HospitalInspections.org

Based on a review of medical records (MR), review of facility policy and procedures and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" prior to discharge for seven of seven medical records reviewed for IMM (MR2, MR5, MR7, MR9, MR10, MR11, MR12).

Findings include:

Review of facility policy "Medicare Important Message," reviewed February 27, 2015, revealed "Each Medicare patient will receive a copy of "An Important Message From Medicare" for all inpatient admissions. This information sheet provides Medicare patients with their treatment rights, and recourse if they feel those rights have not been adhered to by the health care provider ... Admitting Clerk ... places the original copy in the customer's chart ... "

Review on September 11, 2015, of MR2, MR5, MR7, MR9, MR10, MR11 and MR12 revealed these Medicare patients were admitted as an inpatient to the facility. Further review of MR2, MR5, MR7, MR9, MR10, MR11, MR12 revealed no documented evidence that "An Important Message from Medicare" was given to each of these Medicare inpatients.

Interview on September 11, 2015, at 2:00 PM, with EMP3 confirmed there was no documented evidence of an IMM in MR2, MR5, MR7, MR9, MR10, MR11 and MR12. EMP3 confirmed the admitting staff were not obtaining the IMM from any of the facility's Medicare inpatients.

Based on review of medical records (MR), review of policies and procedures and interviews with staff (EMP), it was determined the facility failed to inform each patient of the hospital's internal grievance process and whom to contact to file a grievance in 31 of 31 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31).

Findings include:

Review on September 11, 2015, of policy, "Grievance Procedure 504," dated June 2006, revealed there was no provision in it to inform each patient of the hospital's internal grievance process. Further review revealed the policy did not identify whom patients would contact to file a grievance with the hospital.

Review on September 9 through September 14, 2015, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31, revealed these patients were not informed of the hospital's internal grievance process. Further review also revealed these patients were not informed of whom to contact to file a grievance with the hospital.

Interview on September 14, 2015, at 11:10 AM, with EMP1 confirmed there was no documentation in MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31 that these patients were informed of the hospital's internal grievance process and whom to contact to file a grievance with the hospital.

Based on review of policies and procedures and interview with staff (EMP), it was determined the facility failed to ensure its grievance process included a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.

Findings include:

Review on September 11, 2015, of policy, "Grievance Procedure 504," dated June 2006, revealed there was no provision in it to include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.

Interview on September 11, 2015, at 12:15 PM, with EMP1 confirmed there was no provision in the hospital's grievance procedure to include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.

Based on review of medical records (MR), policies and procedures and interview with staff (EMP), it was determined the hospital failed to inform each patient of his or her visitation rights in 31 of 31 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31).

Findings include:

Review on September 11, 2015, of policy, "Guest Relations Standards: Visiting Hours," no date, revealed there was no provision in it to inform each patient of his or her visitation rights.

Review on September 9 through September 14, 2015, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31, revealed no documentation that these patients were informed of his or her visitation rights.

Interview on September 14, 2015, at 11:30 AM, with EMP1 confirmed there was no documentation in MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30, and MR31 that these patients were informed of his or her visitation rights.

Based on observation, review of policies and procedures and interview with staff (EMP), it was determined the facility failed to ensure that unauthorized employees did not have access to patient medical records.

Findings include:

Review on September 10, 2015, of facility policy "Access After Hours," dated January 2014, revealed "Access to the Medical Record Department by other than Medical Record Department personnel shall be controlled to protect confidentiality of the records and to safeguard the record. Only authorized personnel (other than Medical Record Department Personnel) shall only enter the Medical Record Department after hours to retrieve medical records ... Authorized person: Nursing Personnel Unit Clerks Administration Physicians & Physician Assistants".

Observation on September 10, 2015, at 11:50 AM, of the medical records room revealed a medical record room on the first floor of the hospital. Closed medical records were stored in this room.

Interview on September 10, 2015, at 11:55 AM, with EMP5 confirmed radiology, laboratory, and admissions employees had access to the medical room on the first floor. EMP5 confirmed the hospital's policy did not authorize these employees access to the medical record room.

Based on a review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure two of the Utilization Review committee members were doctors of medicine or osteopathy.

Findings include:

Review on September 9, 2015, of the "Utilization Review Plan," dated 2015, revealed "... E. Utilization Review committee 1. Organization and Composition The Utilization Review committee ... shall be composed of at least one (1) member of the medical staff ..."

Review on September 9, 2015, of the "Utilization Review/Tissue and Transmission" committee meeting minutes from January 2014, through June 2015, revealed only one doctor of medicine or osteopathy attended these meetings.

Interview on September 9, 2015, at 1:30 PM, with EMP1 revealed that the facility's "Utilization Review Plan" only required one (1) member of the medical staff and only one (1) member of the medical staff attended the Utilization Review/Tissue and Transmission committee meetings from January 2014, through June 2015.