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ST BERNARDS MEDICAL CENTER
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on clinical record review, it was determined the Facility failed to ensure 4 (#3, #4, #10 and #12) of 20 (#1-#20) Medicare patients did not have signed initial Medicare Important Notices in the clinical record. Based on clinical record review it was determined that 5 (#4, #5, #7, #10, and #19) of 14 (#1-5, #7, #10, #12-14, #17, and #19-20) patients did not have the Medicare Important Notice in the record at/prior to discharge. Failure to ensure issuance of the Medicare Important Notice did not allow the patients the opportunity to be informed of and aware of their rights as a hospital patient, as well as their discharge and appeal rights. The failed practice affected 1 current patient on the day of survey. Findings follow:
A. Review of the open clinical record of Patient #3 revealed no initial Medicare Important Notices in the clinical records. Findings verified by Clinical Data Abstractor #2 at 1130 on 07/11/12.
B. Review of the closed clinical records of Patients #4, #10 and #12 revealed no initial Medicare Important Notices in the clinical records. Findings verified by Clinical Data Abstractor #2 at 1130 on 07/11/12.
C. Review of the clinical records of five (#4, #5, #7, #10, and #19) of 14 (#1-5, #7, #10, #12-14, #17, and #19-20) discharge patients revealed no Medicare Important Notice in the clinical record at/prior to discharge. Findings verified by Clinical Data Abstractor #2 at 1130 on 07/11/12.
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on clinical record review, it was determined that 3 (#3, #17 and #18) of five (#3, #6, #16-18) open clinical records did not have signed consent for care in the clinical record. Failure to obtain signed consents for care did not afford the patient or their representative the opportunity to make informed decisions regarding his or her care. The failed practice affected 3 of 5 inpatients on the day of survey. Findings follow:
A. Review of the open clinical record of three (#3, #17 and #18) of five (#3, #6, #16-18) inpatients revealed no signed consent for care.
B. The above findings were verified by Clinical Data Abstractor #2 at 1210 on 07/11/12.