HospitalInspections.org

Based on record review and staff interview, the hospital failed to provide the standardized notice to each Medicare beneficiary concerning their rights in 1 of 2 applicable records reviewed in the sample of 10. (Patient #3) Findings include:

1. Per record review, there was no evidence that Patient #3 was provided with the standardized notice "An Important Message From Medicare About Your Rights" within 2 days of admission and not more than 2 calendar days prior to discharge. This was confirmed during interview on 1/5/10 at 9:20 AM with the hospital's Financial Advisor.

Based on record review and staff interview, nursing staff failed to supervise and evaluate the care to each patient in 2 of 10 records reviewed. (Patient # 4 & # 5) Findings include:

1. Per record review, Patient #4's pain assessment was not completed on admission. Physician documentation stated that Patient #4 had right hip pain related to a congenital bone disease. In addition, no daily pain assessment was documented on the "Shift Progress/Reassessment Note" during the patient's hospitalization. This was confirmed during interview with the Vice President of Patient Care on 1/5/10 at 4:45 PM.

2. Per record review, staff failed to complete 15-minute checks on 12/5/09 & 12/6/09 for Patient #5 who was on 15-minute checks due to a history of self-harming behaviors. On 12/5/09 - 12/6/09, the checks were signed off as being done every 30 minutes at 10:45 PM, 11:15 PM, 12:15 AM, 12:45 AM and 1:15 AM and not every 15-minutes as ordered. Per interview on 1/5/10 at 1:30 PM, the Nurse Manager confirmed that checks should have been done every 15-minutes for Patient #5.

Based on record review and staff interview, an adverse patient event reported to the Quality Department in 1 of 3 applicable records reviewed in the sample of 10. (Patient #5) Findings include:1. Per record review, a progress note dated 12/4/09 for Patient #5 stated, "broke wooden bedframe. Upset and talking to staff." Per interview on 1/5/10 at 10:50 AM, the Director of Standards of Quality confirmed that no incident report was completed and forwarded to Quality for review and would of expected this be done.