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.

CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DR GASTONIA, NC 28052 March 30, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical records, and staff interviews, the facility staff failed to provide the Important Message from Medicare (IM) within 2 days of discharge for 1 of 3 sampled closed medical records of patients receiving Medicare (Patient #5), and failed to provide the IM within 2 days of both the patients' admission and discharge for 2 of 3 sampled closed medical records of patients receiving Medicare (Patients' #6 and #8).

The findings included:

Review on 03/29/2017 of the facility policy "Notification of Hospital Discharge Appeal Rights" (policy #191.00 ( ), revised January, 2017), revealed "PROCEDURE ...2. Access Management Staff will have the patient or their representative sign the Important Message from Medicare at the time the patient is admitted to the hospital as an inpatient or an observation ...8. The Follow-up Copy of the Signed Important Message from Medicare will be delivered as far in advance of discharge as possible, but no more than two (2) calendar days before the planned date of discharge ..."

Review on 03/28/2017 of Patient #5's closed medical record revealed an [AGE] year old Medicare beneficiary was admitted to the facility on [DATE] and discharged on [DATE]. The review revealed an IM was provided to the patient upon admission, but no IM was provided within 2 days of discharge.

Review on 03/30/2017 of Patient #6's closed medical record revealed a [AGE] year old Medicare beneficiary was admitted to the facility on [DATE] and discharged on [DATE]. Review revealed there was no documentation of an IM being provided to the patient upon admission nor discharge.

Review on 03/30/2017 of Patient #8's closed medical record revealed a [AGE] year old Medicare beneficiary was admitted to the facility on [DATE] and discharged on [DATE]. Review revealed there was no documentation of an IM being provided to the patient upon admission nor discharge.

Interview on 03/30/2017 at 1435 with a Case Manager and Access Manager revealed initial IMs were signed when patients registered and for those who didn't come through registration (direct admit, Emergency Department), they printed out the IM and went to the floor to have the patient sign it. Interview revealed, the initial IM was automatically printed on day 3 of each Medicare patients' stay. The copy was then taken to the floor for the patient to sign. The Case Manager and Access Manager did not know why the patients did not receive the IMs. Interview revealed it was the facility's policy is to give everyone on Medicare an IM and that is was possible that when registration or case Management went to the floor to have the patients sign, they may have been off the floor for a procedure.
VIOLATION: CONTENT OF RECORD: COMPLICATIONS Tag No: A0465
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical record, the Safety Event Reporting System, and staff interview, the nursing staff failed to document a patient's fall in the medical record for 1 of 5 sampled patients who experienced a fall. (Patient #6).

Findings included:

Review on 03/30/2017 of the facility policy "Documentation of Patient Care" (policy # , revised August, 2015), revealed "Procedure/Guidelines... 5. A clinical description is documented by the nurse caring for the patient during each shift that includes ...b. Patient problems or concerns ..."

Review on 03/30/2017 of the closed medical record of Patient #6, revealed a [AGE] year old female admitted on [DATE] for avascular necrosis of the bone in her left hip.

A Progress Note from the orthopedic physician dated 03/25/2017 at 1738, revealed "I was called by the nurse who stated that the patient fell in her room. She did hit her head but was alert and oriented. She did not complain of any pain and her vitals were stable. Left hip films were obtained to be sure that there was no trauma to the hip. These are negative; the hip is located and there is no fracture. The nurses will monitor the patient's mental status." Review revealed documentation in the nurse's flowsheet on 03/25/2017 at 1457, indicating pain medication was administered for hip pain of "10" out of 10 "aching." A full head to toe assessment, including a neuro assessment was documented as completed at 1457 and a neuro assessment again at 1545. Review revealed an x-ray of the hip was ordered with "reason for exam: fell ." The review revealed pain medication was administered for hip pain, assessments and repeated neuro assessments were completed, and a note from the Orthopedic Surgeon documented the she was notified the patient fell . No documentation, however, could be found in the nurse's notes in the medical record documenting the fall.

Review of the Safety Event Reporting System, revealed Patient #6 fell on [DATE] at 1540 with documented details of the fall.

Interview on 03/30/2017 at 1210 with the DON (Director of Nursing), revealed nursing staff were expected to document patient falls. "They need to make a note in the EMR (electronic medical record), even if they document an assessment." The DON stated a fall would be considered a "concern" and per policy, they should be documented in the medical record.