

Review of the Rules and Regulations of the Medical Staff dated 12/15/08 revealed consultations shall be completed within 24 hours unless otherwise specified by the ordering practitioner.

Review of medical records identified the following:
- Patient #5: The history and physical dictated 9/24/11 and physician order dated 9/25/11 at 1000 indicated a plan to get a gastrointestinal (GI) consult. No evidence of a GI consult was found in the medical record.

- Patient #18: The admission orders dated 11/28/11 indicated a consult with Staff #2 and #4 was ordered. No evidence was found to indicate the consults were obtained.

- Patient# 19: The physician orders dated 11/15/11 at 8:40 am indicated an order for a consult with Staff #4. On 11/16/11 at 12:15pm, a telephone order was noted from Staff #4 ordering an endoscopy on 11/17/11 at 9:30 am with anesthesia. No evidence was found of a complete report or dictated consult report. No evidence was found to indicate the patient was evaluated prior to the endoscopy being performed on 11/17/11.

These findings were verified with Staff #1 on 12/1/11.

Based on policy review, medical record review and interview, the facility did not ensure appropriate medications are ordered upon admission and reconciled in accordance with facility policy for 6 out of 13 transfer patients. (Patient #s 4, 6, 7, 9, 19, and 20)

Findings include:

Review on 11/29/11 to 11/30/11 of the following medical records revealed the following medication documentation discrepancies:
- The Medication Reconciliation form for Patient # 4, 6, 7, 9, 19, and 20 revealed there was no documented evidence that nursing reviewed the medications and clarified any discrepancies upon admission.

Review of the facility's Medication Reconciliation Policy and Procedure dated 10/07 revealed the physician will indicate reconciliation by circling the (C) for continuation or (DC) for discontinuation and authenticate the reconciliation/medication ordering by signature/date and time. The physician will also indicate his/her intent to use as an order sheet by initialing the designated line. If the physician does not want to use this for his/her order form, he/she should sign the form indicating not using as an order sheet and hand write the orders or enter electronically. Unreconciled priority medications (i.e. antibiotics, insulin's, pain medications) will require physician/nurse communication follow-up prior to physician rounds if patient- specific times so require. A registered nurse is responsible for reconciliation of all medications at time of admission.

Interview with Staff #11 on 11/30/11 at 10:45am revealed that nursing should sign on the Medication Reconciliation form indicating that the medications were reviewed and any discrepancies clarified upon admission and transfer between units.

These findings were verified on 11/30/11 with Staff #1 and #11.