Cleveland Clinic Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 33162 Based on record review and interview, the Hospital failed to provide a copy of the Important Message from Medicare (IMM) before discharge as required for 3 of 3 sampled patients (Patients# 1, 2, and 4). The findings included: 42 CFR 405.1205 titled “Notifying beneficiaries of hospital discharge appeal rights” documents, in relevant parts, “Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary’s rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS ...” and “The notice must include the following information: [ ...] The beneficiary’s right to request an expedited determination of the discharge decision including a description of the process under 405.1206, and the availability of other appeals processes if the beneficiary fails to meet the deadline for an expedited determination” and “Delivery of the written notice of rights described in this section is valid if- (i) The beneficiary or the beneficiary’s representative has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, Except as provided in paragraph (b)(4) of this section; and (ii) the notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described In paragraph (b)(2) of this section” and “[B](4) If the beneficiary refuses to sign the notice. The hospital may annotate its notice to indicate the refusal, and the date of refusal is considered the date of receipt of the notice” and “The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary’s representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge.” The hospital’s Policy and Procedure titled “Florida Medicare Important Message: The Follow-Up Copy of the Signed Important Message from Medicare Policy for Care Management,” effective date 11/23/20, date last approved/reviewed 08/28/24, documents in part, the Purpose, “To define the process for the Patient Service Specialist (PSS) to register Medicare and Medicare Advantage plan inpatients appropriately to trigger the creation of an Important Message from Medicare form” and “PSS must make three (3) attempts to achieve a signature from the patient/responsible party within the 2-day admission window” and does not address the provision of follow up copy(ies) before a patient’s discharge from the hospital. 1) Review of the record reveals Patient #1 was admitted on 10/02/25 and discharged on 11/14/25. Further review of the record reveals her insurance is a Medicare plan and a scanned “Important Message from Medicare” that documents by handwritten note the family member refused to sign but does not include a staff member name, signature, date, or time witnessing this refusal and one copy of this form has a fax date of 12/05/25 at 10:12 AM on the top of the form. During interview on 12/17/25 at 4:00 PM, the Manager Care Management, Staff D reported the last IMM for Patient #1 before her discharge on 11/14/25 was dated 11/07/25. There is no evidence of an IMM issued to the patient or family within 48 hours of her discharge from the hospital. 2) Review of the record reveals Patient #2 was admitted on 11/07/25, her insurance was Humana Medicare, a family member signed receipt for Patient #2’s IMM on 11/09/25 at 6:50 PM, and she was discharged on 11/20/25. During interview on 12/17/25 at 4:15 PM, Clinical Risk Manager, Staff A confirmed the IMM dated 11/09/25 was the last IMM before Patient #2 was discharged on 11/20/25. 3) Review of the record reveals Patient #4 was admitted on 12/01/25, his insurance was Medicare Part and B, and he signed receipt for an IMM on 12/01/25 at 6:18 AM. During concurrent review of the record on 12/17/25 at 4:28 PM, Staff A confirmed there was no evidence a subsequent IMM was delivered to the patient or their representative before Patient #4’s discharge on 12/10/25.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33162 Based on interviews and record review, the facility failed to develop adequate nursing care plans for 2 of 3 sampled patients (Patients# 7 and 10). The findings included: The Florida Nursing Plan of Care Standard Operating Procedure, for target group Cleveland Clinic Florida, effective date 7/28/22, provided upon request for the policy and procedures related to nursing plans of care, documents under Instructions, “ The Nursing Plan of Care (POC) provides direction for individualized care of the patient. The plan serves as a guide for nurses in transitioning patient care from one nurse to another and among interdisciplinary teams. It is a means of communicating and organizing interventions to meet the patient’s needs and progress toward goals. The plan encompasses the nursing assessment of the patient, interventions identified for patient care, and patient and family education” And under Creating and Documenting the Nursing Plan of Care, “The RN initiates the POC Flowsheet upon admission;” “Patient problem selection begins upon admission and continues throughout the patient’s stay;” “New problems are added as they are identified;” “”Related to” criteria are selected. If appropriate criteria are not listed the RN may document supporting criteria as a comment under “other: see comment.” Interventions related to specific patient problems are selected from the drop-down list within the POC. The RN may document additional interventions that are not listed under “other: see comment” or within the nursing progress record;” and “The Goal/Outcome for the patient/family is chosen from the Goal/Outcome list. The RN may document additional Goals/Outcomes that are not listed under “other: see comment.” 1) Review of Patient #7’s record reveals she was admitted on 11/15/25 for failing heart valve and endocarditis (infection of the heart) and on 11/26/25 she had a mitral valve (heart valve between the left chambers of the heart) replacement, tricuspid valve (heart valve between the right chambers of the heart) repair, and closure of the patent foramen ovale (opening between the upper heart chambers), during which chest tubes were inserted to drain fluid from between the lungs and chest wall. Patient #7’s Cardiothoracic Progress Note for date of service 12/17/25 at 10:13 AM (during the survey) documents she still had right and left chest tubes draining over 100 ml of fluid in 24 hours and chest tubes were to be removed once they drained less than 100 ml in 24 hours. Review of Patient #7’s Plan of Care for her hospital stay beginning 11/15/25 through the morning of 12/17/25 revealed plan of care categories activated during that stay included Anxiety, Aspiration, Bleeding, Cardiac, Communication, Discharge Planning, Fall, Fluid/Electrolyte, Risk for Infection, Knowledge Deficit, Mobility, Neurological Deficit, Pain, Safety, Selfcare, and Skin. Patient #7’s Plan of Care did not include a care area related to the chest tubes. Review of Patient #7’s plan of care reveals it does not address care of the chest tube sites, monitoring for complications of the chest tubes, or education of the patient related to the presence of chest tubes. During interview on 12/17/2025 at 9:45 AM, Program Manager Accreditation, Staff C and Clinical Risk Manager II, Staff A both reported their belief that the Risk for Infection in the Plan of Care “covered” the chest tubes since it documents risk for infection related to “Lines/Drains/Airways.” During an interview on 12/17/25 at 10:05 AM, the Assistant Nurse Manager of Surgical ICU verified there is no active problem area in the Plan of Care for Patient #7’s chest tubes; that Respiratory Is not open but probably should be; and that their policy does not say chest tubes have to be in the plan of care. 33988 2) Review of Patient #10 ‘s record reveals that he was admitted for cardiogenic shock on 10/27/2025, had a heart transplant on 11/22/2025, and was discharged from the hospital on 12/02/25. Review of Patient #10’ s Blood Administration Record from 11/22/25 at 12:00 AM until 11/24/25 at 12:00 AM reveals he received 14 RBC (Red Blood Cell) transfusions, 6 Platelet transfusions and 6 Frozen Plasma transfusions. Review of Patient #10’s Plan of Care for his entire hospital stay beginning 10/27/25 revealed plan of care categories activated during that stay included Anxiety, Aspiration, Bleeding, Cardiac, Fall, Fluid/Electrolyte, Risk for Infection, Mobility, Pain, Safety, Selfcare, Skin. Patient #10’s Plan of Care did not include a care area related to blood product transfusions. Patient #10’s Plan of Care category for bleeding documents to monitor for signs and symptoms of bleeding and monitor labs (laboratory tests) and the goal/outcomes for bleeding to be controlled, vital signs to remain stable, and to be free of signs/symptoms of active bleeding. Further review of Patient #10’s Plan of Care reveals it does not address monitoring for the risks associated with transfusions, such as monitoring for transfusion reactions. During interview on 12/17/2025 at 2:55 PM, Registered Nurse/Charge Nurse, Staff B reviewed Patient #10 ‘s care plan and confirmed Patient #10 had no care plan area for blood transfusions and the care plan did not include monitoring for complications of transfusion reactions; Staff B explained the EHR (Electronic Health Record) does not have a drop-down care plan area option for transfusions or risks of transfusion reaction but only an option for the risk of (needing) blood transfusions under the category Bleeding, although nurses can do a freeform entry.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 33162 Based on record review and interview, the Hospital failed to provide accurate information regarding Patient #1’s status and care needs to the receiving facility/care provider for 1 of 3 sampled patients (Patient #1). The findings included: Review of the record revealed Patient #1 was admitted on 10/03/25 for subarachnoid hemorrhage and discharged to a nursing home on 11/14/25. During interview on 12/16/25 at 3:13 PM, Accreditation Program Manager, Staff E reported Patient #1 was discharged to the nursing home with a PICC line because the patient’s family member refused to let staff remove it. Staff E was unable to find documentation that staff informed the receiving facility Patient #1 was being sent with the PICC line since report was called before the order to leave it in. During interview on 12/16/25 at 3:24 PM, the Chief Medical Officer stated he was called at the time of Patient #1’s discharge and told the son refused to let her PICC (Peripherally Inserted Central Catheter) line be removed; that since there were no absolute contraindications for her to keep it and he has discharged patients to that same nursing home with PICC lines before, he knew they could provide the care and approved for her to be discharged with the PICC line. Review of Patient #1’s transfer form dated 11/14/25 reveals it does not indicate the presence of a PICC line, but “N/A” (not applicable) under the heading Treatment Devices.”