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Based on record review and interview, the facility failed to provide the Important Message from Medicare to 2 (P-1, P-2) of 10 patients whose medical records were reviewed for provision of the Important Message from Medicare, resulting in the failure to inform the patient or patient's representative of the right to appeal discharge and potential loss of rights for the patient. Findings include:

On 6/24/2025 at 1340, review of the medical record for P-1 revealed he was admitted to the facility from 3/28/2025-4/25/2025. Review of insurance information revealed he did have Medicare. An Important Message from Medicare (IMM) document was not found in the record.

On 6/25/2025 at 0930, review of the medical record for P-2 revealed she was admitted to the facility on 6/8/2025 and a current patient in the facility at the time of survey. Review of the insurance information revealed she did have Medicare. An Important Message from Medicare was no found in the record.

On 6/25/2025 at 1255, Facility Lead Registration (Staff P) and the Regional Lead Registration (Staff Q) were queried if it is an expectation that the Important Message from Medicare (IMM) be signed at the time of admission by the patient or their representative, Staff Q responded, "yes". Staff P revealed the facility had recently changed the process for obtaining consents for admitted patients and the Admitting Department will get the consents signed moving forward.

Review of facility policy titled, "Important Message from Medicare/Discharge Rights, 100-227", policy #13296912, last revised #10/2019 under section titled "Purpose - As a condition of participation in the Medicare program, hospitals must notify Medicare beneficiaries
who are hospital inpatients of their hospital discharge rights. The Centers for Medicare and Medicaid (CMS) mandates hospitals to issue a standardized letter, "An Important Message From Medicare About Your Rights" (OMB Approval No. 0938-0692) to any hospitalized inpatient who is eligible for Original Medicare or a Medicare managed care plan whether Medicare is the primary payer or will pay any portion of the bill after the primary payer. All Medicare patients must receive the Important Message (IMM) each time they are admitted and in most cases before discharge. Federal regulation requires: The issuance of the IMM within 2 calendar days of inpatient admissions."

Based on observation, interview, and record review, the facility failed to accurately track the release of a deceased patient's body taken from the morgue for 1 (P-1) of 10 patients reviewed secondary to a failed system for monitoring the removal of deceased patient bodies from the facility morgue which could increase the potential for loss of dignity and respect for the deceased patient and their families. Findings include:

On 6/24/2025 at 1527 an interview with the Director of Risk Management (Staff C) and the Patient Advocate (Staff R) was conducted and reveals Staff C was notified on 4/29/2025 by the house supervisor that P-1's sister called the facility and was very concerned because when she called to make arrangements to pick up her brother's belongings and the nursing house supervisor told her that he did not know where her brother's body was located because he was no longer in the morgue. Staff C revealed she began to investigate the concern immediately and was able to determine that a local funeral home had mistakenly removed P-1's body without following the proper procedures. Staff C explained P-1's body was returned to the facility's morgue with his belongings, which were returned to his sister. Staff C explained that P-1's sister had requested the medical examiner consider performing an autopsy on P-1 due to the circumstances surrounding his death and his body should have been on "hold". However, due to a miscommunication the funeral home staff thought they could remove him from the morgue to assist with transporting him to another funeral home about 2 hours away.

During an interview with the Executive Director of Nursing (Staff E) it was revealed an Root Cause Analysis (RCA) was held on 5/19/2025 with the 6th Floor Medical/Surgical Unit Manager (Staff L), Chief Nursing Officer (Staff B), the Director of Risk Management (Staff C), the Supervisor of Patient Experience, and the Chief Medical Officer (Staff F) to review the morgue process. Staff E revealed during the meeting it was determined that the facility's electronic tracking system, "Morgue Manager" did not show all staff which patient bodies have been archived and nobody at the facility was responsible for managing the Morgue Manager system. Staff E also explained that historically the facility allowed local funeral home staff to have badge access to the facility and the morgue to be able to pick up bodies without supervision and the expectation was they were to use Morgue Manager to sign patient bodies out. During the RCA the group decided to no longer allow funeral home staff to have this access and they could no longer remove patient bodies without supervision by facility staff. Staff E revealed the funeral home badge access was removed and the local funeral homes were notified about the change in process by Staff A (Vice President of Operations). The house supervisors and Security staff were educated about the change in process by Staff B. When queried if the facility policy had been updated to reflect these changes, Staff E revealed that these changes had not been finalized in the policy. When queried which staff were educated about the process changes and the dates of the education, Staff E revealed the conversations were verbal and they were unable to provide a list of employees that were educated or the date of the education.

On 6/25/2025 at 0950 an interview with the Chief Nursing Officer (Staff B) was conducted and revealed the access to Morgue Manager has been updated and funeral homes no longer have badge access to the facility. Staff B explained that the house supervisors were notified of the change in process in monthly team meetings, but additional education will be provided to the house supervisors and Security after the policy has been finalized.

Review of facility policy titled "Releasing Bodies to Funeral Homes", policy #16489961, last revised 1/2017 was conducted and revealed in the section titled "Purpose - To establish policy and procedure to be followed in the event of death...to maintain the individual's dignity after death, to provide appropriate documentation of death and to prepare the body for expedient release to the funeral home."

Based on record review and interview, nursing staff failed to follow facility policy/guidelines and acceptable standards of practice regarding Code Blue documentation for 2 (P-1, P-8) of 2 patients reviewed for Code Blue documentation resulting in the potential for increased risk of harm for all patients experiencing a Code Blue at the facility. Findings include:

On 6/24/2025 at 1340 record review was conducted for P-1 and revealed a Code Blue Summary was not found in the medical record.

On 6/25/2025 at 1223 record review was conducted for P-8 and revealed a Code Blue Summary was not found in the medical record.

During an interview with the Executive Director of Nursing (Staff E) on 6/25/2025 at 1230 it was revealed she was aware that the facility had previously identified that Code Blue Summary documentation has not been making it into patient medical records. Staff E explained in the April 2025 Emergency Response Work Group Meeting the topic of adding Code Blue documentation in the electronic medical record was discussed because the team had identified the paper Code Blue Summary was not making it into the electronic medical record. When queried if if is an expectation that the Code Blue Summary become part of the patient's permanent record, Staff E replied "yes we are working on developing a process to document in the medical record electronically because the paper Code Blue forms were not making it into the record".

On 6/25/2025 at 1230 an interview with the ICU/Cardiac Unit Manager (Staff G) was conducted and reveals she is responsible for reviewing the Code Blue Summary documentation. When queried if she was able to review the Code Blue Summary for P-1 and P-8, Staff G said yes and was able to produce a paper copy of the Code Record Summary for P-1. When queried why the summary was not part of the permanent medical record, Staff G said staff was supposed to send a copy to medical records and put one in her mailbox for review, but the copies are not making it to medical record all of the time. When queried if she audits medical records to make sure the documentation in the record is present, Staff G responded she is currently not auditing for that but the Emergency Response Work Group is aware it is a problem and they are working on having the Code Blue Summary information be documented electronically.

Review of Facility PowerPoint presentation from the Emergency Response Workgroup for April 2025 reveals an action plan dated 3/2025 that states "Add Code Blue documentation in (name of electronic medical record)", due date 6/30/2025, in progress.

Review of facility policy titled, "Code Blue Cardiac/Respiratory Arrest in the Hospital/Procedure/Assignments", policy #12850958, last revised 12/2022 reveals in the section, "Responsibilities of Code Team Personnel - Upon termination of a Code Blue, will complete Code Blue Summary, Adult or Pediatric Code Blue orders, and Code Blue Evaluation Sheet, and document positive/negative aspects of the Code. The Cardiac Arrest Record becomes part of the chart and will be completed immediately after the Code."