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Based on review of policy and procedure, electronic medical record (EMR) review, and interview, the facility failed to ensure two (#7 and #8) of fifteen (#1-#15) patients reviewed were provided notification of their patient rights upon admission or that four (#1, #6, #7 and #12) of seven (#1, #6, #7, #9, #10, #12, and #14) Medicare beneficiaries received "An Important Message from Medicare" during their admission. The failed practice did not ensure the patients or patient's representatives were notified of their rights as a patient and/or as a Medicare beneficiary. The failed practice had the likelihood of affecting all patients and/or all Medicare beneficiaries admitted to the facility. Findings follow:

A. Review of Policy "Patient Rights and Responsibilities" last reviewed 11/2024, showed patients and/or their representative were "required to acknowledge the existence of shared obligations based upon patients' fundamental rights and responsibilities."
B. Review of "Hospital Admission Agreement" form version 01/16 on 12/4/2024, showed that patients' acknowledge receipt of the list of "Patient Rights and Responsibilities" when they are admitted to facility.
C. A review of the EMR for Patient #7 and #8 showed no evidence the patients and/or their representatives had received or acknowledged receiving a copy of the list of Patient Rights and Responsibilities upon admission or at any time during their hospitalization.
D. A review of the EMR for Patient #1, #6, #7 and #12, who were Medicare beneficiaries, showed no evidence the "An Important Message from Medicare" form had been provided within 2 days of admission or at any other time during their admission.
E. During an interview on 12/05/2024 at 1:15 PM, with the Director of Quality and Patient Safety, the findings in A-D were confirmed.

Based on review of Policy and Procedure, clinical record review, and interview, the facility failed to provide three (#7, #8, and #14) of fifteen (#1-#15) patients reviewed, informed consent. The failed practice did not allow the patients to make informed decisions about services or care provided by the facility. The failed practice had the likelihood of affecting all patients who were admitted to the facility.

A. Review of the "Hospital Admission Agreement" version 01/16 on 12/4/2024, showed that patients were presented this form upon admission to consent and/or acknowledge receipt of the following:
1) Consent for Health Care Services
2) Consent for Independent Practitioners to bill for their services
3) Acknowledgement of Medicare and/or Medicaid Certification
4) Consent for Retention of Specimens
5) Financial Agreement
6) Preauthorization Requirements
7) Assignment for Direct Payment
8) Safekeeping of Personal Valuables
9) Acknowledgment of the Patient Rights and Responsibilities form
10) Acknowledgment of Notice of Privacy Practices
11) Communication Consent
B. Review of clinical records for Patient #7 and #8 showed no evidence that a "Hospital Admission Agreement" form, had been signed or received by the patient or representative during their hospital admission.
C. Review of Patient #14's clinical record showed two consent forms, titled "Blood or Blood Derivatives Transfusion", one signed by the patient but missing the physician and witness signatures, date, and time, the other form was signed by the physician on 11/19/24 but did not have the patient's or witness's signatures, or time. Evidence was requested confirming if transfusion of blood products was required during admission, no evidence was provided.
D. During an interview on 12/05/2024 at 1:15 PM, with the Director of Quality and Patient Safety, confirmed the findings in A-C and stated this form serves as consent for treatment when a patient is admitted to the hospital.