HospitalInspections.org

Based on review of facility policies, review of medical records (MR) and interview with staff (EMP) and patients, it was determined the facility failed to conform to all applicable Federal regulations.

The facility was found to be non-compliant with the following Federal regulation:

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 is not met as evidenced by:

Based on review of facility policy, review of medical record (MR), interview with staff (EMP) and interview with a patient, it was determined the facility failed to follow their policy that required all patients be informed of their patient rights for MR1.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed March 2016 revealed, "All patients, inpatient and outpatient, must be informed of their rights as hospital patients. ... There are established mechanisms to ensure that these rights and responsibilities will be observed and communicated. ... The hospital must inform each patient, or when appropriate, the patient's representative as allowed by State law, of the patient rights. ... ."
Review of MR1 failed to reveal evidence that the patient had been given a copy of or was informed of the Patient Bill of Rights while in the ED.
Interviews conducted on October 7, 2016, at 2:30 PM - 2:50 PM with EMP8, EMP9 and EMP10 revealed that they were not aware that Emergency Department (ED) patients were to be informed of their "Patient Rights" prior to receiving care in the ED, nor would they know what to give patients if they requested a copy of their patient rights.
An interview conducted on October 7, 2016, at 3:00 PM with EMP7, confirmed that the facility did not follow their policy "Patient Rights and Responsibilities" for all ED patients as they do not inform patients of the "Patient Bill of Rights" prior to furnishing care or provide a copy during their ED stay. Further interview confirmed that they did not have a process to provide ED patients with their "Patient Bill of Rights" nor did they have copies of the "Patient Bill of Rights" to give patients, if they requested a copy.
A tour of the Emergency Department on October 7, 2016, at 2:20 PM with EMP1 and EMP7 revealed only four "Patient Bill of Rights" posters were posted in the ED - one on the wall next to the Registration area and one in each of the three ED pods on hallway walls. No copies of the "Patient Bill of Rights" were available to be given to ED patients.

An interview conducted on October 11, 2016, at 11:15 AM with ED patient in Pod A room 8 revealed that they were not given a copy of the "Patient Bill of Rights" nor had they been informed of their patient rights during their ED stay.
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Based on review of facility policies, review of medical records (MR) and interview with staff (EMP) and patients, it was determined the facility failed to conform to all applicable State regulations.

The facility was found to be non-compliant with the following State regulation:

5100.55. Notification of rights. Upon receipt of a person for treatment, the facility shall advise the individual of his rights, and obtain when feasible a written acknowledgement by the person that his rights affecting their treatment were explained. In the event that conditions prevent such acknowledgement or understanding, the process of notification shall be recorded by the person designated and confirmed by a witness.

This is not met as evidenced by:

Based on review of facility policy, review of medical record (MR) and interview with staff (EMP), it was determined the facility failed to follow their policy that required patients who sign for voluntary psychiatric admission be informed of their Mental Health Patient Rights for MR1.

Findings include:

Review of Department of Nursing policy "Evaluation and Management of the Behavioral Health Patient" last reviewed December 2015 revealed, "Voluntary Psychiatric Admissions (201) ... D. If it has been determined that the patient will require a psychiatric admission, and the patient is agreeable, the CIS or EDCM will review the "Explanation of Voluntary Admission Rights" (Form MH 781-BCD) and "Bill of Rights" (MH 782) with the patient and will obtain the patient's signature on the "Consent for Voluntary Inpatient Treatment" (Form MH 781).
Review of MR1 with EMP5 revealed the MH 81 form "Consent for Voluntary Inpatient Treatment" with set form wording on page one, "Before signing this form, your treatment should be explained to you and you must be given a copy of the Patient's Bill of Rights.." the patient's signature dated June 11, 2016, was present below the above wording.
An interview conducted on October 7, 2016, at 1:45 PM with EMP5 revealed that they and their staff were not aware of the Department of Nursing policy "Evaluation and Management of the Behavioral Health Patient" that required the Social Worker staff in the ED to review the "Bill of Rights" (MH 782) with the patient.

An interview conducted on October 11, 2016, at 9:00 AM with EMP3 revealed that they had not reviewed the patient's rights with the patient, nor had they provided a copy to the patient, as that was not their role.

An interview conducted on October 11, 2016, at 9:50 AM with EMP4 revealed that they had explained the "Consent for Voluntary Inpatient Treatment" MH 781 form to the patient and obtained the patient's signed consent. Further interview revealed that they did not provide the patient with a copy of the Patient's Bill of Rights (MH 782), nor did they explain these rights to the patient as required by the MH 81 form "Consent for Voluntary Inpatient Treatment" and their policy.
An interview conducted on October 11, 2016, at 11:30 AM with EMP1 confirmed that they had not followed the mental health regulation or their policy, which required them to provide the patient with a copy of the Patient's Bill of Rights (MH 782), an explain them to the patient when consent was obtained for voluntary mental health admission.