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Based on the review of medical records of three Medicare Recipients, staff interviews, policies and procedure, along with pertinent document provide it was determined that the hospital lacked policies and procedures that effectively ensure that patients have the information necessary to exercise their rights. In addition, the hospital denied one patient the ability to exercise right to refuse medication.

Review of medical records for three Medicare recipients showed all three records lacked patient signatures on the Important Message from Medicare (IMM). Patient #1's medical record lacked an initial IMM. Medical record contained multiple consents signed by the patient for this voluntary admission, but lacked signed IMM. The initial review of the record the IMM was not located; however, the hospital did present a copy during survey day one. The IMM that was present on survey day one was dated 27 days after the patient had been admitted. This IMM was not signed by the patient, a note stating 'Tlk to PT Family IMS/Scan' dated of 3/14/18 was documented. Documentation did not indicate what family member was contacted and informed of the IMM. This patient was admitted voluntary to the unit. The patient signed consents for treatment during admission were present on chart, except for an IMM. On day two of survey, a second IMM for patient #1 was presented that was signed by patient and dated for the day prior.

Patient # 2's medical record had an initial IMM but lacked the patient's signature. This patient was admitted on a voluntary status and had signed consents on chart for admission. The IMM contained a note 'Tlk to Pt family IMS/Scan,' the IMM did list two names and phone numbers. The relationship to patient was not indicated nor which person was contacted. On day two of survey, a second IMM for patient #2 was presented that was signed by patient and dated for the day prior.

Interview with care management representative indicated that only one attempt is made to present the patient with notification of their Medicare right's on admission. It was reported that the hospital "handles too many Medicare patient's to revisit patient for additional attempts to gain signatures and present patients with the IMM." The staff person administering the IMM, independently determines the patient ability to understand their rights. If that staff person decides the patient is unable to understand, they contact the patient's representative to present IMM.

The hospital policy number CLIN010 "Delivery of Important Message from Medicare about Your Rights," in section B.13 indicates that staff delivering IM will document the reasons the patient is unable to sign the IMM and give examples as to how that documentation is to written. The IMM's provided for both patient #1 and #2, lacked a reason for why the patient was unable to sign the IMM's.

The policy number CLIN010 included appendixes and attachments that provided addition instructions regarding the IMM process. This include scripts and a letter template used to inform patient and their representative of discharge right as Medicare recipients. Appendix C, Phone Delivery Script of IM to Representatives, indicate that the patient representative would sent a copy of this notice. The medical records reviewed did not include documentation of IMM being sent to the patient representative.

Patient # 3's IMM was signed by the son on the fourth day of admission. The IMM has a note documented that the son was given the MC message (IMM) at 2:10 pm and dated 12/18/2018 the day of admission.

Medical records reviewed, for both patient # 1 and #2, does not reflect that the patients were presented with the IMM nor made aware of their discharge rights, as Medicare recipients, on admission. The hospital's current process and practice of administration of the IMM fails to effectively ensure Medicare recipients are aware of notification of their rights.

Patient #3 medical record review contained an order for an antipsychotic injection PRN (as needed) medication. The medication was first ordered on the day of admission with the following PRN comment: "Severe agitation, second line if pt [patient] refuses PO (oral) or if PO (oral) ineffective." The medication list did not include an oral dose of the antipsychotic. A subsequent order for this medication, indicated, PRN comments were: "1. Use this IM [intramuscular] PRN only if patient refuses oral PRN OR oral PRN has been tried and found ineffective. 2. Use this IM [intramuscular] PRN only if the patient is hitting or kicking staff or other patients, or is exhibiting uncontrolled yelling or screaming. 3. Notify medical provider if IM [intramuscular] administered." Indication number one for administration of this medication denies the patient the right to refuse the medication and indication number two meant that the nurse was responsible for evaluating the patient's behavior and determining the course of treatment.

On 12/25/2017 at 2130 Patient #3 was physically held by security and nursing staff administered an intramuscular dose of the antipsychotic. The antipsychotic was noted within patient #3 plan of care as a second line medication if the first line mediation, oral Seroquel was not effective. The medical record lacked documentation that the oral first line medication was offered prior to, or the patient consented to receive the intramuscular antipsychotic.

Based on the review of medical records, and restraint policy, it was determined that the physician or other licensed independent practitioner LIP failed to conduct a face-to- face evaluation of patient # 3 after two restraint episodes.

Patient #3's medical record review indicated that twice 'Short Term Restraint/ Physical Hold' were done on 12/25/2017. No face-to- face evaluation, was found for the first restraint that occurred at 1618 and lasted for nine minutes. The second restraint episode at 2130 lasted for ten minutes, included a physical hold and administration of an intramuscular injected medication. No documentation regarding a face-to-face evaluation was found for the second restraint episode.