HospitalInspections.org

Based on document review, observation, record review and staff interview the hospital failed to ensure the Patient's Rights and Responsibilities were reviewed with patients in two of ten (Patient #5 and #10) medical records reviewed and during an interview with one of six patients (Patient #8). The hospital's failure to review Patient's Rights and Responsibilities has the potential to place all patients at risk for not knowing they have rights to make decisions about their care and services during the hospital stay.

Findings include:

- Document review of the hospital's policy titled, "Patient Rights and Responsibilities," with an effective date of 05/31/17 showed the purpose was to communicate and inform patients of their rights as a patient during their stay at the hospital, and to provide an organization-wide statement regarding the patient's rights, responsibilities, and their proper implementation. The policy also showed, the statement of "Patient's Rights and Responsibilities will be posted in the front lobby and other areas of the hospital as appropriate. The Patient's Rights and Responsibilities document is posted in English and Spanish.

Observation on 05/29/18 at 10:25 AM showed there were no Patient's Rights and Responsibilities posted in the lobby. There was a large plastic barrier, from floor to ceiling and wall to wall, on the east side of the lobby. The large plastic barrier was removed later in the day on 05/29/18.

Observation on 05/30/18 at 1:55 PM showed there were no Patient's Rights and Responsibilities posted in lobby or any other area of the hospital.

- Document review of the hospital's "My Health Journal, Wellness Information and Tools for Health" (WITH) notebook that is provided to each patient on admission showed that it contained the Patient's Rights, Privacy Statement, Visitation Rights and how to report concerns, complaints and grievance. A sticker on the front of WITH notebook directs patients to keep the notebook with them at all times.

Review of Patient #5's current medical record on 05/29/18 at 4:00 PM showed he was admitted to the Hospital on 05/23/18 with a diagnosis of Urinary Tract Infection (UTI) (bacteria in the urinary system), Parkinson's Disease, impaired gait and decreased mobility with recent falls. The Adult Admission Assessment General Information section of the record lacked evidence that the Patient's Bill of Rights were reviewed with the patient or family.

Review of Patient #10's current medical record on 05/29/18 at 3:30 PM showed he was admitted on 05/11/18 with left hip fracture, spinal injury, diabetes type II, anemia (low red blood cell count), coronary artery disease (blockage in the arteries of the heart), chronic renal insufficiency (kidneys do not fully function), Deep vein thrombosis (blood clot), Gastroesophageal Reflux Disease (heartburn), Hypertension (high blood pressure), hyperlipidemia (a high concentration of fat in the blood) and sleep apnea (a sleep disorder in which breathing repeatedly stops and starts). The Adult Admission Assessment General Information section of the record lacked evidence that the Patient's Bill Rights were reviewed with the patient or family.

During an interview on 05/30/18 at 2:08 PM, Patient #8 stated that staff did not talk to her about Patient's Rights and she did not know where the Patient's Bill of Rights was located.

During an interview on 05/29/18 at 1:14 PM, Staff M, Staff Educator, said that Patient's Bill of Rights are included in the patient's WITH notebook that is provided to each patient on admission.

During an interview on 05/29/18 at 2:54 PM, Staff A, Director of Quality and Risk Management, said that the hospital does not have a form for patients to sign acknowledging receipt of the Patient's Bill Rights.

During an interview on 05/29/18 at 1:00 PM, Staff B, Nursing Supervisor, stated that all admission paper work is reviewed with new admission patients by the registration staff if the new admission occurs during office business hours, but the nursing staff review the documents with patients admitted after business hours.

During an interview on 05/30/18 at 1:55 PM, Staff P, Director of Plant Operations said that he would look to see if he had the Patient's Bill of Rights somewhere, they had been taken down during the lobby remodel which was completed on 05/29/18.