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UNIVERSITY OF MD CAPITAL REGION MEDICAL CENTER
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on a review of 10 closed medical records, it was determined that the hospital failed to provide the Important Message for Medicare for 6 Medicare recipients as required by the regulation. Specifically, 4 patients received 1 of the 2 required "Important Messages", and 2 patients did not receive the "Important Message".
There was no second " Important Message" found in the medical records two days prior to discharge for the following 4 patients.
Patient #2 was admitted on 9/21/2014 and discharged on 10/3/2014.
Patient #3 was admitted on 9/21/2014 and discharged on 10/1/2014.
Patient #4 was admitted on 9/24/2014 and discharged on 10/1/2014.
Patient #7 was admitted on 9/8/2014 and discharged on 10/3/2014.
There were no "Important Messages" found in the medical records for the following two patients.
Patient #5 was admitted on 9/24/2014 and discharged on 10/2/2014.
Patient #6 was admitted on 9/23/2014 and discharged on 10/3/2014.
In addition the hospital has no policy for providing the second "Important Message." The admitting clerks currently provide the first message, but assignment of responsibility does not exist in policy regarding the provision of the message prior to discharge.
PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING
Tag No.: A0130
Based on the review of 2 open and 10 closed medical records, it was determined that 1 patient who was discharged in October 2014 did not have a plan of care developed for post discharge pain relief.
Patient #1 was admitted on 10/2/2014 and was discharged on 10/6/2014 to an apartment following leg surgery. A review of patient #1's medical record found no pain assessment on discharge or prescriptions for post hospital pain medication.
During an interview conducted by the surveyor with one of the patient's surgeons on 1/5/2015 the surgeon stated that while he could not recollect this specific discharge it would be highly unusual to discharge this type of patient without a pain management plan. However there was no documentation of either prescriptions or patient education regarding pain management found in the the patient's medical records.