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ROXBOROUGH MEMORIAL HOSPITAL
PATIENT RIGHTS: INFORMED DECISION
Tag No.: A0132
Based on review of facility policies and procedures, medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure patients were provided with Advance Directive information per facility policy in four of five medical records reviewed (MR1, MR2, MR3, and MR4).
Findings include:
Review on March 20, 2013, of facility policy "Advance Directives," dated August 2012, revealed "... 4. Will document in medical record that patient was asked whether he/she has an Advance Directive and that patient was given written information."
Review on March 20, 2013, of MR1, MR2, MR3, and MR4, revealed there was no documented evidence in these medical records that the facility provided these patients with Advance Directive information.
Interview on March 20, 2013, at 1:20 PM, with EMP2 confirmed there was no documented evidence in MR1, MR2, MR3, and MR4, that the facility staff provided these patients with Advance Directive information. EMP2 confirmed the facility's policy required staff to document in the patient's medical record that they were provided with Advance Directive information.