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Based on observation, interview and record review the facility failed to ensure patients received their patient rights, for six patients (#3, #8, #17, #21, #22 and #23) of 18 patients reviewed. This failure had the potential to affect all patients admitted to the facility. The facility census was 470.

Findings included:

1. Record review of the facility's standard titled, "Patient's Bill of Rights" dated 10/11, showed no policy, procedure or staff guidance to ensure patients or the patient's representative were provided the patient's rights information.

2. Record review of Patient #3's medical record showed no documented evidence she received a copy of the patient rights.

3. During an interview on 12/03/13 at 10:40 AM, Patient #3 stated that she did not receive her patient rights.

4. During an interview on 12/03/13 at 10:30 AM, Staff A, Registered Nurse (RN), Manager of Three West, stated that the facility did not document the patients receipt of the patient rights.

5. Record review of Patient #8's medical record showed no documented evidence she was informed of her patient rights.
6. During an interview on 12/03/13 at 10:30 AM, Patient #8 stated that she did not receive her patient rights and was not informed of her patient rights.
7. During an interview on 12/03/13 at 10:50 AM, Staff E, Charge Nurse of 4 East/West, stated that there was not a consistent process to document patients were informed of their patient rights. Staff E stated that some nurses document in the medical record that patients received their patient rights, while others did not.
8. During an interview on 12/03/13 at 10:45 AM, Patient #17 stated that he did not receive his patient rights. Patient #17's wife also stated that there was no "booklet" given to them regarding patient rights.
9. Record review of Patient #17's medical record showed no documented evidence that he received a copy of the patient rights prior to care being provided.

10. During an interview on 12/03/13 at 11:15 AM, Staff T, RN, Manager of Nine East, stated that the facility did not document the patients receipt of their patient rights. She stated that unless the nurse documented that the rights had been given there was no way to verify that patients received their patient rights.

11. During an interview on 12/04/13 at 9:45 AM, Staff W, RN, Neurological Trauma Intensive Care Unit Manager, stated that the nurses are to review the patient information with the patient and stated that the facility did not document the patient' receipt of the patient's rights information.

12. During an interview on 12/04/13 at 9:58 AM, Patient #21 stated that he did not receive his patient rights.

13. Record review of Patient #21's medical record showed no documented evidence that he received a copy of the patient rights.

14. Record review of Patient #22's record showed no documented evidence he was informed of his patient rights.

15. During an interview on 12/04/13 at 9:45 AM, Patient #22 stated that he was not informed of his patient rights.

16. During an interview on 12/04/13 at 9:55 AM, Patient #22's family member/patient representative stated that she had not been informed of the patient's rights for Patient #22 and was not aware of the process for filing a complaint.

17. Record review of Patient #23's record showed no documented evidence he was informed of his rights as a patient while in the facility.

18. During an interview on 12/04/13 at 9:45 AM, Patient #23 stated that he was not informed of his patient rights .

19. During an interview on 12/03/13 at 2:52 PM, Staff J, Patient Safety Officer, stated that there was not a process to ensure that patients were informed of their patient rights, that nursing staff were not required to document that they informed patients of their patient rights and that the facility was not monitoring if patients received their patient rights.




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