HospitalInspections.org

Based on record review and interview, the hospital failed to provide 2 of 4 (Patient #'s 1 and 4) sampled Medicare beneficiaries with the required standardized notice, "An Important Message from Medicare" (IM) within 2 days of their admission. The findings are:

A. Review of the medical records for Patient #1 revealed that the patient was admitted to the hospital on 06/03/10. A signed IM notice, dated 06/04/10, the date of Patient #1's discharge, was located in the patient's medical record.

1. Further review of the Patient #1's IM notice dated 06/04/10 revealed a handwritten annotation stating, "To [name of long term acute care hospital]=emergent. Patient unable to sign (confusion)." The note was signed by the case manager and was dated 6/10/10 at 2:30 pm.

2. On 02/04/11 at 8:00 am, during interview, the case manager, stated, "I normally get this (the IM notice) signed within 24 hours prior to discharge. I presented the IM notice to the patient at 2:30 the day of discharge prior to her husband's arrival. I asked her to sign it. She said, 'That's okay, I don't think I can sign it.' I did not think to ask her husband to sign it."

B. Review of the medical records for Patient #4 revealed that the patient was admitted to the hospital on 07/20/10 and discharged on 07/29/10. Only one signed IM notice, dated 07/20/10, the date of admission, was located in the patient's medical record.

1. On 02/09/11 at 11:45 am, during interview, the hospital's Director of Quality/Risk verified that there was no discharge IM notice in Patient #4's medical record.

Based on medical record review and interview, the rehabilitation hospital failed to document the rationale for Patient #1's transfer to a long term acute care hospital. The findings are:

A. Review of Patient #1's medical record revealed that she was transferred to [name of long term acute care hospital] from [name of rehabilitation hospital] on 06/10/10 at 3:20 pm.

1. On 02/04/11 at 8:00 am, during interview, the rehabilitation hospital's case manager stated, "We admitted [name of Patient #1] June 3rd. She had multiple wounds, exteme lymphedema of the lower extremities and was morbidly obese. She was on 260 mg morphine am, 200 mg pm. She wanted us to give her the same dosage. We thought that was way too high. We settled on a lower dosage. I contacted [name of long term acute care hospital] the day prior to her ER visit and also spoke with [name of rehabilitation hospital medical director/attending physician] about her fluctuating mental status (lethargy). He agreed we needed to watch her closely. We ended up sending her to the ER. They sent her back to us. I went to talk to her. She was totally alert. I explained to her that we are a rehab center and that because she didn't want to participate in her therapy, a higher level of care is appropriate. I asked her if it was okay if I contacted [name of long term acute care hospital]. The reason for her subsequent transfer to name of long term acute care hospital was not due to her mental status (decisionmaking ability), but because of her lethargy. It appeared that she was getting too many drugs. She was medically complex. She was unable to meet the participation requirements to be at a rehab center. She didn't show much progress during the week she was here. We didn't have the expertise to get to the bottom of her medical problems. I initially spoke to [name of Patient #1] the day prior and told her I was going to have her evaluated by [name of long term acute care hospital]. The evaluation was completed prior to her transfer to the [name of acute care hospital] ER. I called [name of long term acute care hospital] and told them she had gone to the [name of acute care hospital] ER. They waited for doctor to doctor communication before they decided to admit her. I think she would have gone to [name of long term acute care hospital] anyway if she had not gone to the ER. She agreed to the transfer. I told her at approximately 2:45 pm that [name of long term acute care hospital] had accepted her. She seemed to be pleased. [name of her husband], was sitting on the bed. He asked her if she needed to go there. She said yes. He said, 'I know what's the best thing. Why didn't you call me?' I told him that she was capable of making her own decisions. The [name of long term acute care hospital] docs stop admitting at 4:00. I told them that we had a little over an hour to make the transfer. When they asked me about her going back to [name of acute care hospital], I told them we had attempted to get her back. That's why we sent her to the ER and they sent her back. We hardly ever admit directly to the hospital, generally through the ER. I think that [name of long term acute care hospital] was the appropriate move. I think what triggered everything was the time limit. We got approval from [name of long term acute care hospital] at 2:45, so we only had a little over an hour.

2. Review of case management progress notes dated 06/10/10, signed by the case manager, revealed only the following two entries (there were no case management notes prior to the date of discharge): (a) "To ER last evening-change in mentation. This am condition worse. [Name of attending physician] will call [name of neurologist]. [Name of long term acute care hospital] to eval for admission"; (b) "1520 Transfer to [name of long term acute care hospital]."
3. Further review of Patient #1's medical record revealed no documentation of noncompliance with therapy or rationale for the transfer of Patient #1 to the long term acute care hospital. Furthermore, Patient #1's medical record revealed no documentation to support the case manager's assertion that she had spoken with Patient #1 about evaluation by the staff of the long term acute care hospital on the day prior to transfer.
4. On 02/09/11 at 11:30 am, during interview, the Director of Quality/Risk verified that there was no documentation in Patient #1's medical record to support verbal statements by the medical director or case manager concerning Patient #'s rationale for transfer.