HospitalInspections.org

A complaint investigation was conducted on 12/28/15 to assess compliance in the area of 482.13 Patient Rights. Based on observation, interview, and medical record review, it was determined that the hospital did not ensure that all patients were informed of their patient rights in advance of furnishing care for 15 out of 15 medical chart reviews and 2 of 4 interviewed patients. (Patient identifiers: 1 through 17) Therefore, the complaint was found to be substantiated.


Findings include:

1. An interview was held with the Hospital Quality Director on 12/29/15. The surveyor asked how the hospital notified patients of their patient rights. The Hospital Quality Director stated that the patients rights form was available through registration and was posted in the lobby.

2. On 12/29/15, the surveyor observed the registration process for the Hospital. There was no mention of patient rights. In an interview with the Hospital registrar, she indicated that the only information given to the patients was in a brochure. The brochure she supplied to the surveyor had information regarding privacy and no patient rights information was available. The registration person was asked specifically if there was any information given to the patient or relayed to the patient regarding their patient rights. She replied that there was no other information.

3. On 12/29/15, surveyors interviewed 3 patients in various hospital units and asked if anyone had explained their patient rights to them or given them patient rights written information. For 2 of 3 patients, no patient rights information had been provided. (Pt. Identifier 16 and 17)

4. On review of the complainant medical record the surveyors were unable to verify that the patient had received their notice of patient rights.