HospitalInspections.org

Based on review of facility documention and medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policy to provide new patients with a copy of their Patient Rights at the earliest possible moment of their hospitalization in nine of nine medical records (MR1, MR3-MR10).

Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Last Reviewed: December 2015 ... Policy Area: Organization-Clinical ... Patient Rights ... "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. CHS acknowledges that the patient has the right to make decisions regarding medical care, this includes discontinuation of therapy to the extent permitted by law. Information regarding the patient's rights and responsibilities is made available to all patients including adults and parents or guardians of neonates, children and adolescent patients at the time of admission. This information is also provided to outpatients at the time of registration. The Statement of Patient Rights and Responsibilities is attached as Appendix A of this policy. ... A Statement of the Patient's Rights Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, our patient, is addressed in this Statement of Patient's Rights ... 1. You have the right to respectful care given by skilled staff. ... 2. You have the right to receive care no matter what your age, AIDS or HIV status, ancestry, color, disability, education, gender identity, income, language, marital status, national origin, race religious creed, sex, sexual orientation, union membership, or who will pay your bill. ... 5. You have the right to expect privacy and confidentiality with regard to your care. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 11. Before any procedure (except in an emergency), your doctor must obtain informed consent (permission) from you or from someone who can legally give consent. This means your doctor will explain the diagnosis, treatment, possible complications, and tell you about other treatments. You will be asked to sign a consent form in which you confirm that your doctor has given this information. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... 21. You have the right to ask for a detailed copy of your bill and to ask for information on financial aid with regard to your care. ... 23. You have the right to request a discharge plan. Upon discharge, you will be given information for your follow-up health care. ... 33. You have the right to be informed of your rights at the earliest possible moment in the course of your hospitalization. ... ."

1. Review of Advanced Wound Healing Center meeting minutes dated February 6, 2017, revealed, "... Old Business 1. Documentation issues: ... SOC [Start of Care] packets should be given and document that this was done. ... ."

2. EMP1 provided a sample of the Start of Care (SOC) packet. Included in the packet/folder were documents entitled, "A Statement Of The Patient's Rights," "When you should call the Wound Healing Center," "Basic Wound Care," "Billing Information," "No Butts About It Tobacco Cessation Program," "Guidelines for Managing Your Pain," and a brochure entitled, "Wound Treatment that offers hope for healing."

3. Review of the patient's medical record (MR1) and closed medical records (MR3-MR10) dated February 7, 2017, through February 13, 2017, was conducted with EMP1 to ascertain the completion of nursing documentation that indicated that the Start of Care (SOC) packet was provided to new patients at their initial visit to the Wound Healing Center. Nine of Nine medical records (MR1, MR3-MR10) reviewed failed to reveal documented evidence that the Start of Care packet was given to the patient at their initial visit to the Wound Healing Center.

EMP1 confirmed the above findings.