HospitalInspections.org

Based on document review and interview, the facility failed to ensure that it complied with 42 CFR 405.1205(c)(1) for 3 of 4 medicare patient medical records (MR) reviewed. (Patient #3, 11 and 22)

Findings include:

1. Review of 42 CFR 405.1205 (b)(c)(1) indicates the following; "Advance written notice of hospital
discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary ' s rights as a hospital inpatient, including discharge appeal rights. The hospital
must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary ' s admission to the hospital.
(2) Content of the notice. The notice must include the following information: (i) The beneficiary ' s rights as a hospital inpatient including the right to benefits for inpatient services and for post-hospital services in accordance with 1866(a)(1)(M) of the Act.
(ii) The beneficiary ' s right to request an expedited determination of the discharge decision including a description of the process under § 405.1206, and the availability of other appeals processes if the beneficiary fails to meet the deadline for an expedited determination.
(iii) The circumstances under which a beneficiary will or will not be liable for charges for continued stay in the hospital in accordance with 1866(a)(1)(M) of the Act.
(iv) A beneficiary ' s right to receive additional detailed information in accordance with § 405.1206(e).
(v) Any other information required
by CMS.
(3) When delivery of the notice is valid.
Delivery of the written notice of rights described in this section is valid if-
(i) The beneficiary (or the beneficiary ' s representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and
(ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section.
(4) If a beneficiary refuses to sign the notice. The hospital may annotate its notice to indicate the refusal, and the date of refusal is considered the date of receipt of the notice.
(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary ' s representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge."

2. Review of patient #3's MR indicated the patient was a Medicare patient and was admitted to the facility on 12-12-11 and was discharged on 12-16-11. Patient #3's MR lacked documentation that the patient was given the Medicare Important Message no more than 2 days prior to discharge.

3. Review of patient #11's MR indicated the patient was a Medicare patient and was admitted to the facility on 12-03-11 and was discharged on 01-12-12. Patient #11's MR lacked documentation that the patient was given the Medicare Important Message no more than 2 days prior to discharge.

4. Review of patient #22's MR indicated the patient was a Medicare patient and was admitted to the facility on 12-19-11 and was discharged on 12-20-12. Patient #22's MR lacked documentation that the patient was given the Medicare Important Message on admission or prior to discharge.

5. On 03-13-12 at 1345 hours, staff #41 confirmed that the Medicare Important Message/Rights is given to Medicare patients only during admission and not prior to discharge.

Based on document review, the facility failed to ensure that each patient was informed of the address of the state agency to file a grievance.

Findings include:

1. Review of the Client's Rights, Inpatient Unit, given to patients on admission lacked documentation of the address of the state agency to file a grievance.

Based on document review and interview, the facility failed to ensure that its policy/procedures for patient grievances included providing a written notice of the facility's decision of the grievance process.

Findings include:

1. Review of policy #: I.D.6, Consumer Complaint, lacked documentation that after investigating the grievance a written notice would be sent to the person filing the grievance.
This policy/procedure was last reviewed/revised on 01-24-11.

2. On 03-13-12 at 1430 hours, staff #41 confirmed that the facility does not send written notices after patient grievances are investigated.

Based on document review, the facility failed to ensure that when patients are restrained, the restraints are discontinued at the earliest possible time for 1 of 3 restraint medical records (MR) reviewed (Patient #2).

Findings include:

1. Review of policy/procedure S-2.3, The Seclusion/Restraint Process, indicated the following on page 4;
"N. The RN can order reduction in restraints or early release if the patient demonstrates he/she is no longer
- a danger to him/herself or
- a danger to others"
This policy/procedure was last reviewed/revised on 03-07-11.

2. Review of patient #2's MR indicated the patient was placed in 4 point restraints on 05-21-11 at 0600 hours. Review of the Restraint/Seclusion Flow Sheet dated 05-21-11 indicated the following;
0815 hours - sleeping quietly on back.
0830 hours - clt sleeping, breathing loudly
0845 hours - clt sleeping, snoring
0900 hours - clt sleeping quietly on her back
0915 hours - clt taking deep short breaths, restless attempting to move.
0930 hours - clt resting quietly
0945 hours - clt resting quietly on back
1000 hours - clt slept peacefully on back
1015 hours - clt slept quietly on back
1030 hours - clt slept quietly on back
1045 hours - clt slept quietly on back
1100 hours - RN assessment
1115 hours - Drank 4 oz OJ; urinated minimal amount in bedpan
1130 hours - ROM performed on all limbs
1145 hours - clt spoke with staff, clt tearful
1200 hours - clt seen by doctor
1215 hours - clt moved to 2 pt restraints, left arm right leg
1230 hours - clt sat up ate 100%
1245 hours - clt sitting up finished eating
1300 hours - clt sleeping
1315 hours - took vitals
1330 hours - client sleeping
1345 hours - client sleeping
1400 hours - client sleeping
1415 hours - client sleeping
1430 hours - client sleeping
1445 hours - client sleeping
1500 hours - client sleeping
1515 hours - client urinated - bedpan
1530 hours - client resting
1545 hours - client unlocked at 1535 hours
Review of patient #2's MR after being reduced to 2 point restraints at 1215 hours lacked documentation of the patient being a danger to self or others from 1245 hours to 1535 hours. It could not be determined why the patient was still in restraints after 1245 hours.

Based on document review and interview, the hospital failed to measure, analyze and track quality indicators for 1 directly-provided and 1 contracted service in its Quality Assurance Performance Improvement (QAPI) program, failed to measure (have monitors for) 1 contracted service as part of its QAPI program and failed to analyze (have standards for) 1 directly provided service and 2 contracted services as part of its QAPI program.

Findings:

1. Review of the hospital's QAPI program indicated it failed to measure, analyze and track quality indicators for the directly-provided transcription service and the contracted radiology service, failed to measure (have monitors for) contracted maintenance services as part of its QAPI program and failed to measure (have monitors for) the directly provided maintenance service and biohazardous waste, housekeeping contracted maintenance services as part of its QAPI program.

4. On 3-14-12 at 12:30 pm, upon interview, employee #A2 indicated there was no documentation of the above activities in the hospital's QAPI program and no documentation was provided by exit.

Based on document review and interview, the governing board failed to periodically review the hospital's QAPI program for 7 directly-provided services and 9 contracted services.

Findings:

1. Review of the minutes of the governing board for calendar year 2011 indicated the board did not review the hospital's QAPI program for the directly-provided services of alcohol drug, discharge planning, maintenance, medical records, psychiatry, transcription and infection control.

2. Review of the minutes of the governing board for calendar year 2011 indicated the board did not review the hospital's QAPI program for the contracted services of biohazardous waste, biomedical engineering, dietary, housekeeping, laboratory, laundry, maintenance, pharmacy and radiology.

3. On 3-14-12 at 12:30 pm, upon interview, employee #A2 indicated there was no documentation of review by the governing board of the above activities and no documentation was provided by exit.

Based on document review and interview, the facility failed to conduct utilization review by physicians who were not professionally involved in the care of the patient whose case was being reviewed in 1 instance.

Findings:

1. Review of a document entitled Inpatient Utilization Review, dated 6-7-11, indicated patient MR#1 was reviewed on 6-20-11 by physician MD#1.

2. Review of the Medical Staff Meeting minutes dated 6-21-11 indicated physician MD#1 was a part of the Utilization Review activity conducted on that date.

3. On 3-13-12 at 2:55 pm, upon interview, employee #A2 indicated physician MD#1 had treated patient MR#1.

Based on document review, the facility failed to perform preventive maintenance (PM) on 12 patient care beds and testing of 1 overhead paging system used during patient emergencies.

Findings:

1. On 3-12-12 at 11:45 am, employee #A3 was requested to provide documentation on all patient care beds. Documentation was provided for only 2 beds.

2. On 3-12-12 at 3:30 pm, upon interview, employee #A6 indicated there were 12 other beds and there was no documentation of PM on the beds. No documentation was provided prior to exit.

3. On 3-12-12 at 11:45 am, employee #A3 was requested to provide documentation of PM on the facility's overhead paging system used during patient emergencies.

4. On 3-14-12 at 9:20 am, upon interview, employee #A6 indicated testing of the system was included as annunciation during fire drill activities. The employee was requested to provide documentation that the system was operable and no documentation was provided prior to exit.