HospitalInspections.org

Based upon record review and interview, the facility failed to ensure evidence that 1 of 2 patients reviewed for rights (Patient #1) were informed of their patient rights orally and in writing; in advance of furnishing patient care, and in accordance with the facility's policy.

Findings included:

Review of the Facility's Policy and Procedure for Patient Rights and Responsibilities, last reviewed October 2015 revealed: Notification of Rights, A. At the time of admission, voluntary/involuntary patients or the parent or legal guardian of minor patients shall be provided a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language. C. Staff shall ask the patient or the parent, or guardian to sign and date a copy of the Patient's Bill of Rights form prior to admission to acknowledge the written and verbal explanation of those rights. The signed copy shall be filed in the patient's medical record. If the patient is unable or unwilling to sign, a brief explanation of the reason will be entered on the document.


Record review of Patient #1's medical record revealed there was no evidence or documentation that Patient #1 was provided or informed of the Patient's Bill of Rights either orally and/or in writing. Further review of Patient #1's History and Physical dated 03/10/16 revealed Patient #1 stated he had never been hospitalized for psychiatric treatment in the past, nor had he ever been treated for depression. Patient #1 also stated that he was going through a divorce and thought he was coming to the facility for marriage counseling and ended up being admitted under emergency detention due to discussion of suicidal and homicidal thoughts.


In an interview with the Director of Performance Improvement (PI) on 08/02/16 at 1:15 PM stated the patients were supposed to receive the Patient's Bill of Rights for All Patients upon the admission process. The PI Director stated the Patient Bill of Rights form had a place for the patient to sign to ensure evidence through documentation and that form was placed in the Patient's record. The Director of PI confirmed there was no documentation in Patient #1's permanent record to support this requirement.