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Based on clinical record review, policy and procedure review and staff interview, it was determined there was no evidence 10 of 10 (#1-#10) patients signed an acknowledgment they received their patients rights as required by policy and procedure "Patient Rights and Responsibilities/Title VI". The failed practice did not assure the patient or legal representative was informed on admission of their patient right's. The failed practice affected five (#1-#5) current in-patients and five (#6-#10) discharged patients and had the potential to affect all patients admitted to the facility. The findings were:

A. Review of the policy and procedure "Patient Rights and Responsibilities/Title VI" revealed "The patient or their legal representative will be asked to sign the consent form which states in it that they have received a copy of the Patient's Rights and Responsibilities form."
B. There was no evidence the patients signed an acknowledgement of receiving the patient rights information as required by policy and procedure 10 of 10 (#1-#10) clinical records reviewed.
C. Interview on 03/29/11 at 0948, the Vice President of Nursing confirmed the clinical record did not contain a signed acknowledgement the patient received the patient rights information; she stated she would find out process. At 1030, the Vice President of Nursing stated there was not a process for patients to sign an acknowledgment for patient rights

Based on review of complaints/grievances and staff interview, it was determined there was no evidence the complainant was informed of the contact person of the hospital, the outcome of the investigation and the date of completion for three (#1, #3 and #4) of four (#1-#4) complainants. The failed practice prevented the complainants from receiving resolution to the submitted complaint/grievance. The failed practice had the potential to affect all complaint/grievance submitted for resolution. The findings were:

A. Review of policy and procedure "Patient Complaint/Grievance" revealed:
1) The Department Manager is responsible for drafting the response letter for the COO (Chief Operating Officer). The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion (estimated if resolution is not yet complete.)...."
2) "A response letter shall be forwarded to the patient or patient representative not later than 7 days after receipt of the grievance even though the hospital's resolution may not be fully complete within the seven-day limit. If this is not the final response, then it is referred to as the Interim Response and that Option should be selected on the electronic program and the date entered. If this option is chosen a Final Response letter must be sent later and recorded in the electronic program. A hard copy of the response letter is kept on file by the CEO's (Chief Executive Officer) Executive Assistant."

Review of Complaint #1, #3 and #4 revealed there was no documented evidence the complainant received notification of the resolution to the complaint to include the contact person for the hospital, outcome of the investigation and the date completed. Interview on 03/29/11 at 1547, the Vice President of Nursing confirmed the complaint findings.

Based on clinical record review, policy and procedure review and staff interview, it was determined 3 (#1, #4 and #6) of 10 (#1-#10) patients did not have a discharge plan initiated within one working day of the admission. The failed practice prevented the patient's post hospital discharge needs being identified, assessed and arranged before discharge. The failed practice affected Patient #1, #4 and #6 and had the potential to affect all patients admitted to the hospital.

A. Review of the policy and procedure Utilization Management revealed the following regarding discharge planning:
1. Under "Admission Review", it was written "During admission review on acute medical-surgical unit/units, the Case Manager will meet with the patient and/or family to initiate an assessment of the patient's discharge planning needs if applicable.
2. Under "IX. Discharge Planning/Social Services, it was written, "The process of Discharge Planning begins prior to, or at admission, for all acute care medical-surgical patients. The Case Manager screens all patients to assess their potential post-hospitalization needs.." "The Case Manager assesses discharge planning needs within one working day of the patient's admission and initiated discharge planning if nursing home or rehabilitation placement, durable medical equipment, home health care, hospice or transportation is needed...".
B. Review of policy and procedure "High Risk Screen-Social Service" revealed "Patients admitted are screened by nursing personnel as part of the admission nursing assessment for discharge planning needs. The high risk patients identified are referred to Clinical Resource Management for screening and evaluation. "Assessment will be initiated within one business day if deemed appropriate."
C. There was no evidence discharge planning was performed as required by policy and procedure for Patient #1, #4 and #6 as follows:
1. Patient #1 was admitted on 03/26/11. Review of page 4 of the Patient Admission Record dated 03/27/11 under discharge planning revealed there were no items checked that required a Social Service Consult. Review of the Progress Noted dated 03/27/11 at 1115 by Case Management revealed "Case management UR (Utilization Review) complete. Pt (patient) meets in-pt (in-patient) status. WBC (white blood cell) 33. Pt considering Hospice. Will decide after oncology consult." The clinical record did not have any note regarding Patient #1's discharge planning needs. Interview on 03/29/11 at 1003, the Case Manager Supervisor #1 confirmed there was no evidence Patient #1 was assessed for discharge planning needs. Case Manager Supervisor #1 presented the form "Northwest Health System-Case Management Worksheet" and stated Case Managers were to complete the form. She confirmed it was not in the clinical record for Patient #1. Case Manager Supervisor #1 was questioned on how discharge planning needs were addressed in the care plan; she stated a lot of times self care deficit would be where we would identify needs such as oxygen, etc. Case Manager Supervisor #1 confirmed there was no discharge needs addressed on the care plan.
2. Patient #4 was admitted on 03/26/11. Review of page 4 of the Patient Admission Record dated 03/26/11 revealed the patient had triggers for Social Service Consult. There was no evidence Case Management had seen the patient as of 03/29/11 at 1100. The discharge planning assessment should have been conducted on 03/28/11 (one working day). Interview on 03/29/11 at 1100, Case Manager Supervisor #1 confirmed the patients discharge needs had not been assessed yet; she stated she would do it today. Interview on 03/29/11 at 1247, the Director of Case Management stated it was not entered into the computer to notify Case Management that a consult was needed.
3. Patient #6 was admitted on 02/28/11 and was discharged on 03/08/11. Review of the Patient Admission Record dated 02/28/11 revealed under Discharge Planning, the patient had two triggers which reflected the patient was to be referred to Social Services. Review of Progress Notes from 02/28/11 to 03/08/11 revealed there was no evidence the patient was referred to Social Services and received an assessment of their discharge needs. Interview on 03/29/11 at 1420, the Director of Case Management confirmed there was no Case Management addressing the patient's discharge needs.