HospitalInspections.org

Based on findings from document review, medical record (MR) review (Patient's #1 - #12 and Patient's #14 - #15) and interview, hospital staff did not provide patients' and/or their representative with a copy of Patient's Bill of Rights as required by New York State regulation in Title 10 New York Codes, Rules and Regulations (NYCRR) 405.7. This lack of notification does not ensure the patient and/or representative had received the information necessary to exercise their rights.

Findings include:

-- The hospital's policy and procedure (P&P) titled "Patient Rights," last reviewed 9/2015, does not instruct staff to provide a copy of Patient's Bill of Rights to patients presenting to the emergency department (ED) and document in the MR whether the patient accepted or declined receiving a copy. Also, it does not identify staff responsible for providing the copy to patients.

-- MR review of Patients #1 - #12, #14 and #15 all lacked documentation of patients receiving or declining a copy of the Patient's Bill of Rights.

-- During interview with Staff A (Director of Emergency Services), on 10/5/16 at 2:30 pm, he/she indicated a copy of Patient Rights are given to patients admitted to the hospital, not to patients in the ED.

-- During interview with Staff B (Registration Specialist), on 10/5/16 at 3:30 pm, he/she does not provide ED patients with a copy of Patients Rights.

-- During interview with Staff C (Senior Vice President Operations/Chief Nursing Officer), on 10/6/16 at 4:45 pm, he/she acknowledged the above findings.