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Based on review of facility policies and procedures and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to inform Medicare patients of their rights, in advance of furnishing or discontinuing patient care whenever possible for four of 12 Important Message from Medicare medical records reviewed (MR58, MR61, MR67, and MR68)

Findings include:

Review of facility policy "Important Message from Medicare/Detailed Notice of discharge", dated April 2009, revealed "Patient Access: 1. ... All Medicare eligible inpatients will receive and sign a copy of the Medicare IM notice within two (2) calendar days of admission. ... Case Management ... 5. The Case Management Assistant ... will deliver the [second] IM to the patient and will be available for questions. 6. Once the IM is delivered to he patient or representative, documentation occurs in [computer system] that captures the delivery of the IM."

1) Review of MR58 revealed that this Medicare patient was admitted on December 1, 2010, and was discharged on December 6, 2010. Further review of MR58 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

2) Review of MR61 revealed that this Medicare patient was admitted on December 2, 2010, and was discharged on December 3, 2010. Further review of MR61 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form, upon admission, from the facility.

3) Review of MR67 revealed that this Medicare patient was admitted on December 6, 2010, and was discharged on December 10, 2010. Further review of MR67 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form prior to discharge from the facility.

4) Review of MR68 revealed that this Medicare patient was admitted on December 6, 2010, and was discharged on December 8, 2010. Further review of MR68 revealed no documented evidence that the patient was given or notified of the "An Important Message From Medicare About Your Rights" form, upon admission, from the facility.

5) Interview with EMP5 on January 6, 2011, at approximately 10:15 a.m. confirmed the above findings.

Based on review of facility policy and procedure, review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure that accurate documentation for temperature and humidity levels were maintained for critical areas that included the surgical suite, C-Section operating room, endoscopic procedure rooms, newborn nursery, newborn intensive care unit, post anesthesia care units and the cardiac catheterization lab.

Findings include:

Review of facility policy "Heating, Ventilating, and Air Conditioning Surgical Suites," reviewed April 10, 2010, revealed, "Procedure ... 2. Humidity and temperature in the surgical suites are continuously monitored and recorded by the energy management system in the Boiler room. 3. The permissible range for temperature is 70-75 degrees F, and humidity 50-60% ..."

1) On January 6, 2011, surveyor requested temperature and humidity logs for January 1, through January 6, 2011, for the surgical suite, C-Section operating room, endoscopic procedure rooms, newborn nursery, newborn intensive care unit, post anesthesia care units and the cardiac catheretization lab.

2) Review of facility documents provide for the dates requested "Trend Report," revealed temperature and relative humidity logs levels for the above areas with date ranges between "12/31/99 through January 6, 83."

3) Review of facility document "Trend Report" for OR4 [Operating Room] dated "January 06, 83" revealed humidity level ranges between 17% and 18% for the date "Dec 31, 99."

4) Review of facility document "Trend Report" for OR5 dated "January 06, 83" revealed humidity level ranges between 18% and 20% for the date "Dec 31, 99."

5) Review of facility document "Trend Report" for NICU [Newborn Intensive Care Unit] dated "Jan 06, 83" revealed humidity level ranges between 14% - 29% for the date "Dec 31, 99 through Jan 01, 00."

6) Review of facility document "Trend Report" for the "C Sect" [C-Section Operating Room] dated "Jan 06, 83" revealed temperature levels between 63 and 65 degrees F for the date "Dec 31, 99."

7) Review of facility document "Trend Report" for the CVOR#1 [cardiovascular operating room] dated "01/01/00" revealed temperatures between 52 - 65 degrees F and humidity level ranges between 15% and 27% for "12/39/99 through 01/01/00."

6) Interview with EMP4 on January 6, 2011, at approximately 2:45 p.m. confirmed that the facility documents "Trend Report" did not contain accurate dates for temperature and humidity levels for the above areas and that the facility was unable to provide accurate temperature and humidity levels for those areas due to a computer problem.

Based on policies and procedures and medical records (MR), and interviews with staff (EMP), it was determined the facility failed to document in patients' medical records that the Skilled Nursing Facilities' lists were provided to patients or individuals acting on patients behalf, in three out 12 SNF medical records reviewed (MR38, MR43, and MR44).

Findings include:

1) Review of Facility policy "Nursing Home Placements", dated April 2009, revealed that there was no provision in this policy to document in the patients' medical records that the SNF list was provided to the patients or individuals acting on their behalf.

2) Review of MR38, MR43, and MR44 revealed that these patients were discharged to a Skilled Nursing Facility. There was no documented evidence in MR38, MR43, and MR44 that these patients received the SNF list.

3) Interview with EMP10 on January 6, 2011, at approximately 9:45 a.m. confirmed that there was no documented evidence in MR38, MR43, and MR44 that the SNF list was provided to these patients or individuals acting on the patients behalf.


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Based on policies and procedures and medical records (MR), and interviews with staff (EMP), it was determined the facility failed to document in patients' medical records that the Home Health Agencies (HHA) lists were provided to patients or individuals acting on patients behalf, in eight out ten HHA medical records reviewed (MR49, MR50, MR51, MR52, MR53, MR54, MR56, and MR57).

Findings include:

1) Review of "Discharge Planning from Acute Care for Home Health Services", dated October 2010, revealed that there was no provision in this policy to document in the patients' medical records that the HHA list was provided to the patients or individuals acting on their behalf.

2) Review of MR49, MR50, MR51, MR52, MR53, MR54, MR56, and MR57 revealed that these patients were discharged with Home Health Agency services. There was no documented evidence in MR49, MR50, MR51, MR52, MR53, MR54, MR56, and MR57 that these patients received the HHA list.

3) Interview with EMP5 on January 6, 2011, at approximately 10:00 a.m. confirmed there was no documented evidence in MR49, MR50, MR51, MR52, MR53, MR54, MR56, and MR57 that the HHA list was provided to these patients or individuals acting on the patients behalf.