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2005 5TH STREET

MONROE, WI 53566

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on record review and interview, the facility failed to ensure Pts were provided all their rights in writing upon admission,for 1 of 1 (pt. #1) records reviewed for patient rights in a sample of 1.

Findings include:

Per review on 2/17/15 at 11:00 AM of facility Pt Rights sheet given to Pts upon admission, that were in effect on the date Pt #1 arrived at the facility (1/19/15), and review of Pt #1's MR, the following rights are missing:

The right to receive care in a safe setting.

The right to formulate an Advanced Directive.

Per interview on 2/17/15 at 11:45 AM with CQM B, CQM B confirmed that the above rights were missing from Pt #1's medical record.