HospitalInspections.org

Based on a review of facility policies and medical records (MR) and interview with staff (EMP), 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 a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to inform all patients of their patient rights for six of six medical records reviewed (MR1 through MR6).

Findings include:

A review of facility policy "Patients' Bill of Rights and Responsibilities" effective date 10/21/2016 revealed, "PURPOSE It is the purpose of this policy to identify patient rights and responsibilities, and to clarify mechanisms by which patients are advised of those rights and responsibilities. SCOPE This policy applies to all patients, employees and staff of the Hospital of the University of Pennsylvania (HUP) and those parts of the Clinical Practices of the University of Pennsylvania (CPUP) which practice as or in conjunction with HUP, operating under the HUP license. This policy also applies to: (1) those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g., HUP's inpatient rehabilitation facility; (ii) private entities that lease space in property owned or leased by HUP only if they provide contracted clinical services to HUP; and (iii) personnel that provide contracted clinical services to HUP patients. ... . PROCEDURE 1. At the time of admission, The Admission Center staff gives those patients who are seen in the Admission Center a copy of the statement of Patient's Bill of Rights and Responsibilities as listed below. 2. Each patient receives a statement of the Patients' Bill of Rights and Responsibilities at the time of admission and/or upon arrival at the patient's room. ... ."

1. A review on May 22, 2017, of MR1 revealed the patient was admitted as an observation patient on December 2, 2016. Further review failed to reveal documentation that the patient was informed of their patient rights.

2. A review on May 22, 2017, of MR2 revealed the patient was admitted to the Emergency Department (ED) on May 21, 2017. Further review failed to reveal documentation that the patient was informed of their patient rights.

3. A review on May 22, 2017, of MR3 revealed the patient was admitted to the ED on May 22, 2017. Further review failed to reveal documentation that the patient was informed of their patient rights.

4. A review on May 22, 2017, of MR4 revealed the patient was admitted to the ED on May 20, 2017. Further review failed to reveal documentation that the patient was informed of their patient rights.

5. A review on May 22, 2017, of MR5 revealed the patient was admitted to the ED on May 22, 2017. Further review failed to reveal documentation that the patient was informed of their patient rights.

6. A review on May 22, 2017, of MR6 revealed the patient was admitted to the ED on May 20, 2017. Further review failed to reveal documentation that the patient was informed of their patient rights.

An interview conducted on May 22, 2017, at 2:50 PM with EMP3 confirmed that MR1 through MR6 did not contain documentation that patients were informed of their Patient Bill of Rights.

7. An interview conducted on May 22, 2017, at 2:50 PM with EMP15 revealed that patients registered at Out-patient Radiology were not given a copy of the Patient Bill of Rights and were not informed of their patient rights.

8. An interview conducted on May 22, 2017, at 3:00 PM with EMP16 revealed that patients registered at Out-patient Apheresis were not given a copy of the Patient Bill of Rights and were not informed of their patient rights.

An interview conducted on May 22, 2017, at 3:20 PM with EMP3 confirmed that patients registered in Out-patient Radiology and Out-patient Apheresis were not given a copy of the Patient Bill of Rights and were not informed of their rights.

An interview conducted on May 22, 2017, at 3:30 PM with EMP1 confirmed that the facility did not inform all patients of their patient rights.