HospitalInspections.org

Based on record review, policy review, and staff interviews the Hospital failed to inform each patient of the patient's rights in advance of furnishing care or ensure staff followed a policy titled Patient Rights which required staff to inform patients and/or their representative of the patient rights upon their admission for 9 of 15 sampled patients (pt#'s 2, 3, 4, 5, 6, 10, 11, 13 and 15).

Findings include:

- The hospital's policy and procedure titled "Patient Rights" reviewed on 12/21/11 stated the policy's purpose was to "ensure each patient/family admitted to Hospital was aware of their guaranteed rights and their responsibilities...Each patient/family admitted to Hospital will receive a copy of the Patients Rights Policy upon admission."

- Patient #2's medical record reviewed on 12/20/11 revealed a start of care date of 10/7/11 with diagnoses of wound from burn at home, skin graft, respiratory failure with tracheotomy, sepsis (infection in the blood), insulin dependent diabetes mellitus, status epilepticus (brain seizures won't stop), clostridium difficule (infection in the intestines) and acute renal failure (kidneys no longer work). Patient #2 received patient rights on 10/10/11, 3 days after admission. The medical record lacked a rationale for the delay in providing the patient or their representative with patient rights.

- Patient #3's medical record reviewed on 12/21/11 revealed a start of care date of 8/12/11 with diagnosis of intra abdominal abscess (pocket of infected fluid and pus). Patient #3 received patient rights on 8/15/11, 3 days after admission. The medical record lacked a rationale for the delay in providing the patient or their representative with patient rights.

- Patient #4's medical record reviewed on 12/21/11 revealed a start of care date of 10/24/11 with diagnosis of endocarditis (inflammation of lining in the heart). Patient #4 received patient rights on 11/3/11, 10 days after admission. The medical record lacked a rationale for the delay in providing the patient or their representative with patient rights.

- Administrative Staff A interviewed on 12/22/11 at 9:10am acknowledged the Hospital failed to give all the patients their Patient Rights within 24 hours of admission. Staff A indicated management at the Hospital was aware staff had not provided/informed all patients with patient rights prior to providing care as instructed by regulation and hospital policy.

The hospital's failure to provide/inform all patients with patient rights prior to providing care as instructed by regulation and hospital policy also affected patient #'s 5, 6, 10, 11, 13 and 15.