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Based on document review, and interview the facility 1) failed to ensure four of ten patients (#5, #7, #9,and #10) received the Important Message from Medicare within two days of admission and/or not more than two calendar days before the patient's discharge and 2) failed to ensure the Important Message from Medicare was accurate with information in order for patients to call and appeal discharge from the hospital for three of ten (#3, 4, 8) medical records reviewed for IMM, from a total sample of 10 resulting in the potential that all medicare patients or their representatives at this facility will not have the information necessary for them to exercise their rights.
Findings include:

1) On 02/06/2018 at 1130 during medical record review it was revealed that patient #7 was admitted on 01/18/2018. The consent to treat was signed on that day, but the required Important Message from Medicare (IMM) was not signed until 01/22/2018.
On 02/06/2018 at 1145 staff A was asked about the IMM delay. Staff A stated "I do not know why it was not signed until the 22nd."

On 02/07/2018 at 0930 during medical record review it was revealed that patient #9 was admitted on 11/22/2017. The consent to treat was signed on that day, but the required IMM was not signed until 11/29/2017.
At 1000 staff C was asked about the IMM delay. Staff C stated "I do not know why it was not signed until the 29th."

On 02/07/2018 at 1130 during medical record review it was revealed that patient #10 was discharged to rehab on 12/26/2017. The required IMM was not located in the medical record.
At 1145 staff E was asked if she could locate a signed IMM for the discharge on 12/26/2018, after looking through the medical record, staff E stated "I do not know why it is not on the chart."



36887

1) On 2/6/2018 at 1115, during medical record review, it was revealed that Patient #5 was admitted on 1/25/2018. The consent to treat was signed on 1/25/2018, but the required IMM was not signed until 1/29/2018.

Facility policy #ADM 045 titled "Issuance of the Important Message from Medicare for all Medicare Beneficiaries" last revised 8/6/2014 was reviewed on 2/7/2018 at 1411. Policy states, "The initial copy of the IM (Important Message) will be issued by the Admission Coordinator within 48 hours of admission. If it is over a holiday, weekend, or after hours, the IM must be issued by a designated clinical staff person, educated in this process to be in compliance with the time frame for issuance."

2) On 2/6/2018 at 1115 during the review of Patient #3's medical record, it was revealed the IMM being used had inaccurate information for patients to call and appeal discharge from the hospital, listing the Quality Improvement Organization (QIO) as MPRO instead of the correct QIO which is KEPRO. Staff A confirmed this finding at the time of discovery. KEPRO was designated the QIO for facilities in this geographic region in 2014. It should be noted that the telephone number listed for MPRO is now being used by a retail company.

On 2/6/2018 at 1125 during the review of Patient #4's medical record, it was revealed the IMM being used listed the QIO as MPRO instead of the correct QIO of KEPRO. This finding was confirmed by Staff A at the time of discovery.

On 2/7/2018 at 0940 during the review of Patient #8's medical record, it was revealed the IMM being used listed the QIO as MPRO instead of the correct QIO of KEPRO. This finding was confirmed by Staff A at the time of discovery.

Staff A was queried on 2/7/2018 at 1415 as to why some medical records had IMM's which listed the QIO as MPRO and others which listed the QIO as KEPRO to which she replied, "The admissions counselor had some old forms mixed in her file."

Based on document review and interview the facility failed to ensure that all orders including verbal orders are dated, timed and authenticated promptly by the ordering practitioner or by another responsible practitioner for seven of ten (#1, 2, 5, 7, 8, 9, 10) medical records reviewed resulting in the potential for inacurate medical care for all patients treated at this facility. Findings include:

On 02/06/2018 at 1130 during medical record review it was revealed that patient #7 was admitted on 01/18/2018. There was a large number of physician orders that were not authenticated with physician signature, date and time. These un-authenticated orders included: admission orders, heparin protocols, wound algorithms, ventilator settings, medication changes, consults, pre and post operative orders.

At 1145 staff E (Health Information Manager) was asked about the lack of physicians signature, date and times. Staff E stated "Many of our physicians only come here occasionally so we fax the verbal/telephone orders to them for their signature, I have baskets for the charts of discharged patients for the 5 regular physicians, they sign their orders on their next rounding day, unfortunately they do not always date and time their orders. We do consider the records completed as long as they sign the orders, even if they do not date and time the orders."

On 02/07/2018 at 0930 during medical record review it was revealed that patient #9 was admitted on 11/22/2018. There was a large number of physician orders that were not authenticated with physician signature, date and time. These un-authenticated orders included: ventilator settings, medication changes, X-rays, and consults.

On 02/07/2018 at 1130 during medical record review it was revealed that patient #10 was discharged to rehab on 12/26/2017. There was a large number of physician orders that were not authenticated with physician signature, date and time. These un-authenticated orders included: admission orders, heparin protocols, wound algorithms, Restraints, ventilator settings, medication changes, and consults.


36887

On 2/7/2018 at 0805 during review of Patient #1's medical record it was revealed that Patient #1 was admitted on 8/7/2017. There was a large number of physician orders that were not authenticated with the physician's signature, date, and/or time. These un-authenticated orders included: admission orders, resuscitation orders/consent, magnesium and potassium replacement protocols, hypoglycemia protocols, insulin order sets, venous thromboembolism risk factor/protocols, wound algorithms, ventilator settings, medication changes, and consults.

On 2/6/2018 at 1058 during review of Patient #2's medical record it was revealed that Patient #2 was admitted on 12/27/2017. There was a large number of physician orders that were not authenticated with the physician's signature, date, and/or time. These un-authenticated orders included: admission orders, respiratory therapy protocols, medication changes, x-ray orders, and consults.

On 2/6/2018 at 1140 during review of Patient #5's medical record it was revealed that Patient #4 was admitted on 1/25/2018. There was a large number of physician orders that were not authenticated with the physician's signature, date, and/or time. These un-authenticated orders included: admission orders, insulin order set, pressure injury prevention order set, heparin infusion protocols, venous thromboembolism risk factor/orders, hypoglycemic protocols, wound treatment algorithms, medications, and consults.

On 2/7/2018 at 0940 during review of Patient #8's medical record it was revealed that Patient #8 was admitted on 10/5/2017. There was a large number of physician orders that were not authenticated with the physician's signature, date, and/or time. These un-authenticated orders included: admission orders, resuscitation orders/consent, wound treatment algorithms, insulin order sets, and restraint orders for application and discontinuation.

Facility policy #C03 titled "Concurrent Analysis of Medical Records" last revised 10/4/2017 was reviewed on 2/7/2018 at 1430. Policy states, "It shall be the policy of the hospital to perform concurrent analysis on in-house medical records to ensure completeness and accuracy of documentation prior to discharge. All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures...At least weekly, in-house records will be checked for the following: 1. Authentication, date and time on reports not limited to H&P (history and physical), consults, operative/procedure reports, progress notes, discharge summary and authentication, date and time on all dictated reports."