HospitalInspections.org

Based on medical record review, policy review and interview, it was determined that the facility failed to inform the patients or patients' representative of the patient's rights in advance of furnishing or discontinuing patient care for five (5) of ten (10) patients reviewed (Patients # 2, #3, #4, #5, and #8).

The findings include:

During medical record reviews on December 12, 2017 between 9:00 A.M. and 12:00 P.M. the following was revealed:

Patient # 2 was admitted on November 2, 2017 at approximately 4:25 P.M. The consent for treatment was signed by two (2) hospital staff witnesses with documentation stating "patient unable to sign". There is no documentation that patient rights were reviewed or offered to the patient or the patient's representative.

Patient # 3 was admitted on November 1, 2017 at approximately 9:48 P.M. The consent for treatment was signed by two (2) hospital staff witnesses with documentation stating "patient unable to sign". There is no documentation that patient rights were reviewed or offered to the patient or the patient's representative.

Patient # 4 was admitted on November 10, 2017 at approximately 11:57 A.M. The consent for treatment was signed by two (2) hospital staff witnesses with documentation stating "patient unable to sign". There is no documentation that patient rights were reviewed or offered to the patient or the patient's representative.

Patient # 5 was admitted on November 7, 2017 at approximately 6:20 P.M. The consent for treatment was signed by two (2) hospital staff witnesses with documentation stating "patient unable to sign". There is no documentation that patient rights were reviewed or offered to the patient or the patient's representative. A family member of Patient # 5 signed a consent for treatment on November 9, 2017.

Patient # 8 was admitted on December 7, 2017 for elective surgery. The consent for treatment and patient rights received was signed, initialed and dated by the patient on November 13, 2017. There is no documentation that consent for treatment was signed and patient rights were reviewed or offered to the patient or the patient's representative on December 7, 2017.

The facility policy provided by Staff Member # 1 on December 12, 2017 at approximately 11:15 A.M. titled "Notification of Patient Rights and Responsibilities" reads in part: "If a patient is admitted without decision making capacity and there is no family, guardian or healthcare agent present every effort shall be made to provide written notification of rights and responsibilities as soon as the patient has capacity or family, guardian or Healthcare Agent arrives."

An interview with Staff Member # 1 on December 12, 2017 at approximately 11:20 A.M. revealed "the registration staff are aware. There is room for improvement regarding patient rights".

An interview with Staff Member #10 on December 12, 2017 at approximately 1:35 P.M. revealed "An elective surgery patient signs the consent for treatment and patient rights when the pre-op testing is done within thirty (30) days of the surgery date and it is not signed or offered again. There is no policy for this."

The findings were discussed with Staff Members # 1, #6, #11 and #12 on December 12, 2017 at approximately 3:00 P.M. during the exit interview.