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Based on record reviews and interviews, the hospital failed to ensure each patient was presented a signed copy of the "An Important Message from Medicare" no more than 2 calendar days before discharge as evidenced by failure to have documented evidence that a signed copy was presented within 2 calendar days of the patient's discharge for 1 (#3) of 2 (#3, #5) discharged patient records reviewed from a sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1CQO, revealed no documented evidence that the information regarding the requirement that the signed copy of the "An Important Message from Medicare" be given to the patient no more than 2 calendar days before discharge.

Review of Patient #3's medical record revealed she was admitted on 08/02/17 and discharged on 08/17/17. Further review revealed no documented evidence that a signed copy of the "An Important Message from Medicare" was presented to Patient #3 within 2 calendar days of discharge.

In an interview on 01/30/18 at 2:10 p.m., S1CQO indicated she "assumed" the An Important Message from Medicare" was being given by the nurse to the patient at discharge. She confirmed there was no documented evidence in Patient #3's medical record that the signed copy was given to Patient #3 at discharge.

Based on record reviews and interview, the hospital failed to ensure it implemented its grievance process as evidenced by failure to have documented evidence of the investigation of the grievance for 2 (#3, #5) of 2 patient grievances reviewed.
Findings:

Review of the policy titled "Complaint and Grievance process, presented as a current policy by S1CQO, revealed that when a complaint or grievance is presented while the patient is still an inpatient, the concerns shall be investigated. Further review revealed the conclusion/resolution shall be documented on an Occurrence report and sent to Risk Management.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 08/02/17 and discharged on 08/17/17. Review of the "Complaint/Grievance Form" signed by S1CQO on 08/14/17 revealed that Patient #3's daughter called was told her mother was going home on 08/14/17 when she called to inquire about her mother. Review of the Grievance Log revealed the grievance issues included the following: Patient #3's daughter was "upset because no one had communicated to you the discharge ;plan for your mother; you were told that the day of discharge was to be today and then told that it was on Friday; you were told that there was an accepting skilled facility that had accepted your mother but stated that you wanted to visit them prior to her being sent there." Review of the comments documented on the Grievance Log revealed the following: "Administration and the CQO have completed the investigation; we have had a family conference with both you, and your brother to discuss the discharge plans for your mother; you agreed with the discharge plan and to visit some skilled nursing facilities letting us know of your decision; we apologized for any misunderstanding this issue may have caused." There was no documented evidence of the investigation that occurred prior to the issue being closed on 08/14/17 and a letter being sent to Patient #3's daughter on 08/21/17.

Patient #5
Review of Patient #5's medical record revealed she was admitted on 08/17/17 and discharged on 08/25/17. Review of the "Complaint/Grievance Form" signed by S1CQO on 08/22/17 revealed the grievance was received by email from Patient #5's daughter on 08/21/17. Further review revealed grievance issues included the following: communication by the dietitian to the complainant's sister (another daughter of Patient #5) on 08/19/17 that Patient #5 would be discharged on 08/21/17 or 08/22/17 which was a total surprise and contrary to all the information that had been previously communicated; described the message given on 08/19/17 as feeling punitive based on some issues that Patient #5 had experienced on 08/17/17; communication to our family has been less than satisfactory because the hospital does not have a case manager; mistakes have been made that affected Patient #5's well-being, one which involved a blood draw on 08/18/17. Further review of the documentation presented by S1CQO revealed no documented evidence of the investigation that occurred regarding the complaints regarding the dietitian's communication and the situations referred to that occurred on 08/17/17 and 08/18/17.

In an interview on 01/30/18 at 2:10 p.m., S1CQO confirmed that she did not document the investigation she conducted that included reviewing the above patients' medical records and interviews with staff.

Based on record reviews and interview, the hospital failed to ensure each patient or his or her representative was informed of their right to make informed decisions regarding his or her care as evidenced by failure to have the patient or his or her representative sign the consent for treatment for 1 (#4) of 5 sampled patient records reviewed for signed consent for treatment from a sample of 5 patients.
Findings:

Review of the policy titled "Consent: Informed for Treatment", presented as a current policy by S1CQO, revealed that each patient/legal representative seeking admission shall sign the admission consent for treatment form.

Review of Patient #4's medical record revealed he was admitted on 01/19/18. Review of his "Conditions Of Treatment And Admission" revealed no documented evidence that he or his legal representative had signed the consent for treatment as of 01/29/18. The second page of the consent had blank lines for the signature of patient or authorized patient representative, emergency contact name, emergency contact phone number, witness, witness #2 if applicable, and date (month, day, year, time).

In an interview on 01/29/18 at 12:00 p.m., S4RN indicated she didn't know why Patient #4's consent had not been signed. She further indicated she had been off for 3 days and didn't know why it had not been signed within the 10 days since admit.

Based on record reviews and interviews, the hospital failed to ensure the patient's discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. This evaluation was not evident in 4 (#1, #2, #3, #5) of 5 patient records reviewed for discharge planning evaluations from a sample of 5 patients.
Findings:

Review of the policy titled "Social Work/Case Management Services", presented as a current policy by S1CQO, revealed that discharge planning is initiated at the time of admission and actively involves both the patient and family and/or other designated caregiver. The patient and family are assisted in identifying and arranging care resources appropriate to the defined needs of the patient at the time of discharge. The social worker/case manager serves as an advocate for the patient to return home or to be discharged to the least restrictive environment possible and informs the patient and family of the estimated date of discharge following the initial team conference and updates after each team conference. Further review revealed introduction of the case management role to the patient and family should be done within 24 hours of admission excluding Saturday and Sunday. There was no documented evidence that the policy addressed the time interval for completing the case management admission assessment.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 01/22/18 with diagnoses of Diabetes Mellitus, Hypertension, Peripheral Vascular Disease status post Left Below the Knee Amputation from 2012, and Right Below the Knee Amputation on 01/12/18. Review of his "Case Management Admission Assessment" documented by S2LCSW on 01/24/18 revealed prior to admission he lived alone in a senior independent living apartment and required supervision or assistance with household chores, laundry, meal preparation, and shopping that was provided by personal care attendants. Further review revealed that his durable medical equipment included a standard walker, a shower chair, a prosthetic left leg, and a broken scooter. Further review revealed the initial discharge plan was to return home with sitters. There was no documented evidence of the name and relationship of the primary and secondary caregivers, the availability and ability to assist and the type of assistance that could be provided by the caregivers (supervision/companion only; light hands-on assist; lifting assistance), and whether the patient was comfortable with the caregiver's assistance with toileting, bathing, dressing, and hygiene.

In an interview on 01/30/18 at 3:02 p.m., S2LCSW indicated the rehab department contacts a company to see about getting the patient a scooter. She confirmed that she is supposed to coordinate the needed services for patient #1 and had not yet discussed his needs with the therapists until the treatment team meeting today (8 days after admit). S2LCSW indicated Patient #1 had no caregiver other than the personal care attendant sitter, and she didn't document this fact when she completed the discharge planning assessment.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 01/18/18 with diagnoses of history of Stroke with right-sided hemiplegia and Right Hip Hemiarthroplasty on 01/12/18 following a fall that resulted in a right femoral neck fracture. Review of Patient #2's "Case Management Admission Assessment" documented by S2LCSW on 01/22/18 (4 days after admit) revealed he lived with his spouse who works, and he was moderately independent for ambulation with use of a wheelchair and cane prior to admission. He required supervision or assistance with household chores, laundry, meal preparation, shopping, and transportation. Further review revealed his support system included his wife and a niece. There was no documented evidence of the availability and type of assistance provided by the caregivers and whether Patient #2 was comfortable with the caregiver's assistance with toileting, bathing, dressing, and hygiene.

In an interview on 01/30/18 at 3:10 p.m., S2LCSW confirmed the initial discharge planning evaluation for patient #2 was not complete.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 08/02/17 and discharged on 08/17/17 with diagnoses of Right Femur Wedge Compression Fracture (no surgical intervention needed), Debility, Anemia, Hypertension, Hypothyroidism, Atherosclerosis, and Hyperlipidemia. Review of her "Case Management Admission Assessment" documented by S1CQO on 08/07/17 (5 days after admit) revealed she lived alone in a private residence prior to admission and was moderately independent with bathing and requires supervision or assistance with ambulation, bathing (documented above as moderately independent), dressing, and eating with assistance provided by home health. Further review revealed no documented evidence that her income, transportation needs, and insurance and prescription coverage were assessed. Further review revealed no documented evidence that a primary and secondary caregiver were identified, the availability of each, the caregivers to assist and the type assistance provided, and whether Patient #3 was comfortable with the caregiver's assistance with toileting, bathing, dressing, and hygiene. Documentation revealed that the patient/family rehab expectation/goals was "to return home to prior functioning levels. There was no documented evidence of a summary of findings and potential barriers to discharge documented by S1CQO.

In an interview on 01/30/18 at 10:38 a.m., S1CQO indicated the case management assessment needs to be done within 3 business days, and Monday was the third business day after admission. S1CQO confirmed the above-listed items were not completed on the initial discharge planning evaluation.

Patient #5
Review of patient #5's medical record revealed she was admitted on 08/08/17 and discharged on 08/25/17 with a diagnosis of Intertrochanteric Fracture of the Proximal Right Femur. Review of her "Case Management Admission Assessment" documented by S1CQO on 08/10/17 revealed Patient #5 lived with adult children prior to admission, and her prior level of function was modified independence with cane/walker and bedside commode. Further review revealed her primary caregiver was a daughter who was available 24 hours a day with no documented evidence of the ability of the daughter to assist and the type of assistance that could be provided. Further review revealed no documented evidence of a summary of findings and the potential barriers to discharge documented by S1CQO.

In an interview on 01/30/18 at 2:25 p.m., S1CQO confirmed the above findings.