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FORT MEMORIAL HOSPITAL 611 SHERMAN AVE E FORT ATKINSON, WI 53538 June 10, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review the registration staff and/or patient care coordinators at this facility failed to notify Medicare recipients of their right to appeal their discharge upon admission and/or discharge in 4 out of 10 MR reviewed (Pt. #1, 2, 5, and 8).

Findings include:

The facility's policy titled, "Important Message-Medicare beneficiary Protocol," dated 8/2014, was reviewed on 6/9/2015 at 12:30 PM. The policy states in part, "1. The Important Message (IM) CMS-R-193 Standardized notice must be issued to all Medicare Part A recipients by the hospital within 2 says [days] of admission to inpatient services...Registration personnel shall educate the patient on the important points as delineated and will deliver the IM in person and ask the patient or representative to sign the IM...The patient must sign and date the IM and be given a copy of the original. One copy is held or available via the PCC [Patient Care Coordinator] staff and given approximately 24 hours before discharge."


Pt. #1's closed MR revealed that Pt. #1 was admitted to the facility on [DATE] and discharged on [DATE]. There is no IM for admission or discharge in the MR. This finding was confirmed by QA B on 6/9/2015 at 2:20 PM.

Pt. #2's closed MR revealed that Pt. #2 was admitted to the facility on [DATE] and discharged on [DATE]. Pt. #2 was incapacitated during this admission (found to be unable to make own decisions) and a family member was appointed to make decisions for Pt. #2. There is no IM for admission in the MR signed by Pt. #2 or the family member and no IM for discharge. This finding was confirmed by QA B on 6/9/2015 at 3:05 PM.

Pt. #5's newly closed MR revealed that Pt. #5 was admitted to the facility on [DATE] and discharged on [DATE]. There is no indication the IM was given prior to discharge. This finding was confirmed by QA B on 6/10/2015 at 9:20 AM.

Pt. #8's closed MR revealed that Pt. #8 was admitted to the facility on [DATE] and discharged on [DATE]. There is no indication that the IM was given prior to discharge. This finding was confirmed by QA B on 6/10/2015 at 11:52 AM.
VIOLATION: DELIVERY OF SERVICES Tag No: A1133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview staff at this facility failed to obtain physician orders for occupational therapy and failed to monitor wound status for 1 of 10 MRs reviewed (Pt. #5).

Findings include:

Pt. #5's MR revealed that Pt. #5 was admitted to the facility on [DATE] with CHF and [DIAGNOSES REDACTED] (failure of the lymphatic system in the body to remove fluid from the body resulting in a build up of fluid) of the lower extremities. Between 5/31/2015 and 6/2/2015 Pt. #5 was given Lasix intravenously (medication through the vein to remove some of the excess water from the body). Per interview with PT G on 6/10/2015 at 9:15 AM this resulted in the leg wraps used during [DIAGNOSES REDACTED] therapy (special massage technique used to move the fluids out of the extremities, compression wraps are then applied to maintain a gentle but constant pressure on the tissue), applied prior to admission, to become loose and ineffective.

During the interview on 6/10/2015 at 9:15 AM with PT G, and per PT G's MR documentation, upon assessment of Pt. #5 on 6/2/2015, PT G noted the wraps were loose and there was a small venous stasis ulcer on the lower front portion of the right leg. Per facility protocol, the leg was cleansed and a mepilex dressing (foam dressing used for wound care) was applied, which in PT G's documentation was to be managed by nursing, and PT G contacted the [DIAGNOSES REDACTED] specialists to provide therapy to Pt. #5.

Per MR review, there are no physician orders for OT to start [DIAGNOSES REDACTED] therapy.

On 6/3/2015 OT H started [DIAGNOSES REDACTED] therapy with Pt. #5. OT H acknowledged in documentation that a dressing was in place on the lower right leg and completed the compression wraps after the massage.

The next [DIAGNOSES REDACTED] therapy from OT H documented was 6/8/2015. There is no mention of the wound status or dressing change in the documentation on this date.

There is no documentation in the MR indicating the compression wraps or wound was re-evaluated for the 5 days between [DIAGNOSES REDACTED] therapy sessions or through the date of discharge on 6/10/2015.

Per interview with PT G on 6/10/2015 at 9:15 AM regarding the frequency of [DIAGNOSES REDACTED] therapy, PT G stated that it is usually every other day or 3 times per week. PT G also stated that nursing would not have done wound care on Pt. #5's right leg because OT was managing the compression wraps.

The MR findings were discussed with and confirmed by QA B on 6/10/2015 at 9:30 AM.