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Based on review of 11 medical records and review of hospital policies, it was determined that the hospital failed to provide 1 patient (patient #7) with the initial "Important Message from Medicare (IM)" within 2 days of admission and 1 patient (patient #8) with the Important Message within 2 days of admission and 2 days prior to discharge.

The IM is a standardized form that notifies Medicare patients of their hospital discharge appeal rights and must be provided to each Medicare beneficiary who is an inpatient within 2 days of admission. The IM is to be signed and dated by the patient to acknowledge receipt. Furthermore, the hospital is required to present a copy of the signed IM to the patient within 2 calendar days before the patient's discharge.

Patient #7 was admitted to the hospital on 1/18/2016 for elective surgery. The medical record was reviewed and no initial IM had been completed and placed in the patient's medical record.

Patient #8 was admitted to the hospital on 1/15/2016 and was discharged on 1/21/2016. The patient received the IM on 1/18/2016, 3 days after admission and 3 days prior to discharge.

The hospital's Procedure for Discharge of a Patient was reviewed. Per the procedure the IM is to be signed by the patient at discharge. Review of patient records revealed that Patients #4, #6, #7, #8, #10 and #11 received information about the IM. Signed copies of the IM were not found in the patients' medical records.

Failure to provide Medicare patients the Important Message from Medicare has the potential to violate the patients' rights to the discharge appeal process.

Review of complaint and grievance files and the hospital's policy revealed that the hospital failed to adequately establish a process for prompt resolution of patient grievances. The hospital had identified an email as a complaint which therefore required no documented follow-up. Per hospital policy an email is always considered a grievance. Because the email was identified as a complaint, notification and resolution were not sent to the patient per requirement. This practice has the potential to result in a delayed response to the complainant without notification from the hospital.