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Based on interview and record review, the hospital failed to provide documented evidence of advance notice of non-covered medicare services for 10 of 30 sampled patients (50, 51, 52, 53, 54, 55, 56, 57, 58, and 59) upon admission. This had the potential to result in the patients being unaware of their rights.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 50 with Intensive Care Unit Director (ICUD), on 7/18/16, at 3:05 PM, it was noted Patient 50 was admitted on 7/11/16. There was no documented evidence Patient 50 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record (EMR - electronic medical record).

2. During a concurrent interview and review of the clinical record for Patient 51 with the ICUD, on 7/18/16, at 3:15 PM, it was noted Patient 51 was admitted on 7/10/16. There was no documented evidence Patient 51 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

3. During a concurrent interview and review of the clinical record for Patient 52 with the ICUD, on 7/18/16, at 3:20 PM, it was noted Patient 52 was admitted on 7/14/16. There was no documented evidence Patient 52 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy in the clinical record.

4. During a concurrent interview and review of the clinical record for Patient 53 with the ICUD, on 7/18/16, at 3:25 PM, it was noted Patient 53 was admitted on 6/3/16. There was no documented evidence Patient 53 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy in the clinical record.

5. During a concurrent interview and review of the clinical record for Patient 54 with the ICUD, on 7/18/16, at 3:30 PM, it was noted Patient 54 was admitted on 7/16/16. There was no documented evidence Patient 54 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

6. During a concurrent interview and review of the clinical record for Patient 55 with the ICUD, on 7/18/16, at 3:35 PM, it was noted Patient 55 was admitted on 7/18/16. There was no documented evidence Patient 55 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

7. During a concurrent interview and review of the clinical record for Patient 56 with the ICUD, on 7/18/16, at 3:39 PM, it was noted Patient 56 was admitted on 7/14/16. There was no documented evidence Patient 56 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy of the notice in the clinical record.

8. During a concurrent interview and review of the clinical record for Patient 57 with the ICUD, on 7/18/16, at 3:44 PM, it was noted Patient 57 was admitted on 7/11/16. There was no documented evidence Patient 57 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy of the notice in the clinical record.

9. During a concurrent interview and record review of the clinical record for Patient 58 with the ICUD, on 7/18/16, at 3:46 PM, it was noted Patient 58 was admitted on 7/15/16. There was no documented evidence Patient 58 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

10. During a concurrent interview and record review of the clinical record for Patient 59 with the ICUD, on 7/18/16, at 4:02 PM, it was noted Patient 59 was admitted on 7/14/16. There was no documented evidence Patient 59 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record and she stated the Director of Case Management (DCM) was responsible in providing the notices to the patients.

During an interview with the DCM, on 7/19/16, at 9:30 AM, he stated he was unaware of the advance notice but insisted he would provide information to the patients of non-covered supplies or equipments upon discharge. He was unable to provide evidence of the notice for medicare non-covered services. The DCM also stated the hospital did not have current policy on Medicare Advance Beneficiary Notice of Non-coverage.

Based on interview and record review, the hospital failed to provide documented evidence nine of 30 sampled patients (41, 42, 43, 44, 45, 46, 47, 48, and 49) received patient rights information. This had the potential to violate the patients' rights.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 41, with Registered Nurse (RN) 20, on 7/19/16, at 9 AM, it was noted the patient was admitted on 7/17/16. There was no documented evidence the patient was provided a copy of the patient rights. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights. She stated it should be scanned into the electronic medical record (EMR).

2. During a concurrent interview and review of the clinical record for Patient 42, with RN 20, on 7/18/16, at 3:45 PM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

3. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:05 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

4. During a concurrent interview and review of the clinical record for Patient 44, with RN 20, on 7/19/16, at 9:35 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

5. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

6. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:20 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

7. During a concurrent interview and review of the clinical record for Patient 47, with RN 20, on 7/19/16, at 11 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

8. During a concurrent interview and review of the clinical record for Patient 48, with RN 20, on 7/19/16, at 11:05 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

9. During a concurrent interview and review of the clinical record for Patient 49, with RN 20, on 7/19/16, at 11:15 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

The hospital policy and procedure titled, "Patient Rights and Responsibilities" effective date 8/88, indicated in part, "To assure that patient rights and responsibilities are understood and adhered to by patients and Hospital Staff..."

Based on interview and record review, the hospital failed to ensure advance directive information was provided to eight of 30 sampled patients (40, 41, 42, 43, 45, 46, 47, and 48) and/or failed to determine if the patients have an advance directive on file. This had the potential for the patients' wishes to go unnoted regarding care.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 40, with Registered Nurse (RN) 20, on 7/18/16, at 2:30 PM, there was information the patient had an advance directive but there was no copy of the advance directive in the patient's clinical record. RN 20 acknowledged there was no copy of the advance directive in the patient's clinical record.

2. During a concurrent interview and review of the clinical record for Patient 41, with RN 20, on 7/19/16, at 9 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

3. During a concurrent interview and review of the clinical record for Patient 42, with RN 20, on 7/18/16, at 3:45 PM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

4. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:05 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

5. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

6. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:20 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

7. During a concurrent interview and review of the clinical record for Patient 47, with RN 20, on 7/19/16, at 11 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

8. During a concurrent interview and review of the clinical record for Patient 48, with RN 20, on 7/19/16, at 11:05 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

The hospital policy and procedure titled, "Advanced Health Care Directives" effective date 2/1997, indicated in part, "To ensure patient participation in the Health Care Decision Making Process by assuring that Beverly Hospital recognizes the patient's right to direct future medical treatment using... Advanced Health Care Directives... Beverly Hospital observes all provisions of the Advanced Health Care Directives... and assures that every adult patient receiving medical care is asked, if they have an Advanced Health Care Directives... or is given information about Advanced Health Care Directives..."

Based on interview and record review, the hospital failed to follow its policy and procedure for verbal or telephone orders when the physician failed to sign orders within 48 hours for three of 30 sampled patients (58, 60, and 61). This had the potential to result in medical errors and medical records are not maintained according to standards of practice.

Findings:

1. During a review of the clinical record for Patient 58, the Physician's Order dated 7/15/16, indicated Patient 58 was to receive Ondasetron (prevents nausea and vomiting) 4 mg (milligrams) IVP (intravenous push) every six hours as necessary. During further review of the clinical record, there was no documented information the verbal order for Patient 58 was authenticated by the physician since the date it was ordered.

2. During a review of the clinical record for Patient 60, the Physician's Order dated 7/10/16, indicated Patient 60 was to receive "Acetaminophen (for pain and fever) 650 mg Rectal Q 6H PRN (every six hours as necessary) Reason: Fever greater than 101." During further review of the clinical record, there was no documented evidence the verbal order for Patient 60 was authenticated by the physician since the date it was ordered.

3. During a review of the clinical record for Patient 61, the Physician's Order dated 7/14/16, indicated Patient 61 was to receive Levofloxacin (antiinfective/antibiotic) 500 mg/100 ml (milliliter) in 100 ml PB (push bolus) every 24 hours. There was no documented evidence the physician authenticated the order since the date it was ordered.

During an interview with the Intensive Care Unit Director (ICUD), on 7/19/16, at 9:30 AM, she reviewed the clinical record for Patient 58, Patient 60 and Patient 61 and she verified the verbal/telephone orders were not authenticated. She gave no further information.

The hospital policy and procedure titled "Physician's Orders: Telephone Orders" dated 11/2015, read in part, "To enable Clinical Staff to follow Physician's instructions for medications, treatments, and procedures... All telephone orders and telephonic reporting of critical test results will be documented in patient's Medical Record, read back to the originator of the order or test result and the originator will confirm accuracy of the order or test result... The responsible Physician is to authenticate all telephone orders within 48 hours by dating, timing and signing telephone orders..."