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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 (IM)" for three of five medical records reviewed (MR1, MR2, and MR3).

Findings include:

Review of facility policy "Important Message From Medicare (IMM)" last reviewed September 2013, revealed "...Procedure: The first IMM is issued by the admission staff (no more than 7 days prior), must be signed/dated by the patient or representative, and provided a signed copy at that time. The second IMM is presented to the patient or representative by admission staff at least 72 hr following admission but no more than 48 hours prior to discharge. The second IMM must be signed/dated by the patient or representative, and the patient is provided a signed copy at the time..."

A review on May 14, 2015, of MR1, MR2, and MR3 revealed the Important Message from Medicare was not contained in the medical record for three of five medical (MR1, MR2, and MR3) records reviewed.
An interview conducted on May 14, 2015, at 10:35 AM with EMP1 confirmed the medical records did not have a signed copy of the "Important Message From Medicare."

Based on review of facility documents, medical records, patient interviews (PT) and interview with staff (EMP), it determined that the facility failed to have a system in place to ensure that a patient's family or representative of their choice and physician were contacted as soon as possible after the patient was admitted for five of five medical records reviewed (MR1, MR2, MR3, MR4 and MR5).

Findings include:

A review of facility documents failed to reveal evidence of an approved facility system that the patient's family or representative of their choice and physician would be contacted as soon as possible after the patient was admitted.

A review on May 14, 2015, of MR1, MR2, MR3, MR4 and MR5 revealed no documentation that the patient's family or representative of their choice and physician was notified as soon possible after the patient was admitted to the hospital.

Interviews conducted on May 14, 2015, from 1:30 PM to 2:30 PM with PT1, PT2, and PT3, confirmed that the patient's family or representative of their choice and physician were not notified as soon possible after the patient was in the hospital.

An interview conducted on May 14, 2015, at 10:30 AM with EMP1 confirmed that the facility did not have a system in place to ensure the patient's family or representative and physician were notified promptly after the patient was admitted. Further interview with EMP1 confirmed that MR1, MR2, MR3, MR4 and MR5 did not contain documentation that the facility asked the patient if the patient wanted their physician to be contacted.

Based on review of facility documents and interview with staff (EMP), it determined that the facility failed to have a written procedure for investigating allegations of abuse and neglect that occurred in the hospital, and a written procedure with methods to protect patients from abuse while the investigation is being conducted.
Findings include:

A review of facility documents failed to reveal evidence of a written procedure for investigating allegations of abuse and neglect that occur in the hospital, and a written procedure with methods to protect patients from abuse while the investigation is being conducted.
An interview conducted on May 14, 2015, at 10:25 AM with EMP1 confirmed that the hospital does not have a written procedure for investigating allegations of abuse and neglect that occur in the hospital, and methods to protect patients from abuse while the investigation is being conducted.

Based on review of facility policy and staff interview (EMP), it was determined the facility discharge plan did not match the needs as determined by the discharge planning evaluation for one of 25 medical records (MR) reviewed (MR9).

Findings include:

A review on May 13, 2015, of MR9 revealed the following endocrinology notes:

A review of "Endocrinology Inpatient Consult Report" dated February 18, 2015, revealed, "...He was diagnosed with T2DM > 10 yrs ago, based on routine blood work, never been on any meds, A1c on admission 12.9%, He has no PCP, no health insurance..." Further review of the consult revealed, "...He need SW assistance on how to get the insulin/s on discharge..."

A review of "Endocrinology Inpatient Consult Report" dated February 20, 2015, revealed, "...He need SW assistance on how to get the insulin/s on discharge..."

A review of "Endocrinology Inpatient Consult Report" dated February 21, 2015, revealed, "...Again, needs SW assistance. Also needs glucometer, test strips, lancets..."

A review of "Endocrinology Inpatient Consult Report" dated February 22, 2015, revealed, "...Again, needs SW assistance. Also needs glucometer, test strips, lancets..."

A review of "Endocrinology Inpatient Consult Report" dated February 23, 2015, revealed, "...I asked bedside RN to teach him insulin administration. Pt states he knows how to use a glucometer, he had OneTouch years ago. Prescriptions needed for D/C: Levemir vials, syringes, glucometer (recommend ReLiOn at Walmart), test strips, lancets..."

A review of the medical record revealed there was no care coordination note until the day of discharge, which revealed, "Patient is in the process of completing application for MA insurance. SW met with patient today to inform him to fill his prescriptions at Wal-Mart Pharmacy."

An interview conducted on May 14, 2015, at 10:20 AM with EMP6 confirmed there was no care coordination documentation to address glucometer, test strips, vials, or lancets.

Based on review of medical record (MR) and staff interview (EMP), it was determined the facility did not properly implement the discharge plan for one of 25 medical records (MR) reviewed (MR10).

Findings include:

A review on May 14, 2015, of MR9 revealed the physical therapist recommended a rolling walker for home use. Further review of the medical record revealed no care coordination notes to address the rolling walker for home use.

An interview conducted on May 14, 2015, at 10:20 AM with EMP6 confirmed there was no care coordination notes to address the rolling walker for home use. Further interview with EMP6 revealed the need for the rolling walker was not documented in the physical therapy discharge assessment therefore the need for the rolling walker "did not get carried over to care coordination."

Based on review of facility policy and staff interview (EMP), it was determined the facility discharge planning policy did not include a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements.

Findings include:

A review on May 13, 2015, of the facility policy "Discharge Planning" last reviewed October 2014, revealed the policy did not address a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements.

An interview conducted on May 13, 2015, at 2:05 PM with EMP11 confirmed the policy did not address a process for ongoing reassessment of the discharge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements.