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Based on hospital procedure review, "An Important Message From Medicare About Your Rights" form CMS-R-193 review, medical record review and staff interview, the hospital staff failed to inform patients who were Medicare beneficiaries of notification of rights regarding the discharge appeal process (IM notice form CMS-R-193) within two days of the admission and/or no more than two calendar days before the patients' discharge for 6 of 10 Medicare beneficiary patient admitted for inpatient hospital services (#4, 5, 6, 7, 9 and 12).

The findings include:

Review of hospital "Medicare Discharge appeal Process," not dated, revealed "1. If the patient has been here 2 days or less, the IM (An Important Message From Medicare About Your Rights) notice was issued on admission. Confirm that is was signed. The responsibility for getting it signed rests with Registration, however, patient can't leave until signature is obtained. 2. Give IM notice within 48 hours of discharge. ..."

Review of Case Management department procedures, not dated, revealed F. Delivery of Second Notice of "Your Rights as a Medicare Patient" Medicare patients receive a notice of "Your Rights as a Medicare Patient" when they are admitted to the hospital. They receive a second copy of this notice within two days of discharge. The second copy is delivered by a Case Manager to the patient or family when appropriate. If the patient is not responsible for him/herself, the guardian or next of kin will be given the second notice. ..."

Review of "An Important Message From Medicare About Your Rights" form (CMS-R-193 approved 05/07) revealed, "...If you think you are being discharged too soon: ...*You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). ...*If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital... *Step by step instructions for calling the QIO and filing an appeal are on page 2. ... Please sign and date here to show you received this notice and understand your rights. ..."

1. Open record review on 09/01/2010 of Patient #4 revealed a 68 year-old female admitted 08/16/2010 with abdominal pain. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed documentation by a Case Manager staff member that an "IM (Important Message) second notice" was delivered on 08/16/2010 (day of admission). Review of the record revealed no evidence of an IM form CMS-R-193 signed by the patient or patient's representative in the patient medical record. Further review of the record revealed the patient was discharged on 09/01/2010. Record review revealed no evidence an IM form CMS-R-193 was provided to the patient or patient's representative no more than two days prior to discharge.

Interview on 09/02/2010 at 1410 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview confirmed there was no evidence of a signed IM form available in the patient's medical record. Interview revealed the Case Manager was responsible for providing a second IM notification to the patient or patient's representative no more than two days prior to discharge. Interview revealed the second notification was not signed and a copy was not retained. Interview revealed the Case Manager documents that the second notice has been delivered in the patient's medical record. Interview confirmed there was no evidence the second IM notice was provided to Patient #4 or the patient's representative no more than two days prior to discharge. Interview revealed the staff were unable to explain the documentation in the patient's medical record that the second IM notice was delivered on the day of admission. Interview confirmed the hospital staff failed to follow guidelines for informing a Medicare beneficiary patient of discharge appeal rights, to include the Important Message from Medicare which contained instructions for filing a discharge appeal with the QIO.

2. Closed record review on 09/01/2010 of Patient #5 revealed a 71 year-old male admitted 08/27/2010 with shortness of breath and cellulitis of the left lower extremity. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed a IM form CMS-R-193 signed by the patient and dated 08/26/2010 (day of admission). Review of the record revealed the patient was discharged on 08/31/2010. Record review revealed documentation by a Case Manager staff member that a "IM second notice" was delivered on 08/27/2010 (four days prior to discharge). Record review revealed no evidence an IM form CMS-R-193 was provided to the patient or patient's representative no more than two days prior to discharge.

Interview on 09/02/2010 at 1415 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview revealed the Case Manager was responsible for providing a second IM notification to the patient or patient's representative no more than two days prior to discharge. Interview revealed the second notification was not signed and a copy was not retained. Interview revealed the Case Manager documents that the second notice has been delivered in the patient's medical record. Interview confirmed there was no evidence the second IM notice was provided to Patient #5 or the patient's representative no more than two days prior to discharge. Interview confirmed the hospital staff failed to follow guidelines for informing a Medicare beneficiary patient of discharge appeal rights, to include the Important Message from Medicare which contained instructions for filing a discharge appeal with the QIO.

3. Closed record review on 09/01/2010 of Patient #6 revealed a 91 year-old female admitted 08/15/2010 with a subdural hematoma after a fall and pneumonia. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed a IM form CMS-R-193 signed by the patient's representative and dated 08/15/2010 (day of admission). Review of the record revealed the patient was discharged on 08/31/2010. Record review revealed documentation by a Case Manager staff member that a "IM second notice" was delivered on 08/20/2010 (eleven days prior to discharge). Record review revealed no evidence an IM form CMS-R-193 was provided to the patient or patient's representative no more than two days prior to discharge.

Interview on 09/02/2010 at 1420 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview revealed the Case Manager was responsible for providing a second IM notification to the patient or patient's representative no more than two days prior to discharge. Interview revealed the second notification was not signed and a copy was not retained. Interview revealed the Case Manager documents that the second notice has been delivered in the patient's medical record. Interview confirmed there was no evidence the second IM notice was provided to Patient #6 or the patient's representative no more than two days prior to discharge. Interview confirmed the hospital staff failed to follow guidelines for informing a Medicare beneficiary patient of discharge appeal rights, to include the Important Message from Medicare which contained instructions for filing a discharge appeal with the QIO.

4. Closed record review on 09/01/2010 of Patient #7 revealed an 81 year-old female admitted 05/26/2010 with uncontrollable abdominal pain due to expanding hematoma and end stage renal disease. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed a IM form CMS-R-193 signed by the patient's representative and dated 05/26/2010 (day of admission). Review of the record revealed the patient was discharged on 06/07/2010. Record review revealed no evidence an IM form CMS-R-193 was provided to the patient or patient's representative no more than two days prior to discharge.

Interview on 09/02/2010 at 1410 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview revealed the Case Manager was responsible for providing a second IM notification to the patient or patient's representative no more than two days prior to discharge. Interview revealed the second notification was not signed and a copy was not retained. Interview revealed the Case Manager documents that the second notice has been delivered in the patient's medical record. Interview confirmed there was no evidence the second IM notice was provided to Patient #7 or the patient's representative no more than two days prior to discharge. Interview confirmed the hospital staff failed to follow guidelines for informing a Medicare beneficiary patient of discharge appeal rights, to include the Important Message from Medicare which contained instructions for filing a discharge appeal with the QIO.

5. Closed record review on 09/02/2010 of Patient #9 revealed a 75 year-old male admitted 07/10/2010 with mild memory impairment and right visual field impairment. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed no evidence of an IM form CMS-R-193 signed by the patient or patient's representative in the patient medical record. Further review of the record revealed the patient was discharged on 09/12/2010. Record review revealed no evidence an IM form CMS-R-193 was provided to the patient or patient's representative no more than two days prior to discharge.

Interview on 09/02/2010 at 1415 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview revealed the Case Manager was responsible for providing a second IM notification to the patient or patient's representative no more than two days prior to discharge. Interview revealed the second notification was not signed and a copy was not retained. Interview revealed the Case Manager documents that the second notice has been delivered in the patient's medical record. Interview revealed that a two day admission would only require the first IM notice to be delivered to the patient. Interview confirmed there was no evidence an IM notice was provided to Patient #9 or the patient's representative. Interview confirmed the hospital staff failed to follow guidelines for informing a Medicare beneficiary patient of discharge appeal rights, to include the Important Message from Medicare which contained instructions for filing a discharge appeal with the QIO.

6. Open record review on 09/01/2010 of Patient #12 revealed a 72 year-old female admitted 08/31/2010 with atrial fibrillation. Review of the record revealed the patient was a Medicare beneficiary. Review of the record revealed an IM form CMS-R-193 signed by the patient and dated 08/25/2010 (six days prior to admission).

Interview on 09/01/2010 at 1515 with administrative staff revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record. Interview confirmed the IM notice was provided to Patient #12 six days prior to admission. Interview confirmed there was no IM notice provided to the patient within two days of admission. Interview revealed the staff member thought an IM notice would be acceptable as long as it was provided no more than seven days prior to admission, therefore the IM notice was not provided to Patient #12 at the time of admission. Interview revealed current hospital procedures for the delivery of IM notices failed to delineate acceptable time frames for IM notification.

Based on policy review, observation, infection control log review, medical record review and staff interviews, the hospital failed to ensure their infection control policies and procedures were followed for 2 of 6 patients requiring isolation (#1 and #2).

The findings include:

Review of the hospital's policy, "Multi Drug Resistant Organism (MDRO) Identification, Notification of Communication or Isolation Status", effective 10/31/2008, revealed, "PURPOSE: The Infection Control Alert will serve as a mechanism to identify those patients who are identified as infected or colonized with a multi-drug resistant organism. For the purpose of this protocol, a multidrug resistant organism is Methicillin resistant staphylococcus aureus (MRSA)... . POLICY/PROTOCOL: Infection control RN will activate Infection Control Alert when the Infection Control department is notified of a positive culture. Only the Infection Control RN may activate or de-activate the Alert. Infection Control Alert Information will flow to the staff nurse daily worksheet. The activated Infection Control Alert will automatically appear with any future registrations of this patient at XX Hospital...The 'flag' will remain activated for future admissions/registrations at XX Hospital until discontinued by Infection Control...".

Review of the hospital's policy, "Isolation Precautions", effective 11/17/2008, revealed "...Transmission -based Precautions: These precautions are used for patients with documented or suspected infections that are highly transmissible or epidemiologically important for which additional cautions beyond Standard Precautions are needed to interrupt disease transmission in the hospital. There are four types of Transmission-based Precautions: ...3) Contact Precautions 4) Special Enteric Precautions...III. Accountability for Isolation Precautions A. The physician, patient care nurse, or the Infectious Control Department may initiate Isolation precautions. ...C. A physician's order is required for discontinuing isolation precautions. D. Any problems or discrepancies, which arise concerning isolation precautions, should be referred to the Infection Control Manager or the Operations Assistant in her absence... IV. Isolation Precaution Signs A. Isolation precautions will be indicated by a sign on the patient's door. The sign will signify the type of isolation precautions in effect as well as the PPE (personal protective equipment) required before entering room...Appendix E...Contact Precautions ...PPE: Everyone must wear gloves and gown at minimum upon entering room...Contact Standing Orders Contact Precautions Protocol...1. Place patient on Contact Precautions for Know or suspected, all age groups a. Multidrug resistant organisms (MDRO) such as MRSA...2. Place the orange 'Contact Precautions' sign on the patient's door b. Place a stop sign in the door holder...".

1. Review of the hospital's "Current Isolation List", presented by the Infection Control Nurse 08/31/2010 at 1400 revealed Patient #1's name listed with Contact Isolation due to MRSA.

Observation during unit tours 08/31/2010 at 1520 revealed no signage indicating Contact Precautions on Patient #1's door. Observation further revealed no PPE outside Patient #1's door.

Open record review for Patient #1 revealed a 63 year-old female admitted 08/23/2010 with nausea, vomiting, diarrhea and oxygen-dependent chronic obstructive pulmonary disease. Record review revealed a "Patient History/Screening" dated 08/23/2010 with "Isolation: Contact". Further record review revealed a physician's order dated 08/23/2010 at 0650 for "...Stool for C. diff (clostridium difficile - bacterial intestinal disease) x (times) 3...". Record review revealed Patient #1 was placed on Special Enteric Precautions on 08/23/2010. Review of the laboratory results for Patient #1 revealed the stool cultures were negative for C-diff. Further record review revealed a physician's order dated 08/29/2010 at 1800 to discontinue C-diff precautions. Record review revealed no documented evidence that Patient #1 remained on contact precautions due to positive MRSA on 08/30/2010 and 08/31/2010.

Interview on 08/31/2010 at 1520 with the charge nurse revealed Patient #1 should have remained on contact precautions due to the patient having a positive culture for MRSA within the past year. Interview revealed special enteric precautions were discontinued 08/29/2010 due to negative stool cultures for C-diff. Interview confirmed Patient #1 was not currently on contact precautions, there was no signage on the patient's door indicating isolation precautions and no PPE outside the door for staff and visitor use.

Interview on 08/31/2010 at 1545 with the infection control nurse revealed Patient #1 had a positive sputum culture for MRSA on 03/18/2010. Interview revealed Patient #1 should have remained on contact precautions due to MRSA after the special enteric precautions were discontinued.

Interview on 09/01/2010 at 1040 with the Infection Control Practitioner revealed "we follow the CDC guidelines related to MRSA. They recommend patients should remain on contact precautions for one year after a positive MRSA culture". Interview further revealed "contact and enteric precautions are the same. They both require gowns and gloves. The only difference is that handwashing with soap and water is required for special enteric".

Interview on 09/01/2010 at 1350 with a staff nurse revealed the nurse was Patient #1's care nurse on 08/30/2010 beginning at 0700. Interview revealed the nurse was told in shift report that Patient #1 had been discontinued from isolation precautions. Interview further revealed "I checked with the charge nurse before I removed the PPE and signage from the door and I was told all precautions had been dc'd (discontinued)". Interview further revealed, "I don't remember whether I checked the Infection Control flag in her record". Interview further revealed, "she should have remained on contact precautions due to a history of MRSA".

Further record review on 09/01/2010 at 1100 for Patient #1 revealed no documented evidence the patient was placed on contact precautions 08/31/2010.

Interview on 09/01/2010 at 1300 with a staff nurse revealed the nurse was Patient #1's care nurse on 08/31/2010 from 0700 until 1900. Interview revealed the unit manager told her Patient #1 needed to be on contact precautions due to a history of MRSA within the year. Interview further revealed "she was placed on contact precautions at 4:00 yesterday (08/31/2010). I didn't notice the Infection Control flag alert before then". Interview further revealed, " I didn't document that I placed the patient on contact precautions. It was an oversight".

Interview on 09/01/2010 at 1410 with a staff nurse revealed the nurse was the charge nurse for Patient #1 on 08/31/2010. Interview further revealed "if the patient has been here before and they've had MRSA, the Infection Control flag shows up on the nurse's and the charge nurse's worksheet. The flag was on, I just thought it had been discontinued". Interview further revealed "once I found out there had been a mistake, I went and got the isolation precaution box and put it on her door".

2. Closed record review of Patient #2 revealed a 71 year-old female admitted 05/21/2010 with chronic obstructive pulmonary disease. Record review revealed an "ED (Emergency Department) History and Assessment" dated 05/21/2010 at 1202. Review of the assessment revealed "...Isolation: Standard/Universal Infection Control Alert - MRSA...". Record review revealed no documented evidence that Patient #2 was placed on contact precautions until 05/27/2010 (7 days after admission).

Interview on 09/01/2010 at 1040 with the Infection Control Practitioner revealed "we follow the CDC guidelines related to MRSA. They recommend patients should remain on contact precautions for one year after a positive MRSA culture". Interview revealed Patient #2 was positive for MRSA 12/03/2009. Interview confirmed Patient #2 should have been placed on contact precautions on admission to the hospital 05/21/2010.

Interview on 09/02/2010 at 1240 with a staff nurse revealed the nurse admitted Patient #2 to the unit on 05/21/2010. Interview further revealed "the only way I could know if she had MRSA was to ask the patient. She was not the best historian and no family was with her when she came in. I don't remember an alert showing up on her chart". Interview further revealed, "I don't believe that Infection Control calls the floor to notify us about patients needing to be on isolation due to MRSA". Interview confirmed Patient #2 was not placed on isolation precautions on admission due to the hospital 05/21/2010.

Interview on 09/02/2010 at 1400 with the infection control nurse revealed "nurses really would not have had any way to know she was positive for MRSA prior to our Meditech (electronic record/documentation system) upgrade in June". Interview further revealed, "we do not compare our daily census with our historical MRSA log. I probably should". Interview further revealed, "we've got opportunities for improvement in our processes".