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Tag No.: A0117
Based on review of 5 open records and 10 closed medical records, it was determined that two of the ten closed records did not contain documentation that the patients were informed of their rights as hospital patients.
There is a two page form to be signed on admission by the patient or their representative regarding rights and responsibilities. The form includes consent for treatment, patient rights, responsibility for valuables, payment guarantee, Medicare authorization, and the information release for insurance benefits.
Closed record #10 was a patient admitted to the hospital on 5/18/12. The form upon review on 8/24/12 in a closed medical record was blank. There is no documentation that the patient or his/her representative had been informed of the patient rights. The form has space provided to document why the patient cannot sign or is unable to sign the form. These areas are also blank.
Closed record #15 was a patient admitted to the hospital on 5/17/12. The form upon review on 8/24/12 in a closed medical record was blank. There is no documentation that the patient or his/her representative had been informed of the patient rights. The form has space provided to document why the patient cannot sign or is unable to sign the form. These areas are also blank.
Tag No.: A0386
Observation and review of the hospital ' s Nursing Service job descriptions on 08/24/12, revealed that there were (4) job descriptions (RN I & II, Nurse Manager, and Director of Patient Care Services) that lacked specification as to who "supervises" these individuals or to whom they report.
The Nursing Service is responsible for the 24 hour delivery of patient care and involves various responsibilities, elegation of duties and over site/monitoring by designated staff. Lines of authority are important in the provision of safe patient care and general operation of the nursing service.
Tag No.: A0450
Based on a review of 4 open records and 11 closed medical records, it was determined that two of the eleven closed records were not complete.
Closed medical records for patient #10 and patient #15, who were admitted in May 2012, are incomplete since the documentation forms for patient rights were blank upon review on 8/24/12. The form has space provided to document why the patient cannot sign or is unable to sign the form. These areas are also blank.