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SHERIDAN MEMORIAL HOSPITAL
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on medical record review, document review, staff interview and review of the facility's policy, the facility failed to inform the patient of their rights in advance of furnishing care for 2 of 11 sample patients (#5, #9). The findings were:
1. Review of the electronic medical record for patient #5 showed an admission to the transitional care unit (TCU) on 1/5/24. Further review showed the absence of a "Conditions for Registration/Services/Admission" document as well as the absence of a "Conditions of Admission Transitional Care and Rehabilitation Services" document.
2. Review of the electronic medical record for patient #9 showed an admission to the medical unit on 12/17/23. Further review showed the absence of a "Conditions for Registration/Services/Admission" document.
3. Review of the "Conditions for Registration/Services/Admission" document as well as the "Conditions of Admission Transitional Care and Rehabilitation Services" document showed both were utilized by the facility during the registration process to acknowledge the patient had been notified of their rights.
4. Interview with the Patient Access Manager on 1/23/24 at 10:39 AM revealed that inpatients should be registered within 48 hours of arrival and patients admitted to the TCU were required to sign both the "Conditions for Registration/Services/Admission" document and the "Conditions of Admission Transitional Care and Rehabilitation Services" document to acknowledge their rights and responsibilities and patient #5 had not done so. In addition he revealed that patients admitted to the medical unit were required to sign the "Conditions for Registration/Services/Admission" document and he verified patient #9 had not done so.
5. Review of the facility's policy, "Patient Rights and Responsibilities" revised 08/30/23 showed..." B. Every patient, or when appropriate their representative, is provided a notice of their rights and responsibilities...D. Receipt of the Patient Rights and Responsibility Notice is documented in the patient's electronic medical record."