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Based on review of (13) open medical records and (10) closed medical records, it was determined that in (3) out of (13) open medical records reviewed, the hospital failed to provide patients #12, 16, and 20, with notification of their discharge rights via the Important Message from Medicare (IMFM).

Patient #12 is a 70 year old, admitted to the 5 West Unit of the facility on 04/30/13 for fever, urinary tract infection, infection of a stent (MRSA-Methicillin Resistant Staphylococcus aureus), and was on contact isolation.
A review of the patient's medical record on 05/10/13 revealed that the patient's 3-ring binder medical record lacked an Important Message from Medicare. Further investigation, indicated that the document was not scanned into the patient's electronic medical record. The 5 West Clinical Manager called and spoke with the hospital registration/admitting staff, who confirmed that the IMFM had never been provided the patient and a copy of a completed one was not located.
Patient #16 is an 88 year old, admitted to the hospital on 04/17/13 for a cough that had lasted 2 weeks. Observation and review of the patient's closed medical record on 05/10/13 with (2) licensed nurses via (2) computers, revealed that the patient lacked an IMFM and a general "Consent to Treat." Interview of the (2) licensed nurses confirmed that these important documents had not been provided the patient or other designated person related/connected to the patient's care.
Patient #20 is a 70 year admitted to the hospital with altered mental status after a fall on 5/7/13. Review of patient #20's medical record on 5/10/13 revealed, no Important Message from Medicare form in the patient's chart. The hospital is not in compliance with the regulation since it did not provide the patient his IMFM and therefore they did not inform the patient of his rights as a Medicare recipient within two days of admission. Failure to provide patients the IMFM and to obtain the "Consent to Treat" precludes the patient or designated others from having necessary information in the decision of furnishing or discontinuing care.

Based on review of the hospital policy and procedure, it was determined that the hospital policy does not meet the expected length of time for resolution of grievances nor provision of a written response.

A review of the hospital's Complaint and Grievance Resolution policy under procedure revealed a response should be made to the complainant in writing or by telephone by the responsible department within 10 business days. If an investigation cannot be completed within the specific time period, it will be necessary for the department to send the preliminary response to the Quality/Risk Management Department. On the third page of the policy is a page titled Grievance Procedure Attachment to Patient Complaint Policy, number 8 states a written resolution to the grievance is requested to be sent within 7 days. If it cannot be resolved within 7 days, an acknowledgement letter is sent acknowledging what the complaint is and giving the estimated date when the resolution/response letter will be sent. Number 10 includes the specific information that should be covered in the written response.

The policy appears to be in the process of revision but at the time of survey the policy did not meet the regulatory guidelines and has conflicting information.

Based on review of the medical record it was determined that there was no documentation indicating that Patient #1 was no longer alert, oriented, unable to understand the risk and benefits of the procedure, deferred the decision to her grandson, or that her grandson was the patient's legal guardian or now her decision maker.


Patient #1 is an 86 year old female who was admitted to the Good Samaritan Hospital on April 4th, 2013 for a wound dehiscence of a left above the knee amputation. Based on review of the medical record it was determined that at the time of admission and throughout the hospitalization Patient #1 was assessed as alert and oriented times three with no neurological deficits. As a result, further review of the medical record indicates that Patient #1 was her own spokesperson and on admission signed her consent to treatment. The consent to treatment also included authorization to release medical information, assignment of insurance payment benefits to the hospital, acknowledgement of financial responsibility, acknowledgement of receipt for information regarding patient rights and responsibilities and certification that Patient #1 understood the contents of the form.

However, despite documentation in the medical record indicating that Patient #1 was alert, oriented, and her own spokesperson, review of the medical record specifically the "Consent for Surgery/Anesthesia/Transfusion form signed on April 8th, 2013 at 12:15PM for the performance of a Revision of the Left Above the knee Amputation indicates that the physician documented in the section for patients unable to sign that he "spoke to Grandson Leroy" The physician also signed and dated the attestation indicating that the grandson had received and understood an explanation of the nature of the procedure/care or operation, benefits, alternatives, risk and likely results of the procedure. However, there is no documentation indicating that Patient #1 was no longer alert, oriented, unable to understand the risk and benefits of the procedure, deferred the decision to her grandson, or that her grandson was the patient's legal guardian or now her decision maker.

Review of the hospital's education and training of staff, and staff's demonstrated knowledge regarding safe application and use of all types of restraint or seclusion revealed that security staff are not trained in safe physical holds used when secluding and restraining patients as evidenced by:

At the time of the survey it was determined that the hospital staff providing direct patient care is trained in care and management of the patient in seclusion and restraint. The hospital security can also be called to assist with the placement of patients in seclusion or restraint. However, the security staff does not receive the same training as the nursing and direct care staff including physical holds. Per the Coordinator of Accreditation Services, the security staff education and training is police style. The security staff has not been trained in the same techniques as the RNs and direct care staff.

The hospital has not met the regulatory requirements since it does not address the education and training of its security staff assisting in the physical holding of patients for placement in seclusion and restraint. The security staff should be trained in appropriate holds and safe positioning of patients if they will be involved in the seclusion and restraint process to ensure safe application of seclusion and restraint.

Based on review of the patient handbook and the hospital's visitation policy, the hospital's policy does not clearly outline the patient's (or support person, where appropriate) right to consent to receive visitors that he or she designates; including, but not limited to a spouse, a domestic partner (including a same sex domestic partner), another family member or friend and his or her right to withdraw or deny such consent at any time.

Based on review of the hospital's visitation policy and patient handbook, it was revealed that the hospital's visitation policy identifies special considerations or restrictions/clinical reasons where visitation would not be permitted or limited. However, the policy fails to specify that visitation will be allowed regardless of the visitor's race, color, national origin, religion, sex, gender identity, sexual orientation or disability and in accordance with the patient's expressed preferences. The hospital failed to fully provide patients and their support persons (as appropriate) with full details concerning the rights of visitation.