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.

GOOD SAMARITAN HOSPITAL FOURTH AND WALNUT STREETS LEBANON, PA 17042 Jan. 30, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of facility policy, medical records, and interview with staff (EMP), it was determined the facility failed to ensure that restraints were used in accordance with the patient's plan of care for three of three restraint medical records reviewed (MR6, MR7, and MR8).

Findings include:

A review of facility policy "Restraints and Seclusion" last review August 2017, revealed, "...Monitoring...F. Plan of Care - Restraints must be used in accordance with a written modification to the patient's plan of care that reflects assessment, intervention, evaluation, and re-evaluation and time limits of the restraint orders.

A review of MR6 on January 29, 2018, revealed the patient was placed in restraints on July 31, 2017, at 2:51 AM. The plan of care was not updated to reflect the use of restraints until 5:00 PM.

A review of MR7 on January 29, 2018, revealed the patient was restrained on November 24, 2017. The plan of care was not updated to reflect the use of restraints.

A review of MR8 on January 29, 2018, revealed the patient was placed in restraints on December 15, 2017, at 5:16 AM. The plan of care was not updated to reflect the use of restraints until 9:39 PM.

An interview conducted on January 29, 2018, at 1:45 PM with EMP3 confirmed the patients had been restrained and that the care plan was not updated.
VIOLATION: OUTPATIENT SERVICES PERSONNEL Tag No: A1079
Based on review of facility policies, interview with staff (EMP), it was determined that the facility failed to develop a written policy for physician coverage when the assigned physician is absent.

Review of facility policies on January 29, 2018, at approximately 10:00AM, revealed no policy for physician coverage.

Interview on January 29, 2018, at approximately 10:00AM, with EMP2 confirmed that there was no written policy for physician coverage.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to comply with Federal Regulations.

The facility was found to be non-compliant with the following Federal Regulation:

482.13 (a)(1) Patient Rights: Notice of Rights. A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

This is not met as evidenced by:

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide the patient or the patient's representative a copy of the Important Message from Medicare no more than 2 days prior to discharge for one of eleven medical records reviewed (MR11).

Findings include:

A review of facility policy "Medicare Discharge Notice" last revised 4/16, revealed, "The purpose of this policy is to meet the compliance expectation with the Federal Regulations CMS 4105-F on the requirement the re-issuing the Important Message from Medicare (IMM) prior to discharge for all Medicare patients including Medicare as a secondary payer and Medicare Advantage plans...A. Registration staff provide the initial IMM...D. If the patient's length of stay is greater than 48 hours, obtain a new IMM and review with the patient/family/representative within 4 to 48 hours of an anticipated discharge and a signature is required on the medical record copy. ..."

A review of MR11 on January 29, 2018, revealed the patient was admitted on [DATE], and discharged on [DATE]. A copy of the admission IMM was noted on MR11. There was no discharge IMM noted on MR11.

An interview with EMP4 on January 29, 2018, confirmed there was no documentation on MR11 regarding the second IMM.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to comply with the patient's advance directives by failing to address advanced directives for one of 11 medical records reviewed (MR10).

Findings include:

Review of facility policy on January 30, 2018, revealed, "Advanced Directives" last reviewed 8/17 "I. General Information...A. Information Regarding Advanced Directives...2. If the patient's medical condition or incapacitation prevents distribution of the printed materials at the time of admission/registration, and if the condition sufficiently improves so that this becomes possible, then the materials will be distributed to the patient directly at a later time prior to discharge."

A review of MR10 on January 30 2018, revealed the patient was admitted on [DATE], hemodynamically unstable. The box for Advanced Directives was checked with unable to assess documented. No further documentation noted in the MR that once the patient was stable was this area addressed. Patient was discharged on [DATE].

Interview on January 30, 2018 with EMP4 confirmed the above findings.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility policy and procedures, review of medical records (MR) review of documents and interview with staff (EMP), it was determined the facility failed to document in the medical record if the patient requested or declined notification to their physician of the hospital admission for one of 11 medical records reviewed for physician notification (MR10).

Findings include:

Review of facility policy on January 30, 2018, revealed, "Patient's Rights and Responsibilities" last reviewed 7/17 revealed, "Patient Rights...A. Communication...The patient has the right to: Have a family member, another person that they choose, or their doctor notified when they are admitted to the hospital."

A review of MR10 on January 30 2018, revealed the patient was admitted on [DATE], hemodynamically unstable. The box for notification of patient's physician was checked with unable to assess documented. No further documentation noted in the MR that once the patient was stable was this area addressed. Patient was discharged on [DATE].

Interview on January 30, 2018, with EMP4 confirmed the above finding.