HospitalInspections.org

Based on review of hospital documents, medical records and staff interviews, it was determined the hospital failed to provide admission documentation, including written patient rights for 3 of 3 patients (#'s 1, 2 and 3).

Findings include:

Review of hospital documents required for signature upon admission include: Patient Information, Notice of Privacy Practices Patient Acknowledgement Form, Permission to Photograph for Medical Treatment, and Acknowledgement Receipt of Handbook, which includes Patients and Responsibilities.

Review of Quality Assurance Program Improvement (QAPI) meeting for 2/4/14 revealed: "...Admissions department was found to be under compliance with signatures on admission...."

Review of QAPI meeting for 3/11/14 revealed: "....Admission Paper work is still low in compliance. The admission team was severely cut...one person remains in admissions...to help initiate admit paper work the CM (case management) team will be helping when time is allotted...."

Medical record review for Patient # 1 revealed admission to the hospital on 1/7/14. Patient # 1 was accompanied by the spouse on admission and signed the Conditions of Admission form. Patient # 1 discharged to another facility on 1/23/14. The medical record did not contain the required hospital admission documents, including Patient Rights and Responsibilities.

Medical record review for Patient # 2, admitted 3/25/14 revealed on 3/28/14 at 1015 hours that, the medical records did not contain the required hospital admission documents, including Patient Rights and Responsibilities.

Medical record review for Patient # 3, admitted on 3/21/14 revealed on 3/28/14 at 1015 hours that, the medical records did not contain the required hospital admission documents, including Patient Rights and Responsibilities.

The Admissions Coordinator confirmed in an interview conducted on 3/28/14 at 1015 hours that, the medical records for Patient #'s 1, 2 and 3 did not contain the required hospital admission documents, including Patient Rights and Responsibilities.

The Chief Clinical Officer and the Director of Quality Management confirmed in an interview conducted on 3/28/14 at 1015 hours that, the medical record for Patient #'s 1, 2 and 3 did not contain the required hospital admission documents, including Patient Rights and Responsibilities.