HospitalInspections.org

Based on record review and interview the facility failed to ensure staff provide Medicare recipients with the "Important Message From Medicare" within 2 days of admission and within 2 days prior to discharge as per policy to 3 of 4 patient's eligible for Medicare (Patient #6, #8 and #9) in a total sample of 10 medical records reviewed.

Findings include:

Review of policy "Important Message from Medicare (IM or IMM)" lasts revised 5/2021, under Procedure revealed "Hospital personnel must provide the IM at or near admission but no later than 2 calendar days before admission and obtain the signature and signature date of the patient or representative to indicate receipt of notice... The follow-up copy of the IM shall be delivered as far in advance as possible before discharge, but no more than two (2) calendar days before the day of discharge. Retained copies must be placed in the patients' medical record.""

Review of Patient #6's medical record revealed Patient #6 was an 80-year-old admitted on 9/27/2022, was deemed incapacitated, and verbal consent for admission was obtained from her daughter on the day of admission. Patient #6 was discharged 10/19/2022. There was one IMM in patient #6's medical record dated 10/15/2022 at 5:00 PM.

On 12/06/2022 at 9:35 AM during interview with Quality Coordinator D, during review of Patient #6's medical record, Quality Coordinator D stated "that's all I have."

Review of Patient # 8's medical record revealed Patient #8 was a 66-year-old admitted on 8/16/2022. A "Non-Interruption Agreement" was signed 8/16/2022 (not timed) during consent for treatment, indicating consent from previous admission was continued. Patient #8 was discharge 10/16/2022. There was no documentation that a second copy of the Important message from Medicare was issued to Patient #8 prior to discharge.

On 12/06/2022 at 11:15 AM during interview with Quality Coordinator D, during review of Patient #8's medical record, when asked to see the documentation that the second copy of the IMM was issued, Quality Coordinator D stated "I don't have that for her."

Review of Patient #9's medical record revealed Patient #9 was a 74-year-old admitted on 10/07/2022. Consent to treat and Important Message from Medicare About Your Rights was signed by Patient #9 on 10/10/2022 at 1:00 PM (3 days after admission). There was no documentation that a second copy of the Important message from Medicare was issued to Patient #9 prior to discharge.

On 12/06/2022 at 1:32 PM during interview with Quality Coordinator D during review of Patient #9's medical record, when asked if there was another signed IMM in Patient #9's medical record this admission, Quality Coordinator D stated "no."

On 12/06/2022 at 2:15 PM during interview with Director of Quality B, when asked about missing IMM's in patients #6, #8 and #9's medical records, Quality Director B stated "I'm not sure of this process," I just started 6 weeks ago.

Advanced directives

Based on record review and interview the facility failed to provide information on Advance Directives in 4 of 10 inpatients (Patient # 5, #6, #7 and #10) in a total sample of 10 medical records reviewed.

Findings include:

Record review of policy "Advance Directives and Do Not Resuscitate (DNR) Orders," #3.110, last revised 10/2021 under Procedure revealed "If at the time of admission, the patient does not have any Advance Directives, the Director of Admissions or designee will offer information regarding advanced directives to the patient and his/her responsible party. The case manager assigned to the patient will follow up with the patient/family regarding the development of advance directives."

Patient #5's medical record revealed Patient #5 was a 60-year-old admitted 9/02/2022 with altered mental status and respiratory distress with strider (vibrating noise when breathing) for rehabilitation and discharged 11/03/2022. Patient #5's power of attorney (POA) was activated on admission. There was no documentation that Patient #5 had an advanced directive or that Patient #5's POA was offered information regarding the development of an advanced directive.

Patient #6's medical record revealed Patient #6 was an 80-year-old admitted 9/27/2022 with a history of diabetes, vascular dementia (loss of ability to think, remember and reason), essential thrombocytosis (type of chronic leukemia) on a vent and hemodialysis for rehabilitation. Patient #6's POA was activated on admission. There was no documentation that Patient #5 had an advanced directive or that Patient #5's POA was offered information regarding the development of an advanced directive.

Patient # 7's medical record revealed Patient #7 was a 65 year-old admitted 10/27/2022 with a history of quadriplegia and chronic respiratory failure secondary to aspiration pneumonia admitted for rehabilitation and discharged 11/03/2022. Patient #7 was asked about advanced directives on admission and on 10/28/2022 at 10:55 AM a referral was made to case management. There was no documentation that Patient #7 was offered information regarding the development of an advanced directive.

Patient #10's medical record revealed Patient #10 was a 59-year-old admitted 10/17/2022 with a history of end-stage renal disease on hemodialysis, post cardiac arrest, admitted for rehabilitation management. Patient #8 signed a "Non-interruption Agreement" on admission 10/17/2022 (not timed) during consent for treatment indicating consent from previous admission was continued. Previous hospitalization was 9/24/2022 thru 10/08/2022. "Consent to Admission and Medical Treatment" dated 9/24/2022, signed by Patient #10 on 9/28/2022 at 3:40 PM with nothing checked under Advanced Directives. There was no documentation that Patient #10 had an advanced directive or that s/he was offered information regarding the development of an advanced directive.

On 12/06/2022 at 9:15 AM during interview with Director of Quality B, when asked about missing advance directives in the medical records Quality Director B stated another department is responsible for this process, "I will need to ask admissions department" who follows up.

On 12/06/2022 at 2:15 PM during interview with Quality Coordinator D, when asked if there was any other documentation on advanced directives for patients #5, #6, #7 and #10, Quality Coordinator D stated "I have provided you with what I have."