HospitalInspections.org

Based on medical record review and interview the facility failed to provide a copy of an "An Important Message from Medicare" (IM) to 2 (#10, #19) of 3 patients, which could potentially deprive patients or the patient's representative of the information necessary to exercise their rights. Findings include:


During review of patient #10's medical record, on 9/14/11 at approximately 1030, documentation of an IM was lacking in the medical record. The patient was admitted on 9/9/11 and was identified as ready for discharge soon by Nursing Manager #J. Review of patient #19's medical record revealed that he was admitted on 8/21/11 and discharged on 8/24/11. Interview with the Director Patient Support #O and Supervisor Patient Registration #Q, on 9/14/11 at approximately 1400, verified that documentation was lacking in the medical record that the notices had been administered by hospital staff.

Based on record review and interview, the facility failed to afford the patient's representative an opportunity to make informed decisions for 1 (#19) of 3 patient visits. Findings include:

Review of patient #19's Emergency Department (ED) visit record of 8/21/11 at 0153, revealed that he was discharged AMA (against medical advice) at 0356. Interview with the ED Nurse Manager #F, at approximately 1430 with the medical record, revealed that the patient had a diagnosis of dementia and had a designated guardian/representative with formal paper work documented. The Manager stated that the Nurse on duty failed to notify the patient's guardian as specified by the facility policy. The facility policy titled "Against Medical Advice" dated 8/3/09 specified that the responsible party in the case of an incompetent person would be requested to sign the "Release - Acknowledgement of Discharge Against Medical Advice" form.