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Based on review of 12 open medical records and 21 closed medical records, it was determined that in 3 out of 21 closed medical records reviewed, the hospital failed to provide patients #7, #24 and patient #26 with notification of their discharge rights via the Important Message from Medicare (IM).

Patient #7 was admitted to the hospital on 1/17/13 and discharged on 1/23/13 Review of the medical record revealed that despite patient #7 being a Medicare participant the medical record lacked a copy of the important message.

Patient #24 was admitted to the hospital on 1/15/13 and discharged on 1/22/13. Review of the medical record revealed no first or second "Important Message from Medicare" form. The hospital is not in compliance with the regulation since it did not provide the patient his IM and therefore they did not inform the patient of his rights as a Medicare recipient within two days of admission and discharge.

Patient #26 was admitted to the hospital on 2/25/13 and transferred to another area hospital for inpatient treatment as a voluntary admission on 2/27/13. The medical record review revealed the patient was not informed of her rights as a Medicare recipient within two days of her admission, no copy of the Important Message form could be found in the medical record.

Based on review of the hospital policy and procedure, it was determined that the hospital policy does not meet the expected length of time for resolution of grievances nor does it provide for provision of a written response to the complainant.

A review of the hospital's Complaint and Grievance Resolution policy under procedure revealed if the complaint becomes a grievance because of the severity of the complaint, or it was received in writing, the Director, Quality/RM (Risk Management or designee) will be responsible for tracking the status of unresolved complaints and follow up as necessary with the responsible person(s) to ensure the complaint has been investigated, resolved, and appropriate response to the complainant has occurred either verbally or in writing, if requested. In addition, the policy does not indicate any time frames for resolution or grievances. The hospital response to complaints reviewed by the surveyor on average is less than 7 days. Complaints identified as grievances took longer than 7 days. The hospital must attempt to resolve all grievances as soon as possible. The regulation requires the resolution of grievances with written response within 7 days. If a grievance cannot be resolved within the 7 day time frame, the hospital mustl inform the patient or the patient's representative that the hospital will follow-up with written response within a stated number of days in accordance with the hospital's grievance policy. The policy and procedure as written does not meet the regulatory standards.

Based on review of 12 open medical records, interview with the hospital ' s registration manager and nursing staff, in addition to review of policy and procedure it was determined that the hospital failed to query patients # 1, 2, 3, 4, and 16 in regards to whether they had an Advance Directive (AD) and if they did not, would they like to be provided information on developing an Advanced Directive.

During interview with the hospital's Registration Manager it was determined that the hospital will query patients who are admitted to inpatient status. However, patients being evaluated on an outpatient or observational status are not queried regarding if they have an Advance Directive, would like to execute one, or be provided further information. In addition, the Registration Manager informed the surveyors that at this time the computers used by the registrars will not allow them to even enter the information in the computer.

This was evident on review of the medical records demographic sheet. On review of the demographic sheet it was determined that the spaces for information such as AD packet given, AD exists, AD on file, AD changes, and up to date AD on file remained blank.

The following patients lacked evidence of the required query:

Patient #1 is a 68 year old male who arrived and was seen in the Emergency Department (ED) for complaints of chest pain. Patient #1 was subsequently seen by the physician and admitted for observation. However no query for Advanced Directives is documented.

Patient #2 is a 79 year old female who was seen in the ED for complaints of general malaise, decreased oxygen level, lethargy, and urinary tract infection. No query for advanced directives was documented on the demographic sheet.

Patient #3 is a 62 year old male who was seen in the ED for chest pain and admitted for observation. No query for advanced directives was documented on the demographic sheet.

Patient #4 is an 86 year old female seen in the ED for groin pain, weakness, and possible UTI. Diagnostic labs were completed and Patient #4 was admitted for further treatment and care. Further review of the demographic sheet and interview with registration staff indicates that no query regarding advanced directives had been completed.

Patient #16 was admitted on 2/27/13 on observational status. The face sheet was printed out but was blank regarding query of the patient's Advance Directives.

Based on interview with the ED nurse, the surveyor was informed that this information is usually obtained by the registrar. However, there is no indication that this is being done by the registrars and when interviewed by the surveyor on February 28, 2013 the Registration Manager it was revealed that the registrars can ask the questions but the current system will not allow them to input the information. Therefore the information is not captured and documented as required to confirm compliance and ensure that the patient or surrogate decision maker's wishes are honored.

The hospital's current process in regard to Advance Directives does not meet the regulatory guidelines.

Review of the hospital's policy and procedure for Seclusion and Restraint of the Violent Patient revealed an appropriate definition and description of what constitutes seclusion consistent with the regulation; however, it was determined that while the hospital is using what they define as open seclusion, the patient is relegated to a room with staff monitoring the patient who in turn is not allowed to exit the room. The patient at this point is in seclusion not "open" seclusion. In addition, the hospital has a behavioral management intervention called "Dayroom Restriction with Escort" where the patient may not leave the dayroom unescorted. Since the patient cannot exit the dayroom unescorted this would be seclusion.

Based on review of the hospital policy Seclusion and Restraint use for the Violent Patient, the hospital failed to address the timely acquisition of the order for restraint or seclusion prior to application of restraint/seclusion or in emergency application situations. Review of the policy under nurse procedure, indicates that the RN obtains a physician order for restraints or seclusion within one hour of initiation. The regulation requires the physician order to be obtained prior to the application of seclusion or restraint. In recognition that a restraint or seclusion intervention may occur so quickly that an order cannot be obtained prior to the application of restraint or seclusion, the regulation states that in these emergency application situations, the order must be obtained either during the emergency application of restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The hospital policy has not met the regulatory requirements since it does not address the process for an immediate acquisition of restraint or seclusion in the restraint/seclusion policy and procedure.

Based on review of the hospital's policy regarding Seclusion and Restraint use for the Violent Patient, under procedure, if the physician orders notification, the RN informs the physician of change in the patient's condition prior to releasing the patient from restraint/seclusion. The time the physician was notified and the description of the patient's specific behavior is documented in the medical record by the RN. The staff is expected to assess and monitor the patient's condition on an on-going basis to determine whether restraint or seclusion can be safely discontinued. If the nurse has assessed the patient and has determined that the patient is no longer a threat to self or others than the intervention should be terminated. When a physician orders notification prior to releasing the patient this could delay the release of the patient at the earliest possible time if the nurse has difficulty making contact with the physician.

Based on review of 2 out of 21 closed medical records, it was determined that the documentation regarding the patient's admission status was missing from the medical records.
Patient #26 was admitted to the hospital on 2/25/13 and transferred to another area hospital for inpatient treatment as an involuntary admission on 2/27/13. The medical record review revealed no certificates for involuntary admission, application for admission, notification of patient rights and the six questions.
Patient #30 was admitted to the hospital on 12/3/12 and transferred to another area hospital for inpatient treatment. Review of the medical record revealed no certificates for involuntary admission, application for admission, notification of patient rights and the six questions.

Based on review of 3 of 21 closed medical records (patients #8 #22 and #23), it was determined that neither patient had discharge summaries in the medical record.

Patient # 8 was admitted on 1/16/13 and discharged on 1/19/13. Review of the patient's medical record on 2/28/13 revealed no discharge summary.

Patient #22 was admitted on 1/15/13 and discharged on 1/23/13. Review of the patient's medical record on 2/28/13 revealed no discharge summary.

Patient #23 was admitted on 1/17/13 and discharged on 1/23/13. Review of the patient's medical record on 2/28/13 revealed no discharge summary.