HospitalInspections.org

Based on medical record review, staff interview, and facility policy and procedure review, it was determined the facility staff failed to ensure that rights and responsibilities were provided and consent for treatment was obtained from the patient as per facility policy and procedure for four (4) of seven (7) patient medical records reviewed.

The findings include:

On 5/2/2022 and 5/3/2022, the surveyor reviewed the medical records for seven (7) patients.

A review of the records for Patient's #1, #2, and #3 contained no documentation of a completed "Patients' Rights and Responsibilities" form, which includes patient rights and responsibilities, consent for treatment, and the grievance process, in the medical record for at least one hospital encounter for each patient.

A review of the record for Patient #4 contained evidence that the Patient #4 arrived at the facility on 3/10/2022 and the Rights and Responsibilities consent form was not signed until four (4) days into the Patient's admission on 3/14/2022.

During an interview on 5/2/2022 at 1:37 p.m., Staff Member (SM) #11 stated that when registration staff register patients and have them sign the Rights and Responsibilities and consent form, the staff will explain the form to the patient so that the patient understands what they are signing. SM #11 states that registration only obtains verbal consents when the patient has COVID, is suspected to have COVID, or has a medical condition where they are unable to sign. SM #11 stated that there is no policy on obtaining verbal consent. SM #11 stated that if a patient is non-verbal then the registration staff will document "unable to obtain due to medical condition" in the benefit collection notes and will sign "not obtained due to medical condition" on the consent form.

During an interview on 5/2/2022 at 2:13 p.m., SM #13 stated that the Rights and Responsibilities consent form is to be completed for every patient at every encounter or hospital visit.

During an interview on 5/3/2022 at 2:44 p.m., SM #20 stated that the expectation is that registration staff should be completing the Rights and Responsibilities consent form for every patient at every single visit. SM #20 stated that registration staff should document on the form as to why they were unable to obtain consent from the patient. SM #20 stated that patients do not receive any admission packet, paperwork, or pamphlet regarding patient rights and responsibilities, consent for treatment, and the grievance process. SM #20 stated that information is provided on the Rights and Responsibilities consent form that the patient signs.

A review of the facility's document titled "INOVA User Guide" section on Patient Rights and Responsibilities, states in part:
Patient Rights and Responsibilities Frequency
A patient needs to sign a Patient Rights and Responsibilities form:
Once a year at patient level for all outpatient visits
Office Visits, Labs, Radiology
Once per visit at encounter level for every admission
Emergency Room visit
Hospital Outpatient Surgery
Observation
Inpatient
Patient Level = Once a Year
Encounter Level = Every admission

A review of the facility's policy titled "Patient Rights and Responsibilities," states in part:
B. Inova Responsibilities
The Inova facilities shall use all reasonable efforts to ensure that patients are aware of their rights and can exercise their rights effectively.
Each Inova facility will:
1. Provide to each patient or his/her representative a summary of the rights set forth in this policy...

The above concern was reviewed with SMs #1, 2, 3, 13, 15, and 21 at the exit conference.