HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure an Important Message from Medicare was given to 17 of 17 (#1, #10, #12-16, #19-20, #22, #24-29) Medicare patients prior to discharge from the facility. The failed practice created the potential for patients to be uninformed of their rights and could affect any Medicare patient admitted to the facility. Findings follow:

A. Review of closed clinical records revealed 17 of 17 (#1, #10, #12-16, #19-20, #22, #24-29) Medicare patients did not receive an Important Message from Medicare within two days prior to discharge.
B. During an interview on 04/20/12 at 0940, the Social Worker revealed the facility was unaware the Important Message from Medicare had to be signed prior to discharge.

Based on policy review and interview, it was determined the facility failed to have a written policy related to protection of the patient from abuse during an investigation of any allegations of abuse. The failed practice had the potential to affect any patient in the facility. Findings follow:

A. Policy Number 4.5 titled, "Neglect and Abuse of Patients/Grievance Procedure" was provided on 04/19/12 at 1240. Review of the policy revealed no information as to how the patient would be protected, or what would happen to an employee being accused of abuse or neglect during an abuse investigation.
B. Findings were confirmed by the Administrator on 04/19/12 at 1520.

Based on policy review and interview, it was determined the facility failed to ensure the restraint policy and procedure included information about reporting a death in restraints to the Centers for Medicare and Medicaid Services (CMS). The failed practice did not allow the facility to track and trend death in restraints and had the potential to affect any patient in restraints in the facility. Findings follow:

A. The restraint policy was provided for review on 04/19/12 at 0925. Under Section H. Report of Death, the policy stated "If a patient death occurs that is associated with the use of restraint, the following will be contacted immediately in addition to the Administrator of CRRH (Conway Regional Rehabilitation Hospital): 1. DON (Director of Nursing), 2. Ordering Physician, 3. Risk Manager." The policy gave no indication that CMS would be contacted following a death in restraints.
B. During interview on 04/19/12 at 1035 the DON stated they were a restraint free facility. When asked why they had a restraint policy if they were a restraint free facility, the DON stated it was just in case they had to use a restraint. She also stated they use no physical restraints but may occasionally use Haldol as a chemical restraint. Findings were confirmed by the DON at the time of the interview.

Based on review of the Medical Staff Bylaws and interview, it was determined the Medical Staff Bylaws failed to include the required components pertaining to medical histories and physicals (H&P). Failure to include the above mentioned requirements meant the medical staff could not assure it would carry out it's responsibilities to the fullest. Findings follow:

A. Review of the Medical Staff Bylaws on 04/19/12 at 1330 revealed there was no evidence of the required components pertaining to H&P's.
B. The findings were verified, through interview, with the Medical Director and the Administrator.