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Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.

Findings include:

A review of the quality assurance plan on June 18-19, 2015, failed to show any evidence of quality assurance monitoring for the following contracts: Lithotripsy, Anesthesia, Linen/laundry, or Radiology.

An interview conducted on June 19, 2015, at 10:00 AM with EMP2 revealed the facility could not show that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.

Based on a review of medical records (MR), facility documentation, and employee interviews (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare.

Findings include:

A review of medical records revealed the facility failed to provide the patient or the patient's representative a copy of the "Important Message from Medicare (IM)" for four of seven medical records reviewed (MR12, MR13, MR16 and MR17).


A review on June 19, 2015, of facility policy "Important Message From Medicare Policy revision date 2/3/2014" revealed "...I ...The final rule requires hospitals to deliver a revised version of the Important Message from Medicare to inform Medicare beneficiaries who are inpatients about their hospital discharge appeal rights. Notice is required both for Original Medicare beneficiaries and for those enrolled in Medicare Advantage (MA) plans and other Medicare health plans subject to the MA regulations ... II. Who the Important Message Applies to : A. The final rule applies to all Medicare beneficiaries, including enrollees in Medicare Advantage(MA) plans and other Medicare health plans subject to the MA regulations. B. All Medicare beneficiaries, no matter where in the sequence of payers Medicare falls, must receive the IM and Detailed Notice ...II ...Initial(On Admission) Delivery of the Important Message from Medicare(IM). The Important Message from Medicare may be given if the beneficiary is seen during a preadmission visit as long as the visit is not more than 7 calendar days in advance of the admission ...A. Delivery of the Important Message from Medicare (IM) at or near admission, but no later than 2 calendar days following the date of admission ...D. Give the original signed and dated IM to the patient or his/her representative. Place a copy of the signed and dated IM in the patient's medical record ...III. Delivery of the Follow-up IM Prior to Discharge: ...A. Provide the patient or his/her representative a new IM within 2 calendar days of the day of discharge. Give the patient's or patient's representative a new IM within 2 calendar days of the day of discharge. Give the patient or the patient's representative the second signed and dated IM and place a copy of the second IM in the medical record."
A review of medical records revealed MR12, MR13 and MR17 did not have documentation of the Important Message from Medicare being signed by the patient upon admission. The review of MR16 revealed that the medical record did not have documentation of the Important Message from Medicare being signed by the patient within 2 calendar days of the day of discharge. Further review of medical records revealed that MR17 did not have documentation of the Important Message from Medicare being signed by the patient upon admission and discharge.
An interview conducted on June 19, 2015, at 8:50 AM with EMP5 revealed the Important Message from Medicare is only signed by patient's that have Medicare as the primary insurance. Further interview confirmed that the facility policy is not being followed.

Based on a review of facility policy and interview with staff (EMP), it was determined that Memorial Hospital failed to follow their complaint policy by not ensuring that the patient received follow up regarding their complaint.

Findings include:

A review on June 18, 2015, of facility policy "Patient complaint and grievance policy revision date: December 17, 2012" revealed "...Patient complaint: Definitions: A complaint is any expression of dissatisfaction expressed by a patient or family member regarding care, services, a situation, or a staff member that can be resolved immediately, on the spot, by the staff, managers present or their designee ...Patient Grievance: Definition: A grievance is a formal or informal verbal or written complaint that is made to the hospital by a patient, or patient's representative, regarding a patient's care, abuse, or neglect, and issues relating to the hospital's compliance guidelines, which has not satisfactorily been resolved from the patient's or their representative's perspective during or after the episode of care ..."
A review of facility's complaint/grievance log revealed that the facility had designated the concerns reported to the facility as complaints and that the facility had no grievances.
An interview conducted on June 18, 2015, at 2:00 PM with EMP4 revealed that after reading the CMS regulation many of the complaints in the log should have been reported as grievances. Further interview revealed that the facility has not been following their complaint and grievance policy.

Memorial Hospital was not in compliance with the following Federal regulations related to the use of restraints:

482.13(e)(5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner.

This regulation is not met as evidenced by:

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that physician's order contained documentation as to the type of restraint ordered or the time frame for four of four restrained patients' medical records (MR11, MR12, MR13, and MR18).

Findings include:

A review facility policy "Management of Restraints" revised date March 2015 revealed "...C. Orders ...3. The order must have the following elements: a. Date, b. Start and stop time, c. reason for restraint, D. type of restraint used ...g. Time limit for order (max 24 hours). **Physician orders which are missing any of the elements listed above will not be transcribed by the unit secretary and/or the nurse ..."
A review of medical records (MR11, MR12, MR13, and MR18) revealed that the physician's orders did not have documentation as to the type of restraint ordered or the time frame.
An interview conducted on June 19, 2015, at 10:00 AM with EMP6 confirmed that the orders did not indicate the type of restraint or the time frame. Further interview revealed that the physicians would have to manually type in the type of restraint and the time frame into the electronic medical record.

482.13(e)(10) The condition of the patient who is restrained must be monitored by trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

This regulation is not met as evidenced by:

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure accurate documentation of the required patient monitoring for four of four restrained patients' medical records (MR11, MR12, MR13, and MR18).

Findings include:

A review of facility documentation "Management of Restraints", revised March 2015, revealed "...D. Documentation: 1. Document in cerner restraint tab Q 2 hours while the patient is in restraints. 2. During these assessment the following observations must be noted: Circulation, observe behavior, comfort measures, fluids/nourishment, hygiene and elimination, continued need for restraints, and removal of restraints, position change, ROM (range of motion) and skin care".

A review of MR11, MR12, MR13, and MR18 did not contain documentation of assessment of circulation, removal of restraints, ROM and skin care.

An interview conducted on June 19, 2015, at 10:00 AM with EMP6 confirmed the medical records did not contain documentation of the assessment of circulation, removal of restraints, ROM and skin care.

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.

Findings include:

A review of the quality assurance plan on June 18-19, 2015, failed to show any evidence of quality assurance monitoring for the following contracts: Lithotripsy, Anesthesia, Linen/laundry, or Radiology.

An interview conducted on June 19, 2015, at 10:00 AM with EMP2 revealed the facility could not show that all contracted services were evaluated for quality assurance to ensure that services were provided in a safe and effective manner.