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Based on clinical record review and interview, it was determined the facility failed to ensure six (#2, #3, #5, #6, #7, #9 and #10) of eight (#3-#8) Medicare patients admitted to the facility received "An Important Message from Medicare About Your Rights" form within 48 hours of admission and/or received "An Important Message from Medicare About Your Rights" prior to discharge from the facility. Failure to ensure Medicare patients were issued "An Important Message from Medicare About Your Rights" within 48 hours of admission and prior to discharge did not allow the patients the opportunity to be informed and aware of their rights as a hospital patient. The failed practice had the likelihood to affect all Medicare patients admitted to the facility. Findings included:

A. Review of Patient #2's clinical record showed two "An Important Message from Medicare About Your Rights" forms in the record. The forms were not signed or dated by the patient or the patient's representative to determine if the patient received the forms within 48 hours of admission or prior to discharge.
B. Review of Patient #3's clinical record showed the patient was admitted on 06/19/19. There was no evidence "An Important Message from Medicare About Your Rights" was provided within 48 hours of admission to the facility.
C. Review of Patient #5's clinical record showed two "An Important Message from Medicare About Your Rights" forms in the record. One form was signed but not dated. The other form was not signed or dated. It could not be determined if the patient received "An Important Message from Medicare About Your Rights" within 48 hours of admission. There was no evidence the patient received "An Important Message from Medicare About Your Rights" prior to discharge from the facility.
D. Review of Patient #6's clinical record showed the patient was admitted on 04/18/19. There was no evidence "An Important Message from Medicare About Your Rights" was provided within 48 hours of admission.
E. Review of Patient #7's clinical record showed the patient was admitted on 07/15/19. There was no evidence "An Important Message from Medicare About Your Rights" was provided within 48 hours of admission.
F. Review of Patient #9's clinical record showed the patient was admitted on 07/23/19. There was no evidence "An Important Message from Medicare About Your Rights" was provided within 48 hours of admission.
G. Review of Patient #10's clinical record showed the patient was admitted on 07/26/19. There was no evidence "An Important Message from Medicare About Your Rights" was provided within 48 hours of admission.
H. The findings of A through G were confirmed in an interview with the Chief Nursing Officer on 07/31/19 at 10:40 AM.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to include the State Agency's phone number and address on the Complaint/Grievance Process document provided to the patient/patient's representative on admission to the facility for eight of eight (#2-#10) in-patient records reviewed. The failed practice did not allow the patients to place their complaints in writing or call their complaints to the State Agency. The failed practice had the likelihood to affect all patients admitted to the facility. Findings included:

A. Record review of the facility's policy titled, "Complaint/Grievance Policy," with a revision date of 02/2019 showed the Patient Handbook, Notice of Privacy Practices, and Patient Rights and Responsibilities outline how to notify the Arkansas State Health Department if they are dissatisfied with the internal complaint/grievance investigation process and is stated: "Please note that you maintain the right to notify: Arkansas Department of Health (address and phone number provided) in addition to, or in lieu of, utilizing the hospital procedure regarding complaints."
B. Review of Patient #2-#10's clinical records on 07/31/19 showed the Complaint/Grievance Process form did not provide the State Agency's phone number or address. There was no evidence the patient/patients' representative was provided the State Agency's phone number or address to file a complaint.
C. The findings of A and B were confirmed in an interview with the Chief Nursing Officer on 07/31/19 at 10:40 AM.