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Based on a review of facility policy and medical records (MR), and staff interview (EMP), it was determined the facility failed to provide evidence that Medicare patients were provided the Important Message From Medicare (IMM) notice within 48 hours prior to discharge for two of thirty one medical records reviewed (MR15 and MR16).


Findings include:


Review of facility policy and procedure on March 16, 2017, at approximately 2:00 PM revealed, "Case Management Transition Planning...Subject Important Message from Medicare delivery requirements...Update/Reviewed...4/16...Purpose/Regulation Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-129 to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. Policy All hospital must provide, explain, and have signed by the beneficiary (or patient representative), the IMM within two (2) days of admission, followed by delivery of the signed IMM not more than two (2) days prior to discharge (if two or more days have passed since the original IMM was signed.)..."
1. On March 2, 2017, at approximately 12:00 PM, review of MR15 revealed that there was no IMM notice within 48 hours prior to discharge.
2. On March 2, 2017, at approximately 12:40 PM, review of MR16 revealed that there was no IMM notice within 48 hours prior to discharge.
3. During an interview on March 2, 2017, at approximately 2:00 PM, EMP1 confirmed the above findings.

Based on a review of facility documents, medical records (MR) and staff interviews (EMP), it was determined the facility failed to administer insulin with supervision as required by policy for four of 31 medical records reviewed (MR17, MR18, MR19 and MR20).

Findings include:


Review of facility policy on March 3, 2017, at approximately 11:00 AM revealed, "Guidelines to Time and Administration of Specific Medications" Purpose: 1. To provide optimum effect of a medication in conjunction with the patient's clinical data and activity level. 2. To provide realistic follow-through of a medication(s) schedule in the home situation...Medications: 10 ...Insulin...C. Double check Insulin dose before administration with an RN/LPN. Document second RN/LPN initials for double checking insulin in block under nurse administering insulin on profile ...D. Document the verification of the double check on profile..."


1. Review of MR17 on March 3, 2017, at approximately 11:15 AM, revealed that the patient was administered insulin on February 27, 2017, at 1700 and at 2030. Further review revealed no documentation of double checking the aforementioned insulin dose for MR17.

2. Review of MR18 on March 3, 2017, at approximately 11:20 AM, revealed that the patient was administered insulin on February 25, 2017, at 1200, on February 22, 2017, at 1200, and on February 22, 2017 at 1700. Further review revealed no documentation of double checking the aforementioned insulin dose for MR18.

3. On March 3, 2017, at approximately 1:25 PM, interview with EMP4 confirmed the above findings.

4. Review of MR19 on March 3, 2017, at approximately 11:30 AM, revealed that the patient was administered insulin on February 27, 2017, at 1600, and on March 1, 2017, at 1600. Further review revealed no documentation of double checking the aforementioned insulin dose for MR19.

5. Review of MR20 revealed that the patient was administered insulin on January 14, 2017,
January 19, 2017, and January 21, 2017. Further review revealed no documentation of double checking the aforementioned insulin dose for MR20.

6. On March 3, 2017, at approximately 2:00 PM an interview with EMP7 confirmed that the above insulins for MR19 and MR20 were not double checked.

Based on review of facility documents, medical records, and staff interviews (EMP), it was determined the facility failed to complete and document daily (at least once every 24 hours) nursing assessments for all patients and document the presence and site description of an intravenous access port as required by policy for one of 31 medical records reviewed (MR1).

Findings include:

A review of Policy Number III - 5 titled IDD effective 4/98 and reviewed 3/16 revealed, "Purpose: To document patient assessments and reassessments, care provided, response to care, and functional performance and status ... depicting ... patient's rehabilitation needs. Policy: ... document updated information daily regarding each patient's functional status, care, and response to care, utilizing the Interdisciplinary Daily Documentation (IDD) form. ... Procedure: 1. Nursing will prepare the document daily for use by dating and attaching the patient identification label. 2. All staff writing on form must sign, date and time on the appropriate page. Assessment portions must have the required professional signature (RN must conduct the RN Assessment, etc). #. Professional caregivers are responsible for the accuracy and completion ... even when supported by non-licensed staff. ... 5. Daily Nursing Assessments: A. All patients will have ... RN assessment conducted every 24 hours, at a minimum. B. ... other assigned nurses will conduct ... review ... covering the areas needed and/or warranted by ... patient's condition ... C. If any reassessment findings are abnormal, an assessment will be conducted by an RN and a narrative note ... describing problem area, abnormality, intervention, and follow up, signing under the "Additional problem specific system review completed with significant finding within the narrative ". ... time ... assessment will v be noted next to the nurse's signature. D. The assessment is made up of a systemic review of neurologic, ... integumentary, ... , and pulmonary sections. Each section should be completed .... Additional details ... recorded in the narrative notes. E. The Pain section should record ... assessment conducted at time of the full assessment. ... absence should be recorded as "0", not left blank. ... J. Should the need for any additional full RN assessment arise, documentation indicating the completion and findings ... should be recorded in the narrative notes. ... Q. Treatments: This section ... facilitate documentation ... implementation of physician orders and interventions identified on the plan of care. ... Intravenous site Care/Change - ... write how often it needs done: i.e. q (every) shift. Care is flushing peripheral line as ordered and looking at the site. Change is changing the site where the line is located. Place the proper abbreviation in the time slot to indicate it was done and write a narrative note to describe the site or where the IV line is now located. ... If a treatment is ordered that does not have a preprinted space use the blanks at the bottom or cross out a treatment that the patient is not receiving and use that line. R. Sign the bottom ... title and place initials... block after the signature."

A review of MR 1 was completed at the facility on March 2, 2017 and March 3, 2017 and revealed the following: "1. On January 6, 2017 the daily nursing assessment was performed at 0730 by the RN, however it was not completed as required by the facility's IDD policy. The RN failed to complete and/or document the following: a.) Pain assessment; b.) the Bowel Sounds assessment in GI/GU assessment; c.) the Intravenous Access in the Cardiovascular assessment; d.) the Pulmonary assessment (Complaint is related to MR1's pulmonary status); e.) The Integument assessment and f.) The Comprehension and Expression assessments. 2. On January 10, 2017 the daily nursing assessment was performed at 0800 by the RN, however it was not completed as required by the facility's IDD policy. The RN failed to document and/or complete the following: a.) the Vital Signs assessment and b.) the Comprehension and Expression sections. Further review of the IDD revealed a narrative note, "1525 - 20# IV Inserted in L (left) hand in order to administer IV Solumedrol 20 mg. ( steroid injectable) . Pt. tol. insertion well. ... ". 3. On January 11, 2017, the IDD did not have any of systems assessments completed. The only documentation on the IDD was a notation in the GI/GU section that the patient's Last BM of 1-11-17 was documented. 4. The majority of the IDD dated January 12 and 13, 2017 was completed except a.) there was no mention of the IV inserted January 10, 2017 in the Intravenous Access section and b.) the Comprehension and Expression assessment section was not completed. 5. A review of the IDD dated January 14, 2017 was completed at 0800 and revealed a.) Intravenous Access section documented IV/Heparin lock L hand and b) the Comprehension and Expression section was not completed. and 6. A review of the IDD dated January 15, 2017 revealed documentation indicating that the IV/Heparin lock "L hand removed" and the Comprehension and Expression sections were not completed."

In an interview with EMP1 on March 3, 2017 at approximately 10:30 AM, the above findings were confirmed. The above findings were also verified with EMP7 on March 3, 2017 at approximately 11:00 AM. EMP7 stated, "Yes, the IV should have been documented on January 11, 12, and 13, 2017. EMP7 further stated, "all sections of the systems assessment are required to be completed at least once every 24 hours by an RN." Both EMP1 and EMP7 verified that not all the required sections of the IDD had been completed as noted above in one (MR1) of 31 medical recrods reviewed.