HospitalInspections.org

Based on findings from medical record (MR) review, document review and interview, 3 of 3 MRs (Patients #1, #2, and #3) reviewed (for patients whose hospital stay was longer than 2 calendar days), lacked documentation that patients were provided a second follow up Important Message from Medicare (IM) notice by the facility prior to discharge. There was potential that the patient was not aware of their rights to appeal their discharge because the follow up IM was not provided.

Findings include:

-- Per MR review Patient #1 was admitted to the hospital on 2/22/16. Initial IM notice was signed by the patient on 2/22/16. Patient #1 was discharged on 2/29/16. The MR lacked a signed follow up IM notice within 2 days of discharge.

Per MR review Patient #2 was admitted to the hospital on 2/13/16. Initial IM notice was signed by the patient on 2/13/16. Patient #2 was discharged on 3/4/16. The MR lacked a signed follow up IM notice within 2 days of discharge.

The same lack of documentation of a second IM was found in MR for Patient #3.

-- Per review of facility's policy and procedure (P&P) titled "Discharge Notification Instruction- Medicare," last revised 5/15 it indicated, prior to discharge the IM will be presented to the patient by the charge nurse or designee. The receiving party will acknowledge the IM by signing and disagreeing or agreeing with the discharge. The patient is given an original copy and a copy is placed in the chart.

-- During interview with Staff A on 3/4/16 at 9:30 am, he/she confirmed that the above MR's did not contain a second IM notice and should have.