HospitalInspections.org

.Based on clinical record review, facility policies, and staff interviews the facility failed to comply with patient's rights. Hospital staff failed to inform the patient or representative that the patient was an outpatient receiving observation services.
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Findings were:
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Document titled "Medicare Outpatient Observation Notice" form PS-9264 REV 2/2017 (2 Pages) was reviewed. The patient's name and admission date of 1/2/2018 is on the first top page of the document. In the first section the first box is checked - "The testing and evaluation that you require is generally completed on an outpatient basis." At the bottom of the 1st page "Refused to sign" is hand written. The 2nd page which required the signature of the Patient or Representative was incomplete.
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In an interview with the Risk Manager, she stated that no documentation was available in the patient clinical record indicating that the patient or his wife were informed that the patient was on outpatient observation status on 1/2/18. This was confirmed on the morning of 11/28/2018.