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Based on review of 6 grievance files and hospital policy, it was determined that the hospital failed to provide 3 patients with detailed resolution letters including the steps of the investigation, the results and the date completed.

Findings include:

Compliant with this regulation, the hospital's Patient Complaint Policy and Procedure (dated 02/2019), Section 3.3.4.1 stated "The final correspondence to the patient must contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion".

In all three letters, the second paragraph restates the patient's complaints. The third paragraph then states that the "concerns were shared with (staff members from appropriate department) and we will continue to take steps to improve our process". No investigation process was discussed and no completion date is listed. The letters contained scant investigative details and no explanation or resolution for the specific grievances.

Based on review of 7 open and 3 closed records, interviews and hospital policy, it was determined that the hospital failed to supply Patient #4 (P4), a current inpatient, and Patient #6 (P6) with the Important Message from Medicare (IMM) within 48 hours of admission.

Findings include:

Medicare Important Message Policy dated 12/3/2018, Section 2.3, "All inpatient Medicare Beneficiaries will be notified about their discharge appeal rights with the Standardized Important Message Notice. This includes beneficiaries with: 2.3.2 enrollment in Medicare Advantage and other Medicare health plans under MA regulations."

1) P4 was a 65+ year old patient who presented to the Emergency Department (ED) for evaluation of medical and behavioral health conditions. The patient was admitted for 10+ days for treatment and had no IMM was given on admission.

According to the patient's medical record, the insurance listed was a Medicare Advantage Group Plan. Further review failed to show that the Important Message was given to the patient at any time during their stay. When discussed with staff while reviewing the chart, they stated that their understanding, contrary to hospital policy and regulation, was that patients with a Medicare Advantage Plan do not require the Important Message, and that only patients with regular Medicare are required to receive it.

2) Patient #6 presented for a scheduled surgery. Review of P6's medical record showed that the hospital failed to inform P6 of the patient's discharge appeal rights in the Important Message from Medicare (IMM). Patient #6 was admitted to the hospital post- surgical procedure for additional monitoring prior to transfer to rehabilitation facility. The medical record was reviewed on the fourth day of hospitalization the patient and/ or patient's representative still had not reviewed and signed the IMM.

The hospital had provided a copy of the IMM for P6 that was signed on the day of survey, after record review. This IMM notification exceeded the 48 hour timeframe established in the regulation.

Based on review of 7 open medical records, 3 closed medical records and other pertinent documents including policies and procedures, interviews with staff and patients and observations, it was determined that the hospital failed to conduct initial discharge planning assessments, follow up, or appropriately document for 2 of the 3 closed medical record reviewed.

Patient #9 underwent a scheduled elective surgery. The patient was evaluated post-surgery by both Physical and Occupation therapy services, who recommended that the patient be discharged to a rehabilitation facility. Review of the medical showed that the patient was deemed ready for discharge; however, P9 was held an additional day due to needed insurance follow up. The hospital failed to ensure that needed follow-up and planning was in place for this surgical patient.

Patient #10 was a 70+ year old who presented to the emergency department due to an ankle injury from a fall. Patient #10 was admitted for treatment that included consults from orthopedics, neurology, wound - ostomy nurse, and physical therapy services. The recommendations were for non-surgical management, and for the patient to be transferred for continued services at an acute rehabilitation facility. The patient was documented as stable for discharge and was accepted to an acute facility; however the patient remained hospitalized for an additional day prior to being discharged. Patient #10's medical record contained only one documented note from case management services, which lacked elements that were to be included in the initial assessment for discharge planning. In addition this note was documented as being performed one day prior to the patient's admission date, but was noted as being transcribed on the day of discharge.

The hospital failed to conduct and document a timely initial assessment of needs for patient #9 and #10. This failure in both cases contributed to an extended hospitalization stay. Case Management progress note for patient #10 were not clear as to when the information was obtained as the time noted was prior to admission.

Based on a review of 7 open and 3 closed records and policy and procedures it was determined that the hospital failed to provide a safe discharge for Patient #8 (P8) as evidenced by staff not verifying a patient's correct address, not following a physician discharge order and sending a confused and disoriented patient to the wrong address at discharge.

Findings include:

Discharge Planning Policy dated 09/20/2018, Section 10.1 "Transferring Patients to Nursing Home: Transfer arrangements will be coordinated through the Social Worker or Case Manager with the physician, receiving facility and family or patient representative". Section 10.2 "The Case Management staff will ensure all appropriate paperwork is completed and ready for transfer".

P8 was a 65+ year old patient who was transported to the Emergency Department (ED) by a private ambulance from a Long Term Care/Rehabilitation facility for evaluation and treatment for abnormal lab work. Upon examination by the ED physician and nursing, it was documented that the patient was only oriented to self and not place or time. After a few hours in the ED, the patient was determined to be medically stable and an order was written by the physician for the patient to be discharged back to the rehabilitation center. No Social Work or Case Management notes were found in the patient's medical record.

Two certification forms were filled out by the physician for the private ambulance to transport the patient back to the Long Term Care (LTC) facility. One form had two different address listed, neither of which were the address of the LTC where the patient currently resided. Multiple notes were written by the physician and nursing that stated "patient was sent here from a rehabilitation center." However, on discharge, the discharging nurse sent the patient to an address that was not one of the ones on the certification forms, and it was also not listed in the patient's records, and it was not the address of the patient's LTC residence. P8 was also not transported by private ambulance but by a private company transportation service at 11:30 p.m.

The homeowner residing at this address was able to assist the patient in returning to the original rehabilitation center where the patient resided.

Due to the lack of communication between administration, physicians and nursing, a disoriented patient was placed in a dangerous situation that could have resulted in a dire outcome.