HospitalInspections.org

Based on record review and interview, the facility failed to provide the Important Message from Medicare to 1 (#1) of 3 patients whose medical records were reviewed for provision of the Important Message from Medicare, resulting in the failure to inform the patient or patient's representative of the right to appeal discharge and potential loss of rights for the patient. Findings include:

On 6/12/2023 at 1330, review of the medical record for Patient #1 revealed he was admitted to the facility from 11/11/2022-3/10/2023. Review of insurance information revealed he did have Medicare. An Important Message from Medicare (IM) was found on admission; however, none was found for discharge.

On 6/12/2023 at 1435, Case Management Staff M was queried as to if the IM had been given to Patient #1's representative to which she stated, "The patient was discharged to hospice so the IM is not required."

Review of facility policy CC-UM-03 titled "Medicare Beneficiaries Right to Appeal" last revised 1/1/2023 states, "In the following situations, the beneficiary is not eligible for an expedited determination therefore do not deliver the follow-up IM: 1. When a beneficiary transfer to another hospital at the same level of care 2. When beneficiaries exhaust their benefits 3. When beneficiaries end care on their own initiative (elect hospice) 4. Physician does not concur with discharge... "

Review of facility policy #ADM 045 titled "Issuance of the Important Message from Medicare for all Medicare beneficiaries" (sic) last revised 8/6/2014 states, "Follow-up copy of the IM will be issued by the Case Manager within 48 hours of the planned discharge date..."

Based on record review and interview, the facility failed to have a physician order for medical restraints for 3 (#1, 2, 5) of 3 patients reviewed for restraint usage, resulting in the violation of patients' rights and the potential for adverse patient outcomes. Findings include:

On 6/12/2023 at 1330, review of the medical record for Patient #1 revealed he was admitted with diagnoses of acute respiratory failure, encephalopathy, and acute delirium. Patient #1 was placed in medical restraints on 11/11/2022 to prevent interference with medical treatment-pulling of tubes and lines. Daily orders for the medical restraints were present except for the following dates: 11/19/2022, 12/22/2022, and 1/2/2023. The nursing flow sheets were reviewed for restraints and revealed the continued restraint usage on 11/19/2022, 12/22/2022, and 1/2/2023.

On 6/12/2023 at 1412, Clinical Coordinator Staff D confirmed restraint orders should be present on 11/19/2022, 12/22/2022, and 1/2/2023.

On 6/12/2023 at 1540, review of the medical record for Patient #2 revealed he was admitted on 06/01/2023 with a diagnosis of acute respiratory failure and had medical restraints placed to prevent interference with medical treatment. Daily orders for restraints were present except on 6/5/2023. Review of the nursing flow sheet for restraint usage revealed restraints had been continued on 6/5/2023.

On 6/13/2023 at 0958, review of the medical record for Patient #5 revealed he was admitted 12/23/2022-1/17/2023 for acute respiratory failure and had medical restraints placed to prevent interference with medical treatment. Daily orders were present except on 1/2/2023. Review of the nursing flow sheet for restraint usage revealed restraints had been continued on 1/2/2023.

Review of facility policy #R02-N titled "Restraints and Seclusion" last revised 4/1/2023 states, "Restraint must be ordered by a physician... A written order, based on an examination of the patient by the MD/DO (physician) or LP (licensed practitioner) is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate."