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The hospital identified a census of 20 current inpatients. The patient sample included 21 patient records, including open and closed records, inpatients and outpatients. Based on document review, record review, and staff interview, the hospital failed to inform 5 of 17 sampled inpatients (#2, 3, 7, 14, and 16), 3 of 4 sampled outpatients (#18, 19, and 20) and 42,582 outpatients served between 9/28/09 and 9/27/10 by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments of their rights prior to providing services. The hospital failed to inform patients of whom to contact to file a grievance, failed to determine if the patients had Advanced Directives for 4 of 17 sampled inpatients (#1, 3, 14, and 16), 2 of 4 sampled outpatients (#19, and 20) and 42,582 outpatients served between 9/28/09 and 9/27/10 by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments. The hospital did not have a system in place to ensure that patients were informed of their rights and allowed to exercise their rights.

Findings included:

- The hospital failed to inform 5 of 17 sampled inpatients which included 2 closed inpatient records (#2, and #3) and 3 open inpatient records (#7, 14, and 16), 3 of 4 sampled outpatient records which included 1 open outpatient record (#18) and 2 closed outpatient records (#19, and #20) and 42,582 outpatients served by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments of their rights prior to providing services as evidenced at A-0117.

- The hospital failed to inform 5 of 17 sampled inpatients which included 2 closed inpatient records (#2, and #3) and 3 open inpatient records (#7, 14, and 16), 3 of 4 sampled outpatient records which included 1 open outpatient record (#18) and 2 closed outpatient records (#19, and #20) and 42,582 outpatients served by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments who to contact to file a grievance as evidenced at A-0118.

- The hospital failed to determine if the patients had Advanced Directives for 4 of 17 sampled inpatients (#1, 3, 14, and 16), 2 of 4 sampled outpatients (#19, and 20) and 42,582 outpatients served between 9/28/09 and 9/27/10 by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy as evidenced at A-0132.

The hospital identified a census of 20 current inpatients. The patient sample included 21 patient records, including open and closed records, inpatients and outpatients. Based on document review, record review, and staff interview, the hospital failed to inform 5 of 17 sampled inpatients which included 2 closed inpatient records (#2, and #3) and 3 open inpatient records (#7, 14, and 16), 3 of 4 sampled outpatients which included 1 open outpatient record (#18) and 2 closed outpatient records (#19, and #20) and 42,582 outpatients served by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments of their rights prior to providing services.

Findings include:

- The hospital brochure titled: "Patient Bill Of Rights" reviewed on 9/27/10 at 7:35pm revealed that as a patient of the hospital the patient or their legal representative have the right to receive a copy of their Bill of Rights.

The hospital policy and procedure titled "PATIENT'S BILL OF RIGHTS", reviewed on 9/27/10 at 7:35pm and last revised 12/09, failed to instruct staff to provide each patient (both outpatient and inpatient) with a copy of their Bill of Rights.

Review of sampled medical records for inpatients #2, #3, #7, #14, #16 and outpatients #18, #19, and #20 revealed the hospital staff failed to inform and provide these patients with a copy of their Bill of Rights.

Registered Wound Care Nurse A interviewed on 9/28/10 at 4:44pm verified the initial assessment form included a question about patient rights, but nursing staff lacked confirmation the admission's office gave patient's a copy of their rights.

Business Officer Director B interviewed on 9/29/10 at 7:50am verified the hospital did not provide the hospital's outpatients their Bill of Rights.

Registered Nurse C, Director of Emergency, interviewed on 9/29/10 at 10:42am verified the hospital failed to give the Emergency Department patients their rights.

Registered Nurse E, Director of Laboratory/Radiology, interviewed on 9/29/10 at 8:40am stated they thought the admissions office personnel provided patient rights information to the hospitals Laboratory and Radiology patients prior to their procedures, and lacked knowledge that the patients were not receiving this information until now.

Information provided by Business Office Director B, reviewed on 9/29/10 at 10:45am acknowledged the hospital failed to provide patient rights information to 42,582 outpatients served by the hospital between 9/28/09 through 9/27/10. This included 11,190 Emergency Departments patients, 3,922 Wound Care patients, 11,874 Radiology patients (Diagnostic Radiology, Sonogram, Magnetic Resonance Imaging, Computerized Tomography and Nuclear Medicine), 14,420 Laboratory patients, 31 Infusion patients, and 1,145 Physical Therapy, Occupational Therapy and Speech Therapy patients.

Registered Nurse D, Interim Chief Nursing Officer, interviewed on 9/29/10 at 11:20am stated they thought the hospital's outpatients continued to receive their patient rights from the admissions office.

The hospital identified a census of 20 current inpatients. The patient sample included 21 patient records, including open and closed records, inpatients and outpatients. Based on document review, record review, and staff interview, the hospital failed to inform 5 of 17 sampled inpatients which included 2 closed inpatient records (#2, and #3) and 3 open inpatient records (#7, 14, and 16), 3 of 4 sampled outpatients which included 1 open outpatient record (#18) and 2 closed outpatient records (#19, and #20) and 42,582 outpatients served by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments who to contact to file a grievance.

Findings include:

- The hospital brochure titled: "Patient Bill Of Rights," reviewed on 9/27/10 at 7:35pm informed patients how to file a grievance which included multiple agencies and persons including the State Survey and Certification Agency.

The hospital policy and procedure titled "PATIENT'S BILL OF RIGHTS", reviewed on 9/27/10 and last revised 12/09, documented the patient's right to file a grievance and gives direction to patients of whom to contact.

Review of sampled medical records for inpatients #2, #3, #7, #14, #16 and outpatients #18, #19, and #20 revealed hospital staff failed to provide patients with the Bill of Rights brochure which contained the information about filing a grievance.

Business Office Manager B interviewed on 9/29/10 at 7:50am verified the hospital did not provide the hospital's outpatients their grievance information.

Registered Nurse C, Director of the Emergency Department interviewed on 9/29/10 at 10:42am verified the hospital failed to provide the Emergency Department patients their grievance information.

Registered Nurse E, Director of Laboratory and Radiology, interviewed on 9/29/10 at 8:40am stated they thought the admissions office personnel continued to provide the grievance information to the hospitals Laboratory and Radiology patients prior to their procedures, and they did not know the patients were not receiving this information until now.

Information provided by Business Office Director B, reviewed on 9/29/10 at 10:45am acknowledged the hospital failed to provide grievance information to 42,582 outpatients served by the hospital between 9/28/09 through 9/27/10. This included 11,190 Emergency Departments patients, 3,922 Wound Care patients, 11,874 Radiology patients (Diagnostic Radiology, Sonogram, Magnetic Resonance Imaging, Computerized Tomography and Nuclear Medicine), 14,420 Laboratory patients, 31 Infusion patients, and 1,145 Physical Therapy, Occupational Therapy and Speech Therapy patients. Interview with Business Office Director B, on 9/29/10 at 10:45am verified the 42,582 outpatients failed to receive information of whom to contact to file a grievance.

Registered Nurse D, Interim Chief Nursing Officer, interviewed on 9/29/10 at 11:20am stated they thought the hospital's outpatients continued to receive their grievance information from the admissions office.

The hospital identified a census of 20 current inpatients. The patient sample included 21 patient records, including open and closed records, inpatients and outpatients. Based on document review, record review, and staff interview, the hospital failed to determine if the patients had Advanced Directives for 4 of 17 sampled inpatients (#1, 3, 14, and 16), 2 of 4 sampled outpatients (#19, and 20) and 42,582 outpatients served between 9/28/09 and 9/27/10 by the hospitals Emergency Room, Wound Care clinic, Radiology, Laboratory, Infusion Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy departments.

Findings include:

- The hospital policy titled "ADVANCE DIRECTIVES," reviewed on 9/27/10 at 8:30pm, stated "...I...2...during the admission process on the nursing unit, the nurse will inquire about the existence of advance directives and document such on the admission record..."

Review of the initial nursing assessments for inpatients #1, 3, 14, and 16 and the outpatient records of patients #19 and 20 lacked evidence the nursing staff obtained required information from the patients about Advanced Directives.

Registered Nurse F interviewed on 9/29/10 at 8:20am reported patient #20's medical record lacked documentation regarding the patient's decision about Advanced Directives.

Registered Nurse A interviewed on 9/27/10 at 4:25pm and 4:45pm verified patient's #1 and #3 medical records lacked information about Advanced Directives.

Business Officer Director B interviewed on 9/29/10 at 7:50am verified the hospital did not give the hospital's outpatients Advanced Directives information.

Registered Nurse C, Director of the Emergency Department, interviewed on 9/29/10 at 10:42am verified the hospital failed to give the Emergency Department patients Advanced Directives information.

Registered Nurse E, Director of Laboratory/Radiology, interviewed on 9/29/10 at 8:40am stated they thought the admissions office personnel continued to provide Advanced Directives information to the hospitals Laboratory and Radiology patients prior to their procedures, and they lacked knowledge the patients were not receiving this information until now.

Information provided by Business Office Director B, reviewed on 9/29/10 at 10:45am revealed the hospital failed to provide Advanced Directive information to 42,582 outpatients served by the hospital between 9/28/09 through 9/27/10. This included 11,190 Emergency Departments patients, 3,922 Wound Care patients, 11,874 Radiology patients (Diagnostic Radiology, Sonogram, Magnetic Resonance Imaging, Computerized Tomography and Nuclear Medicine), 14,420 Laboratory patients, 31 Infusion patients, and 1,145 Physical Therapy, Occupational Therapy and Speech Therapy patients. Business Office Director B interviewed on 9/29/10 at 10:45am verified the hospital failed to determine if the 42,582 outpatients had an Advanced Directive.

Registered Nurse D, Interim Chief Nursing Officer, interviewed on 9/29/10 at 11:20am stated they thought the hospital's outpatients continued to receive their patient rights from the admissions office.