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INOVA FAIR OAKS HOSPITAL
PATIENT RIGHTS: NOTICE OF RIGHTS
Tag No.: A0117
Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the patient received the patient's rights and responsibilities notice for two (2) of five (5) records reviewed.
The finding included:
On 4/20/2021, the surveyor reviewed two (2) of the five (5) records in the sample. Staff Member (SM) #11 was assisting with navigation of the medical record for Patient #1. The surveyor requested to review the signed document for patient rights and responsibilities for Patient #1. SM #11 was unable to locate the document. SM #11 deferred to SM #8 for assistance; SM #8 was unable to locate the document in the medical record.
While reviewing Patient #2's medical record, the surveyor requested to view the signed patient rights and responsibilities form. SM #11 was unable to locate the form in the medical record. SM #15 began assisting the surveyor with navigation of Patient #2's record. The surveyor requested to review the sign patient rights and responsibilities form; SM #15, with the assistance of SM #8, was unable to located the form.
A review of the facility's policy titled, Patient Rights and Responsibilities, reads in part: "...B. Inova Responsibilities...Each Inova facility will: 1. Provide to each patient or his/her representative a summary of the rights set forth in this policy...."
In the afternoon of 4/20/2021, the surveyor discussed the concern with SMs #1, #2, #4, #6, and #7.
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the patient signed the consent for treatment for two (2) of five (5) records reviewed.
The finding included:
On 4/20/2021, the surveyor reviewed two (2) of the five (5) records in the sample. Staff Member (SM) #11 was assisting with navigation of the medical record for Patient #1. The surveyor requested to review the signed document for consent for treatment for Patient #1. SM #11 was unable to locate the document. SM #11 deferred to SM #8 for assistance; SM #8 was unable to locate the document in the medical record.
While reviewing Patient #2's medical record, the surveyor requested to view the signed consent for treatment. SM #11 was unable to locate the form in the medical record. SM #15 began assisting the surveyor with navigation of Patient #2's record. The surveyor requested to review the sign consent for treatment; SM #15, with the assistance of SM #8, was unable to located the form.
A review of the facility's policy titled, Patient Rights and Responsibilities, reads in part: "...A. Patient Rights...The patient has the right to:... 5. Be well informed about their illness, possible treatments, and likely outcomes of care (including unanticipated outcomes) and to discuss this information with their provider. The patient has the right to designate someone to receive this information on their behalf...".
In the afternoon of 4/20/2021, the surveyor discussed the concern with SMs #1, #2, #4, #6, and #7.