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Based on record review and interview, the facility failed to provide the Important Message from Medicare to 2 of 10 inpatients eligible for Medicare (Patient #7 and #10) in a total of 11 medical records reviewed.

Findings include:

Record review of policy "Important Message from Medicare Follow Up Copy Issuance" effective 9/2022 under Procedure revealed "All beneficiaries of traditional Medicare or Medicare Advantage Plans who are being discharged from a Medicare covered inpatient hospital stay must receive the IM" (Important Message from Medicare) letter.

Patient #7's medical record was reviewed and revealed Patient #7 was a 76-year-old who presented to the Emergency Department on 3/01/2023 at 8:23 AM with dyspnea (shortness of breath) and was diagnosed with new onset atrial fibrillation. Patient #7 was transferred to observation status 3/01/2023 at 11:38 AM and obtained a cardiac catheterization, admitted inpatient 3/03/2023 at 9:06 AM, and was discharged home 3/03/23 at 12:36 PM. There was no Important Message from Medicare in Patient #7's medical record.

On 7/12/2023 at 8:52 AM during review of patient #7's medical record, when asked to see the Important Message from Medicare (IM), Case Manager J stated "I don't see one."

Patient #10's medical record was reviewed and revealed Patient #10 was a 85-year-old who presented to the Emergency Department 4/11/2020 at 6:45 PM with weakness, was admitted to the hospital 4/11/2023 at 9:08 PM, and was discharged with hospice 4/14/2023 at 3:22 PM. There was no Important Message from Medicare in Patient #10's medical record.

On 7/12/2023 at 10:14 AM during interview with Director of Quality H, when asked if the Important Message from Medicare were found on Patient #7 or Patient #10, Director of Quality H confirmed, we "could not find one."

Based on record review and interview, the nursing staff failed to complete nursing assessments per physician orders in 1 of 10 patient medical records (Patient #1) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Nursing Practice Standards of Care and Professional Performance" policy #9058263 effective date 10/2021 under Standards Addressing the Provision of Patient Care revealed "1. Standard of Care 1: Assessment: The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation."

On 7/11/2023 from 12:33 PM to 2:35 PM during review of Patient #1's medical record with Emergency Department Director (ED Director) C, revealed patient #1 presented to the Emergency Department on Memorial Day weekend, Saturday 5/27/23 at 9:39 AM with an altered mental status after a fall. A computerized axial tomography (CAT) scan revealed a large intraparenchymal hemorrhage (brain bleed) and patient #1 was admitted to the general medical surgical floor 5/27/2023 at 4:55 PM with a do not resuscitate (DNR) order. Patient #1's orders were changed to comfort care on 5/27/2023 at 6:23 PM and revealed change frequency of "Head to Toe assessments, vital signs," to one time daily and prn (as needed) for patient comfort." Patient #1 was discharged with hospice care on 5/30/2023 at 4:07 PM. The first head to toe assessment was completed on 5/29/2023 at 8:05 PM. There was no documentation of a head to toe nursing assessment for patient #1 on 5/27/2023, 5/28/2023 or 5/30/2023, as ordered.

On 7/11/2023 at 1:39 PM during interview with Emergency Department Director (ED Director) C, it was noted there was one head to toe nursing assessment completed on 5/29/2023 at 8:05 PM. When asked if a head to toe assessment had been completed 5/27/2023, 5/28/2023 or 5/30/2023, ED Director C stated "not that's documented."

On 7/11/2023 at 1:39 PM during interview with the Director of Inpatient Services D, Director D agreed when comfort care is ordered with a head to toe assessment ordered "one time daily" a nursing head to toe assessment should be documented on admission and daily. Director D confirmed, there was only one head to toe assessment done on 5/29/2023 at 8:05 PM.