HospitalInspections.org

Based on the review of the medical records of seven Medicare Recipients, staff interviews, and other hospital presented documents it was found that the hospital failed to establish and implement policies and procedures that effectively ensure that Medicare patients and/or their representatives have the information necessary to exercise their rights to appeal their discharges. This was true for four of seven recipients (patients 11 and 12.)

The hospital is required to present, "An Important Message From Medicare About Your Rights" (IMM), to Medicare recipients and/or their representatives after admission as an in-patient.

Reviewed medical records revealed that two out of seven Medicare recipient's signed receipt of the IMM exceeded two days. The IMM for Patient #11, a 77 year-old patient, was signed on the 20th day of admission. Staff was unable to provide documentation that the patient could not sign nor was an explanation for the significant delay found in the medical record.


The IMM for patient #12 was signed on the third day of admission.

The hospital lacked an effective process or policy governing the administration the IMM. In an interview with the Director of Patient and Visitor Services on January 24, 2018, explanation of the process along with a copy of the workflow guide was discussed. The workflow document was used to instruct staff on the IMM but did not address or provide direction to staff for following up with the patients when the initial IMM is not presented and signed on admission. The workflow also lacked the specific time frame on admission and before discharge as to when the patient and/or their representative should receive the IMM.

Based on review of medical records, staff interviews, and restraint policy, it was determined that staff failed to release one patient from locked door seclusion at the earliest possible time.

Patient #9 was placed in locked door seclusion at 0810 for aggressive and dangerous behavior. At 0926 the patient was documented as "resting quietly." The observed behavior continued to be documented as awake, quiet or resting quiet from 0926 until 1140, but patient remained in locked door seclusion. Reviewed documentation indicated the patient's behavior stopped presenting a risk at 0926, despite remaining in locked door seclusion. A nursing notes at 1040 stated "discontinuation of seclusion was explained; patient refused," and at 1041 "patient refused to leave seclusion." It was the patient's decision to remain in the seclusion room; however, the seclusion room door should have been unlocked and open from the time the patient ceased to exhibit dangerous behavior. The seclusion documentation reflected that the patient remained in seclusion with the door locked until 1140.