HospitalInspections.org

Based on document review and staff interview, the facility failed to allow patient to exercise his/her rights related to visitors for 1 of 10 (patient #1) open and closed patient medical records reviewed.

Findings:

1. Policy titled Patient Rights and Responsibilities, revised/reapproved 6/2012, indicated on pg. 1, under Policy section, point 2. I., "The hospital establishes and maintains structures to support patient rights, and does so in a collaborative manner that involves the hospital's leaders as well as all relevant others. The structures are based on policies, procedures, and their philosophical basis, which makes up the framework to address both patient care and organizational ethical issues including the following...The patient's right to choose who may visit them during their inpatient stay, regardless of whether the visitor is a family member, a spouse, a domestic partner (including same-sex domestic partner), or other type of visitor, as well as the right to withdraw such consent to visitation at any time."

2. Review of closed patient medical records on 5/27/15 confirmed patient #1 presented to the facility on 5/2/15 for a missed AB (abortion). Patient signed a General Treatment Consent upon admission indicating patient was informed of Patient Rights and Responsibilities. Spiritual Care Notes dated 5/2/15 at 1355 hours indicated male clergy staff (Staff #4, Resident Chaplain) attempted to speak with patient after a "miscarriage", but patient refused to talk to the Resident Chaplain about the "In God's Arms" program or to sign any forms. Another clergy staff (Staff #7, Staff Chaplain) did a follow-up visit to see if the patient had any needs. Patient was very clear of not wanting to be a part of the program or speak to any more clergy staff.

3. Review of facility administrative documents confirmed an Incident Report was filed for an incident that occurred on 5/2/15 for patient #1 as required by facility policy and procedure. This incident report indicated patient was visited by a chaplain and was not interested in participating in the "In God's Arms Program". Approximately 20 minutes later, another chaplain visited the patient who stated he/she still did not want to participate. The patient asked not to have any more chaplains visit, the nurse apologized, and no more chaplains visited the patient. Follow up for this incident report is currently in review for process and policy and the estimated time frame for action planning may be by the end of June, 2015 or sooner.

4. Staff #4 (Resident Chaplain) was interviewed on 5/27/15 at approximately 1246 hours, and confirmed they visited patient while in outpatient surgery to provide information related to "In God's Arms Program". Patient stated they did not want to do the program, clergy tried to explain the reason for the visit, and patient stated again they did not want to do the program.

5. Staff #7 (Staff Chaplain) was interviewed on 5/27/15 at approximately 1347 hours, and confirmed they visited the patient after Staff #4 (Resident Chaplain) visited the patient to explain the "In God's Arms Program". Patient was furious and stated they did not want to do the program.

6. The facility did not follow sections of their policy/procedure Patient Rights and Responsibilities, by not allowing patient to exercise his/her rights related to visitors as required by facility policy and procedure.