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.

MEASE COUNTRYSIDE HOSPITAL 3231 MCMULLEN BOOTH RD SAFETY HARBOR, FL 34695 Sept. 29, 2016
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and staff interview it was determined the facility failed to ensure the patient representative exercised all of the patient rights on behalf of an incapacitated patient for one (#4) of 10 sampled patients.

Findings included:

Patient #4 was admitted on [DATE] and discharged on [DATE]. The detailed review of the record failed to reveal any evidence the facility obtained or attempted to obtain a general consent for treatment from the court-appointed guardian for Patient #4.

The record for Patient #4 included 3 copies of the Important Message from Medicare dated 8/28/16 at 9:29 a.m., 8/29/16 (no time indicated) and 9/1/16 at 12:30 p.m. Each of the forms included documentation the patient was unable to sign due to the patient's condition. Each of the forms had a space for the signature of the Patient's Authorized Representative. All three forms were unsigned. The review of the record revealed no evidence of any attempt to reach Patient #4's guardian to acknowledge receipt and understanding of the Important Message from Medicare.

The facility policy "Informed Consent", policy number 100.144.13, effective 4/2016 was reviewed on 9/29/16. The initial policy statement indicated "Consent to treatment is a necessity for all types of diagnostic procedures and medical intervention". The procedure included obtaining a general consent upon the patient's admission to the facility. "This general consent for treatment is sufficient under those circumstances in which the proposed treatment or examination is non-invasive and poses minimal risks and hazards ... ",

The facility policy "Medicare Important Message (IMM) Distribution of Follow-up Hospital Discharge Appeal Notice", policy number BC-CM-109, revision date 3/16, was reviewed on 9/29/16. The policy indicated all Medicare beneficiaries must be provided with the Important Message from Medicare for each hospital admission. The Procedure indicated if the hospital was unable to personally deliver the IMM to the patient/representative, then the hospital should telephone to advise him/her of the beneficiary's rights for a hospital discharge appeal.

An interview and record review was conducted with the Risk Manager, the Administrative Manager and the Director of Admissions on 9/29/16 at approximately 2:00 p.m. The participants confirmed the above findings.