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KALEIDA HEALTH
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on observation, policy review, medical record review and interview, the facility does not ensure the New York State (NYS) Breastfeeding Mothers' Bill of Rights (BMBR) is posted in prominent patient care areas and a written copy is provided to each patient for 22 of 22 patients (Patient #1-22).
Findings include:
Observation on 10/19/18 at 11:00 AM in Mother/Baby Unit, at 11:30 AM in Neonatal Intensive Care Unit and at 02:30 PM in Labor & Delivery revealed no evidence the BMBR was posted in prominent patient care areas per NY Public Health Law, Article 25, Title 1, § 2505-a - BMBR 20 and Dear Administrator letter 16-18 BMBR dated October 11, 2016.
Review on 11/20/18 of policy "Breastfeeding" last revised 08/13/18 does not include the need to post the BMBR in prominent patient care area and/or that a copy of these rights will be given to breastfeeding mothers.
Review on 11/20/18 of the medical records for Patients #1-22 revealed no evidence the BMBR was received by the patient.
Interview on 11/19/18 at 03:00 PM with Staff (A), Chief of Quality and Safety, Staff (B), RN Chief Nursing Officer and Staff (F), Regulatory Affairs and Risk Management verified that the BMBR is not posted. Interview on 11/20/18 at 11:30 AM with Staff (F), Regulatory Affairs and Risk Management verified the medical record findings.
PATIENT RIGHTS: GRIEVANCES
Tag No.: A0118
Based on policy review, medical record review and interview, the facility does not ensure patient/parent notification of the facility grievance process for 22 of 22 Patients (Patient #1-22).
Findings include:
Review on 11/20/18 of policy " Customer Relations-Grievance (Complaint) Process" revealed during registration, the patient is provided in writing the facility's internal grievance process and the "Your Rights as a Hospital Patient in New York State" booklet. This booklet includes information on the right to file a grievance including NYS Department of Health and other specified agencies contact information.
Review on 11/20/18 on policy "Your Rights as a Hospital Patient" last revised 09/18/17 revealed "Your Rights as a Hospital Patient" booklet will be distributed to all inpatients on admission and documentation of receipt will be located on the "Consent for Treatment and Payment Agreement" form, retained in the medical record.
Review on 11/20/18 of the medical records for Patients #1-22 revealed no evidence that patients/parents were notified of the facility grievance policy, including contact information of the State Agency.
Interview on 11/20/18 at 11:30 AM with Staff (F), Regulatory Affairs and Risk Management verified medical record findings.
PATIENT VISITATION RIGHTS
Tag No.: A0216
Based on policy review, medical record review and interview, the facility does not ensure notification of visitation policies and rights to each patient/parent for 22 of 22 Patients (Patient #1-22).
Findings include:
Review on 11/20/18 of policy " Patient Visitation" last revised 11/23/15 does not include requirements for patient/parent notification of Visitors Rights.
Review on 11/20/18 of the medical records for Patients #1-22 revealed no evidence that patients/parents were notified of the facility's visitation policies and their rights.
Interview on 11/20/18 at 11:30 AM with Staff (F), Regulatory Affairs and Risk Management verified these findings.