The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BOCA RATON REGIONAL HOSPITAL 800 MEADOWS RD BOCA RATON, FL 33486 Aug. 30, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview, the facility failed to inform 3 of 5 patients (#7, #8 and #10) of their rights related to Medicare covered services and discharge. rights.

The findings include:

Clinical record review conducted on 08/29/11 revealed 3 of 5 closed records did not contain the "Important Message From Medicare About Your Rights" notification.

Patient # 7 was admitted to the facility on [DATE] with diagnosis of Fractured Lumbar Vertebrae. The primary payer source was Medicare. At the time of record review, the clinical record did not contain the signed copy of the required, "An Important Message from Medicare About Your Rights" form.
Patient # 8 was admitted to the facility on [DATE] with diagnosis of fracture hip. The primary payer source was Medicare. The clinical record did not contain the signed copy of the required, "An Important Message from Medicare About Your Rights" form.
Patient # 10 was admitted to the facility on [DATE] with diagnosis of bladder neoplasm. The primary payer source was Medicare. The clinical record did not contain the signed copy of the required, "An Important Message from Medicare About Your Rights" form.

Interview with The Executive Director of Medical Surgical Services was conducted on 08/29/11 at 1511. The Director reviewed the three (#7, #8 and #10) sampled electronic records and was not able to locate any documentated supportive evidence indicating the Medicare beneficiaries were given information regarding Medicare covered services and discharge rights. The Director contacted the Case Manager/Social Worker who is familiar with the form. The Case Manager/Social Worker reviewed the electronic records in question and she was not able to locate the notices for Patients # 7, 8 and 10. The Case Manager/Social Worker stated the notices are now given upon registration if the patient is fully admitted . She stated in some instances the case managers would give out the form. She stated one example would be if the patient's hospitalization status is changed from observation to full admit. The Case Manager/Social Worker acknowledged the forms were not given and stated, the Case Management Department is under transition with a new director and they will address this concern. The Case Manager/Social Worker stated there is no specific hospital policy addressing when these forms should be given.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on clinical record review and patient and staff interview, the facility failed to provide appropriate and timely discharge planning evaluation for 1 of 6 sampled patients (Patient # 11).


The findings include:


Interview with the Case Manager (CM), assigned to the 7th floor, was conducted on 08/29/11 at 0958. The Case Manager stated: she is a registered nurse with experience in acute settings; the discharge planning process starts on admission; when a patient is admitted CM meets with the patient typically on the first or second day of admission; the patient is interviewed to obtain information such as, where they live, if they have stairs, family contact, and use of any type of medical equipment. The CM stated she contacts and interacts with the patient and family throughout the hospital stay, and she advises the physician of her recommendations for discharge. The CM stated she discusses the discharge plans and asks patients for their preferences. The CM presented a copy of the "Patient Preference - SNF or Hospice Referrals" form, and verbalized that the patients are kept informed and involved in their plan of care and discharge planning.

Review of the clinical record review for Patient #11 revealed Patient # 11 was first admitted to the facility 08/07/11 with diagnoses of Emphysema and Chronic Obstructive Pulmonary Disease. The History and Physical dated 08/07/11 documents, the patient was admitted with right lower lobe pneumonia and was to receive respiratory treatments, Oxygen therapy and intravenous Antibiotics.

Case management assessment notes dated 08/08/11 document Patient #11 "is independent; used Oxygen and Nebulizer at home; express no needs; will follow and assist as needed; patient verbalized understanding. " The record does not document any further patient interactions or case management notes.
Review of the pulmonologist progress notes dated 08/11/11 disclosed documented, "patient not ready to go home." The plan documented is, continue antibiotic Levaquin.
The Discharge Summary dated 08/12/11 documents, patient sent home on prednisone, and stable for discharge.
Discharge Instructions dated 08/12/11 document, the patient was discharged home and instructed to follow up with primary care physician. Medication Discharge list dated 08/12/11 documents additional orders as Prednisone 10 mg daily, the order notes intermittent therapy as antibiotic Levaquin 750 mg IV every twenty four hours. There is no directive action to continue, discontinue or stop. The antibiotic therapy is not addressed on the discharge instruction form.
Further review of the record failed to reveal antibiotic therapy instructions given to patient upon discharge. The clinical record also fails to document tapering dose instructions for steroids.

Review of Patient # 11's re-admission to the facility on [DATE] revealed the patient was readmitted with diagnoses of Pneumonia, and Exacerbation of Chronic Obstructive Pulmonary Disease.
Review of the record failed to provide a case management assessment or case management notes from 08/22/11 thru 08/29/11.
Review of the physician orders revealed the Primary Care Physician wrote discharge orders on 08/29/11. The orders document discontinue intravenous Solumedrol and start Prednisone 40 mg for two days, then 30 mg for two days, then 20 mg for two days and then 10 mg for two days. Discharge home and follow up in two weeks. Discharge orders from the Infectious Disease Physician dated 08/29/11 document, Ceftazidine 1 gram IV every 8 hours. Another physician order dated 08/29/11 at 1100 documents STAT Physical Therapy evaluation and discharge patient to Skilled Nursing Facility.

Interview with Patient # 11 was conducted on 08/29/11 at 1546. The patient and spouse were present during the interview. The patient stated: he was in the hospital about a week ago and was discharged without notice; he was sent home with three days ' worth of oral antibiotics, which was not enough, and prednisone; when he got home, his pharmacist called the patient ' s spouse to inquire about the tapering of the steroids prescribed. The patient's wife said she had a difficult time trying to locate the hospitalist who called in the prescriptions to the pharmacy to obtain clarification and have the pharmacy dispense the correct medications. The patient stated, he did not receive any instructions regarding antibiotic therapy, but the pharmacy dispensed three doses of oral antibiotic. Patient # 11's wife verbalized she received a call from her spouse on the day of discharge and he stated, "Come and pick me up; they discharged me," and that was the extent of the discharge planning. The patient verbalized he had to return to the hospital a few dates later due to shortness of breath. The patient stated he completed the three days of antibiotic as given, but he was not feeling any better; he was re-admitted on [DATE]. He stated he requested to speak to the case manager on three different occasions, but never saw her until today, for the first time. The patient stated: he wanted to make sure they knew that his wife was not able to take care of him at home and he wanted to go to a rehabilitation facility; he has Medicare and supplemental insurance which would cover the rehabilitation facility. The patient and spouse stated he was not involved in his plan of care; he stated the nurses are doing the best they can by providing information from the physicians, but the physicians do not seem to communicate with each other. The patient stated: he was told today he was going to be discharged home; he is frustrated with this arrangement, because he was previously informed by his infectious disease physician that he was going to require intravenous antibiotic after discharge. The patient ' s wife stated that administering intravenous antibiotic is more than she can handle, and she contacted the case manager and the charge nurse. The patient stated later on, the nurse advised him he was going to be discharged to a Skilled Nursing Facility for intravenous antibiotic therapy, and added, the case manager spoke to them after his wife called the facility and requested to speak to her. The patient stated he was not made aware of the discharge appeal rights; he stated he signed many forms during the admission process, but he is not sure what they are. The patient and wife verbalized their dissatisfaction with the communication between nurses and physicians and with the discharge planning on both admissions. The patient and spouse stated they did choose the Skilled Nursing Facility based on a friend ' s recommendations.

A subsequent interview with the Case Manager, assigned to the 7th floor, was conducted on 08/29/11 at 1618. The Case Manager stated she did not complete an assessment on patient # 11 because of time constrains; she was very busy last week working on patients discharges, and she was not on duty over the weekend. The Case Manager acknowledged an assessment should have been done and stated she was not aware that the patient requested to speak to the case manager. The Case Manager stated she met with the patient today and the discharge plans were put in motion. She stated Patient # 11 would be discharged today to a Skilled Nursing Facility.

Facility policy titled, "Discharge of a Patient/Discharge Planning," documents the following, "All Patients will be provided with an interdisciplinary planned discharge process. Discharge Planning will begin upon admission and continue throughout the patient ' s hospitalization until discharge. All Patients will be provided with safe guidelines and appropriate instructions to enhance wellness and quality of lifestyle upon discharge from the hospital. The Case Manager will be involved in the patient discharge process to coordinate aftercare as appropriate."


Facility policy titled, "Re-Admissions," documents the following, "A case Manager will review the medical records of patients readmitted within ten days of discharge for appropriateness of discharge, quality of care, and systems failure."