HospitalInspections.org

Based on record review and interview, facility staff failed to provide a notice of patient rights in 9 out of 10 patients' (Patients #1, 2, 3, 4, 5, 6, 7, 8, and 10) medical records reviewed in a total universe of 10 patient medical records.

Findings include:

Review of facility's policy #1.2.21, "Patient Rights and Responsibilities," dated 7/10/2024 revealed, "It is the responsibility of the admitting/registration staff, in collaboration with the patient care staff, to provide a copy of Patient's Rights and Responsibilities to patients or their legal guardians upon admission to the hospital."

Review of Patient #1's medical record revealed Patient #1 had a colon screening on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #1.

Review of Patient #2's medical record revealed Patient #2 had a sigmoid colonoscopy on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #2.

Review of Patient #3's medical record revealed Patient #3 had a colon screening on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #3.

Review of Patient #4's medical record revealed Patient #4 had a diagnostic colonoscopy on 5/31/2024. There was no evidence of patient rights being reviewed with or given to Patient #4.

Review of Patient #5's medical record revealed Patient #5 had a colon screening on 5/23/2024. There was no evidence of patient rights being reviewed with or given to Patient #5.

Review of Patient #6's medical record revealed Patient #6 had a colonoscopy/esophagogastroduodenoscopy (a procedure that allow a doctor to examine the upper gastrointestinal tract) on 5/23/2024. There was no evidence of patient rights being reviewed with or given to Patient #6.

Review of Patient #7's medical record revealed that Patient #7 had an esophagogastroduodenoscopy on 4/24/2024. Further review revealed no evidence of patients' rights being reviewed with or given to Patient #7.

Review of Patient #8's medical record revealed Patient #8 had a colonoscopy on 11/8/2023. There was no evidence of patient rights being reviewed with or given to Patient #8.

Review of Patient #10's medical record revealed Patient #10 had a colonoscopy on 7/30/2024. There was no evidence of patient rights being reviewed with or given to Patient #10.

During an interview on 10/01/2024 at 10:02 AM, Patient #11 was asked if they were given their patient rights. Patient #11 stated, "I don't think so."

During an interview on 10/01/2024 at 10:57 AM, Patient #12 was asked if they were given their patient rights. Patient #12 stated, "No one said anything about them."

During an interview on 10/01/2024 at 12:00 PM, Manager D was asked how patient rights are provided to the patient and/or representative. Manger D stated, "Nothing is given to the patients here."

During an interview on 10/01/2024 at 12:50 PM, Registration Staff O was asked what paperwork is signed and gone over with patients upon registration. Registration Staff O stated, "We go over HIPPA (Health Insurance Portability and Accountability Act) and assignment of benefits...No patient rights are discussed here."

During an interview on 10/01/2024 at 1:00 PM, Regulation Specialist E stated, "Patient rights are given to patients when they initially establish care as an inpatient to the hospital. They are hung up on the walls by the elevators."

Based on record review and interview, the facility staff failed to inform patients of whom to contact to file a grievance for 9 of 10 patients' (Patients 1, 2, 3, 4, 5, 6, 7, 8, 10) medical records in a total universe of 10 medical records reviewed.

Finding include:

A review of facility policy #1.2.21 titled, "Patient Rights and Responsibilities," effective date, July 10, 2024, revealed, "B. Responsibility: 1. It is the responsibility of employees, medical staff, students, and volunteers to acknowledge and respect these patient rights and ensure that patients receive adequate information describing their rights. 2. It is the responsibility of the admitting/registration staff, in collaboration with the patient care staff, to provide a copy of Patient's Rights and Responsibilities to patients or their legal guardian upon admission to the hospital... A. Patient Rights Forms are located on UW Health's intranet and public internet sites ... III. Key Policy Elements A. Patients or their authorized representative are informed of their rights in advance of furnishing or discontinuing care whenever possible. At the time of admission (sic) patients to the hospital (sic) patients will receive a copy of their Patient Rights and Responsibilities and at the time of new patient registration in the clinics, within a reasonable period."

A review of facility form titled, "Notice of Privacy Practices" form is undated, revealed, "This information describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights: When it comes to your health information, you have certain rights. This section explains your right and some of our responsibilities to help you ... File a complaint if you feel your rights have been violated. You can complain if you feel we have violated your rights by contacting us using the information on page (no page number is listed) . You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W. Washington D.C. 20201, calling (877) 696-6775, or visiting www.hhs.gov/ocr/privacy/hippa/complaints/. We will not retaliate against you for filing a complaint."

The facility did not provide any forms that reference how a patient can file a quality of care complaint to the facility.

During an interview on 10/01/2024 at 12:00 PM, Manager D was asked how patient rights are provided to the patient and/or representative. Manger D stated, "Nothing is given to the patients here."

During an interview on 10/01/2024 at 1:00 PM with Regulation Specialist E, when asked how the patient would know who to contact if they had a complaint, Regulation Specialist E stated there is a website on UW Health that patients can access the information to file a complaint. When asked how the patient would know to look on the website, she stated she was not sure.