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Based on interviews and the review of medical records and other documents, it was determined that nursing services failed to fully implement its care protocol to ensure adequate evaluation and treatment of patients with pressure ulcers or at risk for developing pressure ulcers.
Deficiencies related to the lack of proper management for pressure ulcers was identified in 9 of 11 applicable medical records.

Findings include:

MR #1

This is an elderly patient admitted on 7/21/10 for evaluation of tachycardia and decreased oral intake. The nursing staff did not implement the Pressure Ulcer Prevention and Treatment Protocol that requires documentation of measurements of pressure ulcers at the following intervals:
-on admission;
-upon identification of a new pressure ulcer;
-weekly;
-upon transfer and/or discharge.

The initial nursing assessment on 7/22 did not document the size of the pressure ulcers on the sacrum and the left heel; except for physician assessment on 7/22 at 11:27 that notes two areas of healing ulcer, stage II, 1cm x 0.5 cm and a left heel eschar. The attending admission assessment at 14:29 also noted a stage II, ulcer on sacrum 1x 0.5 cm and several small ones scattered. In addition, evidence of prior healed pressure ulcers at the sacrum was noted. The nursing staff documented a stage II sacral ulcer and an unstageable left heel ulcer with eschar all through the patient admission course. However, there was evidence that the patient's sacral ulcer did not remain a stage II when yellow slough tissue, 0.3 cm x 0.3 cm was identified on 7/26. The facility's Pressure Ulcer Prevention and Treatment protocol notes that a stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Therefore, the nursing staff incorrectly classified this ulcer as a stage II, when the presence of yellow slough tissue was evident; this finding suggests the ulcer had progressed to a stage III. The nursing staff did not appropriately stage the sacral ulcer and provide appropriate intervention.

At discharge of the patient on 7/28, nursing staff did not appropriately stage the patient ' s pressure ulcers, measure the ulcers and formulate a discharge plan to ensure continuity of care. Nursing assessment on 7/28 noted a stage II sacral ulcer with Allevyn in place and a left heel pressure ulcer with eschar but did not note the size of the pressure ulcer in accordance with the Pressure Ulcer Prevention and Treatment Protocol. However, the physician discharge summary note on 7/27, revealed two areas of healing sacral ulcers, stage II, 1cm x 5cm, and a left heel 3 cm x 3 cm, unstageable with necrotic tissue. This was the first time the dimension of the heel ulcer was noted and a change in the dimension of the sacral ulcer was indicated. Based on the review of the patient ' s discharge notice, there was no nursing plan to ensure the patient received continued wound care post discharge. There was a referral for Home Health Services for resumption of the 24 hour Home Attendant, but no specific referral for wound management was documented.

The patient was readmitted on 8/16/10 for evaluation of fever, generalized weakness, tachycardia and poor oral intake. The physician follow up note on 8/17 revealed a large, 5 x 6cm sacral ulcer, with sub-facial tissue visible, malodorous with weeping discharge. The initial nursing assessment noted an unstageable sacral ulcer with moderate drainage, a stage II pressure ulcer to the left heel and a deep tissue injury to the right heel. There were three areas of skin tears to the left upper arm, left under arm, and left chest. Nursing documentation did not include the size of the pressure ulcers and skin tears. Subsequent nursing assessments failed to note the extent of the pressure ulcers in accordance with the Pressure Ulcer Prevention and Treatment Protocol. At discharge, there was no evidence these pressure ulcers were measured.

The nutritional screen failed to recognize the patient significant weight loss related to inadequate appetite on the initial nursing assessment on 8/17 and on the previous admission on 7/22; nurses noted on both assessments that the patient was eating usual diet and had no weight loss in six months. Geriatrics Resident follow up note on 7/22 revealed the patient ' s family reported approximately 15 lbs weight loss in two months; she had loss of appetite and swallowing difficulties. However, on both admissions, nutrition assessment was within 24 hours of admission due to a different trigger, the presence of pressure ulcers.

--MR #2-
This record reflected delay in provision of wound care consultation. Discharge documentation in the record did not reflect measurement of multiple ulcers at discharge and contained inconsistencies about the location of pressure ulcers and discharge instructions for the treatment of pressure ulcers. In addition, there was a gap in documentation for turning and repositioning of the patient every two hours as required by hospital policy.

This 75 year old male was admitted to the hospital following transfer to the ED on 10/19/10 at 1922 hours from a nursing home with fever and lethargy. Patient had purulent urine .Patient's history was significant for HTN, A-fib , CAD s/p stent placement, and two previous strokes with residual left hemiparesis and aphasia.
The patient was hospitalized multiple times previously for UTI's and multiple resistant organisms, including Acinetobacter, proteus, enterococcus , and urosepsis of his infected stage IV sacral pressure ulcer, which had been debrided in past. The patient had been treated with wound vac at the nursing home.

In the ED on 10/19/10 it was noted the patient had pressure ulcers and wound vac. In the ED on 10/20/10 it was noted at 1200 the patient had a stage 4 sacral decubitus 8 cm x 7 cm x 2.5 deep, and 1.5 cm undermining. The patient's albumin level on 10/19/10 at 21:01 was noted as 1.7.

The patient was sent to the 10 N inpatient unit on 10/20/10 at 1910 hours. Medical documentation at 14:29 on 10/20/10 noted " 8 X 7 X 3 cm back sacral ulcer with undermining 1.5 cm; Generally clean granulation tissue with small areas of slough." "+ left trochanter stage II with erythema, + right trochanter stage I, and skin tears on arms". No measurement was recorded of the trochanter wounds. At that point the plan noted to resume vac wound care.

The nursing adult admission history form dated 10/21/10 at 3:43 noted pressure ulcer of buttock on the problem list, but there was no documented evidence of skin assessment, measurements taken, or staging.

There was no evidence the staff implemented the physician's orders for PEG tube feedings to meet the patient's nutritional needs. For example the order dated 10/21/10 at 1157 noted Promote @ 45 ml/hr to increase by 15 ml, Q8H, for a target rate of 100 ml/hour . Review of nursing intake and output record demonstrated this rate had not been delivered as prescribed.

Review of nursing electronic record determined a gap in turning and repositioning of the patient as required. On 10/22/10, the patient was turned Q 2H at 1600, 2000, and the next entry for turning Q2H was recorded at 0800 on 10/23/10.

The patient received a consultation from the wound care nurse on 10/25/10 (5 days after admission). The note did not reflect measurement of the wounds. Although the facility's policy for Pressure Ulcer Prevention and treatment protocol requires a wound consultation for stage III and IV pressure ulcers, the policy does not specify a time frame for provision of this consultation to address the need for timely interventions for wound care.

There was a discrepancy in the documentation between the wound care nurse and other medical/nursing staff regarding the descriptions of pressure ulcers and directions for wound care. For example, follow up wound care nursing note on 10/27/10 at 19:46 noted the patient had stage IV sacral pressure ulcer measured as 6.2 x 5 x 1.5 cm with undermining from 8-3 pm = 2.3 cm. It was noted the left hip Allevyn foam dressing was removed and was not a pressure ulcer but likely a site from a previous pressure ulcer which healed. Left hip had hyperpigmented skin and flaking of skin. It was stated to continue with negative pressure wound therapy and to keep the duoderm to left hip for protection between 5-7 days.

Discharge instructions were inconsistent regarding the nature and directions for care of the pressure ulcers. At the time of discharge on 10/28/10, nursing instructions noted wound /ostomy care at four sites:
"Site #1: sacral pressure ulcer requiring wound vac at 75 mm Hg continuous therapy-frequency of dressing change: three times daily
Site #2: left hip pressure ulcer -apply xeroform dressing- frequency of dressing change daily
Site #3: right hip -healing pressure ulcer- cover with Tegaderm
Site #4 : left forearm abrasion-cleanse with normal saline, cover with tegaderm- keep dressing dry for daily." Activity noted no restrictions.

MD discharge instructions signed 10/28/10 at 1553 indicated the patient required Solosite and moist dressing (saline gauze) to sacral ulcer once per day, wound vac x 30 days and xeroform dressing x 30 days. Additionally, it noted xeroform dressing to left hip pressure ulcer to be changed daily. No information was recorded about the ulcer on the right hip.

MR #3:
The record for this patient did not demonstrate compliance with the facility's pressure ulcer protocol, in that the patient developed a stage I ulcer on the buttocks and nursing staff did not document the size of the stage I ulcer upon its identification and at discharge. In addition, discharge instructions did not document the presence of the skin ulcer, whereas nursing documentation on the date of discharge reflected the presence of the stage I ulcer on the buttocks.

This 100 year old patient was admitted to the facility on 8/19/10 for altered mental status and right sided weakness. Patient found to have large L MCA stroke. On 8/19/10, nursing ICU record noted no skin breakdown. The patient scored 11 on the Braden scale on 8/19/10 and the pressure ulcer prevention and treatment protocol was started due to the high risk score. Skin was intact with no breakdown based on review of ICU assessment notes. On 8/22/10 and 8/23/10 nursing records noted skin was intact with no breakdown. Turgor was good.

On 8/23/10 at 1832 hours the interdisciplinary plan of care noted a stage I pressure was identified on the buttocks.

Nursing discharge instructions dated 8/25/10 contained no reference to the existence of the pressure ulcer but indicated need to "turn and position". No frequency was listed. Medical discharge summary notes dated 8/25/10 also did not reflect the presence of the stage I pressure ulcer.





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Similar findings were noted in the following 6 medical records:

- MR # 4 had no measurements of the L buttock Stage II throughout the stay from 10/24/10-10/27/10.
- MR # 5 had no measurements of the sacral Stage II throughout the stay from 10/22/10-10/27/10.
- MR # 6 had no measurements throughout the stay from 10/17/10-10/27/10 of the sacral Stage II that later developed eschar.
- MR # 7 had no measurements of the sacral Stage I throughout the stay from 10/26/10-10/27/10.
- MR # 8 had no depth measurement for the sacral Stage III on 10/27/10.
- MR # 9 had no measurement of the sacral Stage II from 7/11/10 to the discharge day of 8/13/10.

Review of the medical records on 10/27/10, 10/28/10, and 11/4/10 noted that the M/S section of the electronic MR had a check off box for turning that does not specify how often the turning occurs.

Based on review of medical records and hospital policy, it was determined that blood transfusions were not administered in accordance with hospital policy. This finding was evident in 2 of 4 applicable records reviewed.

Findings include:

Review of medical record and hospital policy conducted on 10/27/10 to 10/28/10, noted that nursing staff did not adhere to the Hospital Policy # PROC 750, titled "Blood, Blood Components, Factor Concentrates and Factor Derivatives Administration Procedure."

For example:
Policy states that administration for a blood transfusion must not exceed 4 hours per unit. Review of MR # 10 on 10/27/10 noted that on 10/18/10, one unit of packed red blood cells was transfused from 18:00 to 22:15.
Policy states that electronic documentation is to include transfusion end time and a transfusion post assessment. Review of MR # 10 on 10/27/10 noted that on 10/20/10, an end time was documented 14 hours after the start time. The record noted the transfusion start time was 0200 and the end time was 1600. Review of MR # 11 on 10/27/10 noted that a platelets transfusion that started on 10/20/10 at 18:55 had no end time indicated and no post transfusion assessment vital signs.

Based on medical record review, it was determined the facility did not ensure that a patient with a stage IV pressure ulcer received adequate protein intake to meet the patient's nutritional needs to promote the process of healing.

Findings include:

Review of MR #2 on 10/28/10 noted this elderly patient arrived to the emergency department on 10/19/10. The patient was admitted to the hospital for work up of fever and lethargy. It was noted in the ED record and the admitting history and physical that the patient had arrived with a stage IV sacral pressure ulcer from the nursing home. Initial nutritional assessment dated 10/21/10 at 14:03 noted that the patient had a GT tube and patient's estimated nutritional requirements were 2238 calories-140 grams of protein. The dietitian indicated awareness of the pressure ulcer. However, the initial nutrition assessment dated 10/21/10 did not document the blood lab result of low albumin of 1.7 g/dl on 10/19/10.
The prescribed diet on 10/21/10 at 11:57 was Promote at 45 ml/hour x 20 hours with increments of 15 ml per hour, Q 8H, to meet the target rate of 100 ml/hour. The delivery of this order meant that the prescribed diet, without increments, provided the patient at the beginning of this order with approximately 900 calories and 56 grams of protein, which was insufficient to meet his immediate nutritional needs. The estimated protein needs of this patient on 10/21/10 was 140 grams of protein and the blood albumin was 1.7g/dl. The calculation of this order finds that increments delivered at a target rate of 100 ml would not have been achieved for approximately 2.5 days; hence a protein supplement was indicated. Additionally, low blood albumin was not addressed in the diet prescription. The nutrition consult did not consider the evident need for protein supplements to be added to the GT feeding as an interim measure pending the completion of the target rate. Therefore the patient's protein needs were not met to provide immediate nutritional intervention to facilitate wound healing.

The nutrition reassessment dated 10/25/10 indicated the nutritionally relevant labs were within normal limits, despite a repeat albumin of 1.6 g/dl on 10/21/10.

Based on review of records and staff interviews, it was determined that the facility did not consistently provide referrals for identified discharge needs or demonstrate complete integration of pertinent information into written discharge instructions.

Findings include:

The facility did not ensure that information on discharge instructions was complete. Additionally, discharge instructions did not consistently document relevant discharge referrals or include post discharge needs . In 9 of 14 applicable records reviewed for discharged patients, discharge plans/instructions were incomplete or did not include referrals for recommended post discharge needs.

Examples include:


MR # 1:
This 95 year old patient with multiple medical problems including past history of dementia and stroke, was admitted on 7/21/10 for tachycardia and decreased oral intake. The patient had multiple pressure ulcers. The patient was discharged to home on 7/27/10 with reactivation of 24 hour home attendant care, which she had prior to arrival. A referral was made for reinstatement of home attendant services by the social worker. The discharge plan was incomplete because there was no evidence of referrals considered for skilled nursing needs, including need for wound care of pressure ulcers. Additionally, the information on written medical and nursing discharge instructions was inaccurate as both indicated the patient receives a healthy regular diet; the consistency of the diet was not specified. This was in direct contradiction to nutrition assessment on 7/23/10 that indicates the patient received a pureed diet and Glucerna supplement TID.
There was no evidence of certified home health care agency orders in the electronic files of the Department of Care Coordination.


MR #12:
There was insufficient evidence of communication of the patient ' s mental state on discharge instructions for a patient who was sent to a skilled nursing facility. This 85 year old female with vascular dementia was living alone and brought to the hospital two days following a fall in which she was on the floor for an extended period. She was brought to the hospital after the neighbor called an ambulance and found to have sustained a subdural hematoma. The patient was known to Adult Protective Services in the community. Inpatient psychiatric assessment determined the patient did not demonstrate capacity to make discharge planning decisions and it was recommended the patient be referred to a nursing home or home with appropriate supervision. The son, who was the health care proxy, preferred placement for the patient due to safety concerns about the unsanitary conditions present at home. The patient had stated to the facility social worker she would rather be dead if she could not return home and the worker had recorded this finding in the patient ' s record along with attempt to calm the patient. Surveyor interview with the patient at approximately 11:30 Am on 10/28/10 revealed she knew she was going to a facility but that she was upset about not being allowed to return home.
Review of discharge documents including PRI did not demonstrate evidence the patient ' s distraught mental state and feelings of wanting to die had been communicated to the receiving facility. The discharge instructions sent for did not incorporate significant information about this patient ' s mental status on discharge to ensure continuity of care for this 85 year old female who was transferred to a sub-acute rehabilitation facility.
Interview with the Director of Care Coordination & Social Work on 10/28/10 at approximately 3 PM determined the facility sends discharge instructions and medical discharge summary with PRI to receiving facilities. At present the facility does not have a coordinated inter-institutional transfer summary which incorporates information from various disciplines and that they will be piloting one.

MR #2:
This 75 year old male was admitted to the hospital following transfer to the ED on 10/19/10 at 1922 hours from a nursing home with fever and lethargy. Patient had purulent urine .Patient's history was significant for HTN, A-fib , CAD s/p stent placement, and two previous strokes with residual left hemiparesis and aphasia.
The patient was hospitalized multiple times previously for UTI's and multiple resistant organisms, including Acinetobacter, proteus, enterococcus , and urosepsis of his infected stage 4 sacral pressure ulcer, which had been debrided in past. The patient had been treated with wound vac at the nursing home.
This patient was discharged to a skilled nursing facility on 10/28/10.
At the time of the tour on unit 10 N on 10/27/10 at approximately noon, it was noted that an incomplete electronic draft of the discharge summary note, dated 10/25/10, was written in advance. Discharge instructions sent to facility were incomplete and did not include consistent information about the multiple pressure ulcers and directions for care. Nursing discharge instructions differed from the documentation in the medical discharge summary and wound care nursing notes about the pressure ulcer sites and directions for care. The Patient Review Instrument (PRI) dated 10/26/10 noted the stage IV sacral decubitus vac dressing and failed to include information about the bilateral hip ulcers or directions for their care.
While it was noted that the family was in agreement, there was no evidence that an admission Medicare IM notice or the Medicare IM discharge appeals notice was signed or mailed to the patient's representative.
See also tag #A396

MR #3
This 100 year old patient was admitted to the facility on 8/19/10 for altered mental status and right sided weakness. Patient found to have large L MCA stroke. The patient developed a stage I pressure ulcer on the buttocks while hospitalized on 8/23/10.
The patient's wife signed discharge instructions at 11:34 on 8/25/10 for transfer to an inpatient hospice facility. There was no evidence the admission IM was provided and no indication that the discharge IM was provided at least four hours in advance of discharge as required.
Discharge instructions were incomplete and did not contain information about the patient ' s stage I pressure ulcer upon transfer to inpatient hospice. These contained no reference to the existence of the pressure ulcer but indicated need to "turn and position". No frequency was listed. Medical discharge summary notes dated 8/25/10 also did not reflect the presence of the stage I pressure ulcer.
See also tag # A396

MR #21:
This patient had an incomplete discharge planning assessment which failed to address evident safety needs at home. This 87 year old female was brought to hospital on 10/22/10 after having fallen at home. The patient could not recall what had happened. Patient was treated for pneumonia and ARF. Patient was found to have lung nodules and staff planned for outpatient biopsy. The Social Work assessment was not provided until the date of discharge and was incomplete. The assessment noted the patient was recommended for discharge home without services and that she would transport herself home "on her own recognizance." The patient declined the worker's offer to call her family. It was noted the patient had no further social work needs.
The assessment was incomplete because the patient had fallen at home, lived alone, and ambulated only with a cane. No options were provided or assessment for safety.

MR #13:
This patient was discharged on 8/24/10 with inaccurate patient discharge information which included written instructions for administration of dalteparin and Lovenox. It was determined on chart review, the patient was supposed to be on Lovenox only. A follow up note dated 8/25/10 by the PA indicated the patient was discharged on Lovenox and dalteparin the day prior. The PA noted discussion with SW indicated the patient was provided only with Lovenox and instructed to be taking Lovenox only. Follow up unsuccessful efforts were made to reach the patient and a call was made to the MD office staff to follow up. A review of the Home care orders or this patient dated 8/25/10 did not reference a medication list or indicate the outcome of this error made in medication instructions issued to the patient.

MR #14:
The discharge planning assessment was incomplete for this 83 year old patient with Alzheimer disease and Diabetes Mellitus type II who was admitted for lethargy and SOB on 10/20/10. The patient was treated for hyperglycemia and pneumonia.
During tour of the unit by the surveyors on 10/27/10 at approximately noon, it was determined from staff interview that the patient would likely return home that day. A review of the record at that time determined the patient's written discharge summary was completed in advance of discharge on 10/25/10.
Follow-up review of the record determined that the social worker noted on 10/27/10 at 16:26 that this patient was medically cleared for discharge and that arrangements were made to continue home care to start on 10/28/10. Additionally a referral was made for home PT to a certified home health care agency. However it was also noted the discharge was unsafe at that time since the family could not be reached to confirm acceptance of the patient.
The record notes the provision of patient discharge information instructions at 1848 hours on 10/27/10. There was no outcome noted with respect to contact of the family to ensure the final disposition. The discharge instructions were incomplete because these did not include evidence of home PT referral. Follow up with the hospital for review of home care orders on 11/5/10 revealed home care orders included skilled PT.
Additionally, the high risk admission screen provided for this patient on 10/21/10 was inaccurate. The screen noted " evidence of lack of sufficient service in community, i.e. dehydration, found lying on floor, etc. Continuing care needs. " It was determined on interview with the social worker on 10/27 that this form is a computer generated electronic high risk screen . This category populates the record. The patient had never fallen. Follow up discussion with Director of Care Coordination/Social Work on 10/28/10 determined this screen was designed in this manner and this category includes examples, of which some elements may not be relevant to the patient.


MR #15:
This 45 year old female underwent ORIF for a left ankle fracture. Physical therapy assessed patient in the hospital and provided education along with crutches. The record noted the patient would be staying with family in a walk up apartment with one flight of stairs. The patient was assessed to be safe for discharge with home with family, but it was noted she would have to negotiate stairs while sitting with her brother's help. The patient was discharged on 10/28/10 with recommendations from PT on 10/28 for skilled PT rehabilitation to address impairments related to non weight bearing on LLE and safety with functional mobility. A Home Program was recommended. The written discharge instructions did not address this need. The MD documented on the discharge summary that patient "progressed appropriately with PT " .


MR #16:
This 96 year old patient was admitted on 8/5/10 after falling at home. He was discharged to a nursing home on 8/20/10. Review of the Patient Review Instrument ( PRI) record failed to include the patient ' s psychiatric assessment dated 8/16/10 and 8/20/10 which indicated he had no capacity.
Review of PRI dated 8/17/10 lacked inclusion of information about the results of the psychiatric consultation which found the patient to lack capacity. Pt was discharged to a nursing home and this document lacked inclusion of information about the patient's mental status.

Based on review of hospital procedures, QAPI documents, and staff interviews, it was determined the hospital has not fully reassessed significant elements of the hospital's discharge planning process.

Findings include:

It was determined the hospital's discharge planning quality improvement process did not include:
-activities to monitor the timeliness or provision of Medicare discharge appeals notification documents required by CMS;
- complete quantitative analysis of home care agency referrals by agency;
- review of services provided by the on-site certified home health care agency staff .

1. The hospital's QAPI did not identify the lack of formal hospital-wide procedures to ensure compliance with CMS notification requirements for inpatient Medicare beneficiaries about hospital discharge appeal rights.
CMS requirements include specific criteria for the mode and timeframes for delivery of the Important Notice to Medicare Patients ( IM) to patients. CMS mandates IM provision within 48 hours of admission and requires that written follow up notification be issued within 48 hours in advance of discharge, but not less than four hours prior to discharge.

Interview with the Vice President of Regulatory Affairs on 10/29/10 at approximately 1400 determined the hospital is still working on finalizing a draft policy. At that time a draft policy, titled "Notification of in-patient Medicare beneficiaries about their hospital discharge appeals rights" was provided which described a process for distribution of the required Important Notice to Medicare patients. This Federal requirement has been in effect since 2007.

It was stated by the administrator that discharge notices are provided to all patients prior to discharge and are automatically generated when discharge instructions are printed from the computer system. The provision of the notice in this manner does not meet regulatory time frames as required which mandates distribution of the follow up IM in not less than four hours in advance of discharge. The hospital has no tracking system to monitor required time frames.

Interview with case management and nursing staff from inpatient units demonstrated inconsistencies when queried about the system for IM admission notice and discharge appeals notification process. During interview with a member of the nursing staff on unit G10N on 10/27/10, it was stated she was unsure if the patient receives and signs the admission IM notice. Another employee stated the Case manager provides the admission packet to patients. A third employee stated it was the staff of the Admissions Department who provide the initial IM notification after admission.

Applicable medical records reviewed on all dates of the survey demonstrated lack of compliance with Medicare requirements for provision of either the initial Medicare admission (IM) notice or delivery of the correct Medicare discharge appeals notice within regulatory time frames. The regulations mandate IM issuance within two days of admission and require delivery of the follow up IM discharge appeals notice no longer than two days prior to discharge or no less than four hours prior to discharge.

It was determined during the majority of chart reviews that Medicare patients are receiving an incorrect discharge notice. Specific reference is made to the finding that the IM discharge notice being delivered is the notice required by New York State for patients receiving insurance other than Medicare.

This form did not contain consistent language as required by the CMS issued Important Message from Medicare notice (IM). Interview with the hospital administrator on 10/29/10 determined that the discharge notice being generated by the computer for discharge is in fact a discharge notice required by the State of New York. According to CMS, hospitals must use a standardized form (CMS-R-193) referenced in Section 200.6.2. The hospital must display " Department of Health & Human Services, Centers for Medicare & Medicaid Services " and the OMB number. Hospitals may not deviate from the content of the form except as permitted in Section 200.6.

In 25 of 25 applicable records for Medicare patients, there was no evidence that patients received either the IM admission notice or the correct Medicare IM discharge notice. In instances when the patient was unable to sign, there was no documentation of follow-up efforts made to provide the notice to the patient at a later time or of submission of these forms to the patient's representative as required.
Examples include:
The following records lacked one or more of the following:
-provision of the admission IM notice within 48 hours of admission;
-provision of the discharge IM notice at least 48 hours prior to discharge, not less than 4 hours prior to discharge;
-follow up contact with patient and/or representative when the patient was unable to sign for the receipt;
-distribution of the correct standardized Medicare notice as required by CMS.

Refer to MR #s 1, 2, 3, 4, 8, 10, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 27, 28, 29, 30, 31.

2. Review of 2010 second quarterly PPR Provision of Care Social Work Data reporting form tool for chart audits on 10/28/10 determined the hospital did not monitor performance outcomes specific to activities of certified home health agency staff who perform on-site pre-discharge inpatient assessments. During interview with the Director of Care Coordination /Social Work on 10/28/10, it was stated that the hospital authorizes staff from one particular certified home care agency to work in the hospital to assess inpatients who are potential home care candidates prior to discharge.

While QI reports review the numbers of medical records with home care referrals and provision of listings for home care agency choices, these reports lacked monitoring for on-site certified home care agency staff who provide pre-discharge inpatient assessments.

It was stated during interview with the Department of Care Coordination/ Social Work Director on 10/28/10 that the activities of the on-site certified home health care agency staff were not separately evaluated.

The Care Coordination department did not monitor trends in referrals to specific home care agencies. Computer generated numbers indicate the total number of referrals made to all home care agencies each quarter and did not reflect an itemized analysis of referrals made to each specific home health care agency. The statistics reviewed for 2010 noted a total of 1554 discharges were made to all home care agencies made during the third quarter of 2010. At interview with the Director of Care Coordination/Social Work on 10/28/10, it was stated that the total number of home care referrals are monitored, but further analysis by agency or category is not conducted.
It was determined quality assurance documents did not reflect a quantitative breakdown of the distribution of home care agency referrals made to each home care agency to determine trends nor a coordinated effort to audit actual implementation of an initial visit by the home care agency following discharge.