HospitalInspections.org

Based on observation, interview and record review, it was determined that the facility did not ensure that the notice of rights requirements was met. Specifically, for 20 out of 20 sampled patients there was no documented evidence of the patients being notified of their rights. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)

Findings include:

Medical record review was completed on 4/1/21 for patients 1 through 20. For 20 of 20 records reviewed, there was no documented evidence that the patients had received notice of their patient rights.

On 3/29/21 at 2:00 PM, an interview was conducted with the emergency room admitting supervisor. She stated they do not bring up patient rights unless the patient asked about it. She stated they have pamphlet's, but do not give them out because of COVID.

On 3/30/21 at approximately 9:20 AM and 9:30 AM, two patients were observed checking into outpatient surgery. A tablet was handed to both patients. They were asked to sign for permission to treat. No patient rights or advanced directives were mentioned. admission clerk 1 (AC 1) was asked if patient rights were posted anywhere or how patients were notified of their rights. She stated they were not posted; they were on the tablet they sign. AC 1 stated they used to hand out flyers, but stopped due to COVID. The information patients sign on the tablet was requested. There was nothing documented about patient rights or advance directives.

On 3/30/21 at 12:42 PM, an interview was conducted with the director of nursing (DON). The DON stated the facility had a trifold pamphlet that had patient rights information on it. The DON stated that admission staff should be giving those pamphlets out to every patient.

On 3/31/21 at 12:08 PM, the medical surgical unit was called. The surveyor asked to speak to the person that goes over patient rights with patients. The surveyor was transferred to a case manager (CM).

On 3/31/21 at 12:10 PM, an interview was conducted with CM 1. CM 1 stated that the CM's do not go over patient rights. She stated it was her understanding that was a part of the admission process. CM 1 stated she thought it was on the tablet patients signed when admitted, but was not sure because she was not very involved in that process.

On 3/29/21 at 2:45 PM, an interview was conducted with an admission clerk 2 (AC 2). The AC 2 stated she admitted patients for the medical surgical unit, obstetrics unit, intensive care unit, intravenous therapy, and radiology. The AC 2 stated she did not go over patient rights or advanced directives with patients.

No documentation of patients being notified of their rights could be provided.