HospitalInspections.org

Based on a review of medical records (MR) and facility documentation, and employee interviews (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the "Important Message from Medicare (IMM)" no later than 2 calendar days following admission and sooner than 2 calendar days prior to the patient's discharge for one of five medical records reviewed (MR1).

Findings include:

Review of facility policy "Discharge Notification Policy" last reviewed October 21, 2014, revealed "...Medicare beneficiaries are given their rights to appeal their discharge decision at the time of admission and are given a second notice within 48 hours of discharge...during the Registration process all Medicare beneficiaries are given the "Important Message from Medicare" by Registration staff and they are provided with a verbal description of their rights under Medicare to appeal their discharge...Within 48 hours of the anticipated discharge, the case manager or social worker who is coordinating the discharge reviews the patient's rights again and asks the patient to sign the form again..."

1) Review of MR1's admission dated December 27, 2014, with discharge on January 12, 2015, revealed that MR1 was not provided with the IMM within 48 hours of discharge.

2) Review of MR1's admission dated January 21, 2015, with discharge on January 28, 2014 revealed no IMM was provided at the time of admission or within 48 hours of discharge.

During interview on May 5, 2015, at approximately 11:30 AM EMP1 confirmed the above findings and revealed "...their no where to be found (the IMMs)."

Based on a review of medical records (MR) and facility documentation, and staff interview(s) (EMP), it was determined that facility staff failed to accurately document turning and positioning for four of 10 medical records reviewed (MR1, MR6, MR7, and MR8).

Findings include:

Review of facility policy "Skin: Health& Prevention" last reviewed March 6, 2015, revealed "...using the Braden Scale Risk Assessment tool, the nurse will identify patients at risk for impaired skin integrity. Patients are identified at Risk with a total Braden score of <18; a subscale score of 3 or less in any subscale also indicates risk, and alerts the RN to initiate prevention interventions...B. Nursing Prevention Interventions...Nursing interventions for prevention of skin breakdown are selected based on Braden Risk score each subscale...Positioning...Document all attempts to turn or reposition patients. Change position of patients every 2 hours in bed if patient is unable to self-reposition, and every 1 hour if chair bound..."

1) Review of Initial Nursing Assessment for MR1 dated February 2, 2015 at 17:54 revealed "...Braden Mobility (amount /control of body movement): (3) slightly limited...Braden Score: 16..."

2) Review of Occupational Therapy Department Initial Evaluation for MR1 dated February 3, 2015, at 14:45 revealed "...Bed Mobility (the ability to move in ones environment with ease and without restrictions)...Max (Maximum assist)...Rolled to R (right) side with increased pain...Short Term Goals (1 week): 1) Bed mobility mod >1 (moderate assist of one)..."

3) Review of nursing turning and positioning documentation in MR1 for the dates of February 2, 2015 through February 18, 2015 (MR1's date of discharge) revealed the following:

February 2, 2015, at 1800 and 200
February 3, 2015, at 800 and 2000
February 4, 2015, at 800, 1200, 1600, and 2000
February 5, 2015, at 800, and 2000
February 6, 2015, at 800, 1200, 1600, and 2000
February 7, 2015, at 830 and 1346
February 8, 2015 at 800 and 2000
February 9, 2015, at 0000, 400, and 2000
February 10, 2015, at 0000, 450, and 1200
February 11, 2015, no turning and position documentation
February 12, 2015, no turning and position documentation
February 13, 2015, at 800, 1200, and 1600
February 14, 2015, no turning and position documentation
February 15, 2015, at 800, 1000, 1133, 1400, 1600, 1800
February, 16, 2015, no turning and position documentation
February 17, 2015, 800, 917, 1100, and 1239
February 18, 2015, no turning and position documentation

On May 6, 2015, After review of MR1's nursing turning and positioning documentation EMP1 confirmed the above findings and revealed finding "...additional documentation in some areas but not enough documentation..."

4) Review of MR6 revealed a Braden scale of 16-19 from March 20, 2015 through April 1, 2015. Further review of MR6 revealed turning and positioning was documented on:

March 20, 2015, at 830, and 2000
March 21, 2015, at 2000
March 22, 2015, at 2000
March 23, 2015, at 2000
March 24, 2015, no turning and positioning documentation
March 25, 2015, at 2028
March 26, 2015, at 726, and 2015
March 27, 2015, at 1300 and 2000
March 28, 2015, at 0800 and 2000
March 29, 2015, at 800, and 2000
March 30, 2015, at 0800
March 31, 2015, at 0800
April 1, 2015 at 0800

5) Review of MR7 revealed a Braden scale of 16-20 from February 21, 2015 through February 24, 2015. Further review of MR 7 revealed turning and positioning was documented on:

February 21, 2015 and February 22, 2015, no turning and positioning documentation
February 23, 2015 at 1600, 1800, and 2000
February 24, 2015 at 0000, 0400, and 0800

6) Review of MR8 revealed a Braden scale of 14-20 from February 6, 2015 gthrough February 10, 2015. Further review of MR8 revealed turning and positioning was documented on:

February 6, 2015, at 131 and 2027
February 9, 2015, at 0800 and 2000
February 10, 2015, at 2100

7) Interview with EMP1, on April 29, 2015, revealed, "The documentation is not there."