HospitalInspections.org

Based on policy and procedure review, closed medical record reviews, and staff interviews, hospital staff failed to ensure a patient's guardian was informed of the patient's rights prior to discontinuing inpatient care by failing to ensure the guardian received the standardized notice "An Important Message from Medicare" (IM) within two days of admission and within two calendar days of discharge for 1 of 4 discharged Medicare patients reviewed (Patient # 1).

The findings include:

Review of hospital policy, "Discharge Notification Required by Medicare", current date 08/11/2014, revealed "...It is the policy of (Hospital A) to comply with Medicare regulation CMS-4105-F, Notification of Hospital Discharge Appeal Rights. Hospitals must deliver the Important Message (IM) from Medicare to inform all inpatient Medicare beneficiaries about their hospital discharge appeal rights....The purpose of this policy is to ensure Medicare regulation CMS-4105-F is followed by Hospital departments. This regulation requires patients to be informed of their discharge appeal rights upon admission and again within 2 days prior to actual discharge. Inpatient Medicare beneficiaries have the right to request Quality Improvement Organization (QIO) review of a discharge decision. It is the Hospital's responsibility to notify Medicare beneficiaries of this right....Policy Guidelines....A. the Admissions Department will have patients or their representative sign the original IM at admission or within 2 calendar days of admission....B. The IM will be printed on NCR two part paper so the original can be submitted to Medical Records, second copy given to patient, and the third copy placed in the patient chart on the nursing unit....F. Care Coordination staff will identify patients who need a second IM notice as far in advance of discharge as possible, but no more than two calendar days before the planned discharge. The second IM will be delivered by Care Coordination or Nursing Department staff....Delivery of the second IM encounter will be documented in (computer system)....G. Care Coordination will communicate with nursing staff and physicians to minimize the number of notices issued for unexpected discharges. In the event of an unavoidable notice of discharge on the same day as discharge, patients will be allowed a minimum of 4 hours notice to consider their rights. ..."

Closed medical record review for Patient # 1, on 11/04/2015, revealed the Patient was admitted on 09/23/2015 to the Hospital Psychiatric Unit and then discharged and immediately admitted to a medical bed at the same Hospital on 09/25/2015. Review revealed Pt # 1's primary insurance was Medicare. Review of the Medicine History and Physical, dated 09/25/2015 at 2322, revealed Patient # 1 was admitted with an assessment of "Cystic Fibrosis (inherited disorder causing severe damage to lungs and digestive system) exacerbation (worsening of symptoms)....Recent Suicidal attempt....bipolar disorder (brain disorder that causes unusual mood and energy shifts), anxiety and depression... ." Medical Record review revealed a form, "LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON", dated 06/12/2014, which revealed the appointment of a Legal Guardian. Record review revealed two admission IM notices were presented, one on 09/24/2015 (for the Psychiatric Admission) and another on 09/27/2015 (for the Medical Admission). Review revealed both IM notices were signed by Patient # 1. Review did not reveal an IM notice signed by the Legal Guardian. Further medical record review failed to reveal documentation that an IM was presented to either the Legal Guardian or Patient # 1 prior to the Patient's discharge on 10/15/2015.

Review of a document, on 11/04/2015, which was stated by a hospital staff member as given to a nurse at the time the Patient and guardian left the hospital, revealed a handwritten note stating "As legal guardian....I have not been involved in any team meetings or goal setting....I have informed the staff that (Pt # 1) is a danger to himself and others. Yet, today the hospital is discharging (Pt # 1) to my care....Summary understood but not in agreement. ..."

Interview with Manager # 1 and Employee # 1, on 11/05/2015 at 1030, revealed Patient # 1 (not the legal guardian) signed the admission IM notices. Interview revealed the Legal Guardian should have received IM notices. Interview revealed no IM notice was delivered prior to discharge on 10/15/2015 and policy was not followed. Further interview revealed "...but we did not know (Patient # 1) was going home. ..."


NC0011126