HospitalInspections.org

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of the patient's rights in advance of furnishing care as 2 of 10 inpatient medical records reviewed did not contain admission forms signed by the patient which include receipt of the Patient Bill of Rights which resulted in an incomplete record and the patient being uninformed regarding his patient rights.

The findings were:

Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included receipt of the Patient Bill of Rights. The record of patient #1 admitted on 10/2/17 and patient #4 admitted on 8/25/18 did not contain a Conditions of Admission form. The record of patient #1 did contain a "Patient Choice Letter - Used for patients selecting SNF services" signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign."

In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical records of patients #1 and 4 did not contain signed Conditions of Admission forms which included receipt of the Patient Bill of Rights.

Based on review of documentation and interviews with facility staff, the facility failed to inform a Medicare inpatient of a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization as there was no signed Important Message from Medicare form in the medical record of patient #1.

The findings were:

Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The medical record of patient #1, a Medicare patient admitted on 10/2/17 did not contain an Important Message from Medicare form. The record of patient #1 did contain a "Patient Choice Letter - Used for patients selecting SNF services" signed by patient #1's sister who was patient #1's power of attorney.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Additional forms are required in the following situations: Important Message from Medicare ...if the patient is a Medicare or Managed Medicare Inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission ...In addition, the patient's or patient's representative's signature is required ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign."

In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical record of patient #1 did not contain a signed Important Message from Medicare form.

Based on review of documentation and interviews with facility staff, the facility failed to determine upon admission if 2 of 10 inpatients reviewed had formulated advanced directives as the admission forms documenting the advanced directive statements were not completed by patient #1 and 4 upon admission which resulted in an incomplete record and the facility being unaware if patient #1 and #4 had an advanced directive.

The findings were:

Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included the advanced directive statements. The record of patient #1 admitted on 10/2/17 and patient #4 admitted on 8/25/18 did not contain a Conditions of Admission form which included the advanced directive statements. The record of patient #1 did contain a "Patient Choice Letter - Used for patients selecting SNF services" signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...The Advanced Directives statements are contained within the Parallon standard COA (Conditions of Admission) and COS (Consent for Outpatient Services) forms ...Only one of three applicable PSDA (Patient Self Determination Act) statements is initialed or marked by the patient or legally authorized/legally empowered representative."

In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical record of patient #1 and 4 did not contain signed admission forms which included the advanced directive statements.

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of Privacy Practices and obtain Authorization for Release of Information as 2 of 10 inpatient medical records reviewed did not contain admission forms signed by the patient which include the Authorization for Release of Information form and the Notice of Privacy Practices form which resulted in an incomplete record and the patient being uninformed of confidentiality rights.

The findings were:

Electronic medical records were reviewed on 10/23/18 with the assistance of the VP Quality, staff #1. The record of patient #1 and 4 did not contain signed admission forms which included Authorization for Release of Information and the Notice of Privacy Practices. The record of patient #1 admitted on 10/2/17 and patient #4 admitted on 8/25/18 did not contain a Conditions of Admission or Authorization for Release of Information form. The record of patient #1 did contain a "Patient Choice Letter - Used for patients selecting SNF services" signed by patient #1's sister who was patient #1's power of attorney. The record of patient #4 did contain surgical and anesthesia consent forms signed by the patient's mother on 8/29/18 who was patient #4's power of attorney.

The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Other family member signing on patient's behalf: In rare situations where the registrar recognizes the patient's inability to sign and a family member such as a spouse, mother, father, or an adult child of a parent is available to sign on the patient's behalf and a legally authorized individual is not available, the family member representative may sign ...Procedure: Responsible Party, Patient Access. Action, Notice of Privacy Practices. The patient or legally authorized/legally empowered representative or family member initials this section to acknowledge receipt of the Notice of Privacy Practices."

In an interview with the Director of Patient Access, staff #3 on the morning of 10/23/18, staff #3 acknowledged that the electronic medical records of patients #1 and 4 did not contain signed Conditions of Admission forms which included Authorization for Release of Information and the Notice of Privacy Practices.