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Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure the patient and/or patient representative was informed of the patient's rights for thirteen of thirty-four patients selected for review/interview (Patients #8, #12, #13, #14, #15, #20, #21, #22, #24, #27, #28, #29, and #30). Observation and interview revealed patients processed through general registration were given a booklet that contained information regarding Patients Rights and the grievance process. However, those patients that were treated and discharged from the Emergency Department (ED) or admitted for inpatient care through the ED did not receive the booklet and were not informed of their rights.

The findings include:

Review of facility policy titled Grievance and Complaints/Individual Rights, revision date of 09/15/05, revealed in advance of providing care for inpatient or outpatient treatment in the ED, at the first available opportunity upon registration, the facility would provide patients or his/her personal representative a copy of the Patient & Visitor Information Guide that outlined Patient's Rights and Responsibilities, including the Patient Grievance Process. Review of facility policy titled Admitting Process, revision date of 02/26/09, revealed the Patient Access Clerk would give the patient a hospital brochure that outlined patient rights and responsibilities. The policy also revealed admission takes place in the general registration area, express location, ED, or at the patient's bedside.

Observation of the ED entrance on 06/21/12, at 10:45 AM, revealed the Patient & Visitor Information Guide lying on the counter. Observation revealed no evidence of patient rights posted in the waiting room. The ED was observed to have a separate ambulance entrance. Continued observations revealed no patient rights posted in the ambulance entrance or throughout the ED exam rooms.

Observation of the general registration area on 06/21/12, at 10:30 AM, revealed patients who were registered at the regular admission area received a packet that included a booklet entitled the Patient & Visitor Information Guide. A review of the booklet revealed the booklet included patient rights and responsibilities. According to Patient Right #23, the patient had the right to file a grievance, to be informed of the process to review and address the grievance, and to receive a response from the facility regarding the grievance.

Interview with the ED Registration Clerk on 06/21/12, at 10:45 AM, revealed ambulatory patients that presented to the ED waiting room were triaged according to care needs. The clerk stated the patient filled out the triage sheet and staff was to give the patient the booklet with patient rights included. However, she could not say if the patients that arrived by ambulance received that information.

1. A review of documentation in Patient #8's medical record revealed the patient presented to the ED on 01/11/11. Interview with Patient #8 on 06/18/12, at 5:15 PM, via telephone revealed the patient did not know she/he could file a grievance. The patient stated he/she did not receive that information during their hospital stay and, if they had received information related to the grievance process, they would have utilized that process due to concerns they had related to their care.

2. Interview with Patient #14 on 06/20/12, at 9:30 AM, revealed the minor child was admitted to the 5th Floor from the ED on 06/18/12, for diagnosis of Cellulitis. The patient's parent was at the bedside. Interview with the patient and parent revealed the patient did not receive information related to patient rights. The patient's parent stated he/she did not know who to contact regarding any problems at the facility and stated, "Probably the nurse."

3. Interview with Patient #15 on 06/20/12, at 9:40 AM, revealed the patient was admitted to the 5th Floor from the ED. The patient stated he/she did not receive the patient rights information in the ED or when transferred to the unit. The patient did not know how or whom to contact regarding care issues or concerns.

4. Interview with Patient #12 on 06/20/12, at 10:20 AM, revealed the resident came through the ED and was admitted to the 4th Floor of the facility on 06/19/12. The patient stated he/she did not receive any information regarding patient rights in the ED or when admitted to the 4th Floor.

5. Interview with Patient #13 on 06/20/12, at 10:30 AM, revealed the patient was admitted from the ED to the 4th Floor on 06/18/12. The patient stated she/he did not receive any information regarding patient rights in the ED or on the 4th Floor. The patient did not know who to report their concerns to regarding care issues.

6. Observation of a medication pass for Patient #24 on 06/20/12, at 12:10 PM, revealed the patient was admitted to the hospital directly from the physician's office on 06/18/12. Patient #24 stated he/she did not receive information related to patient rights. A review of the packet given to the patient after admission to the nursing unit revealed it did not contain information regarding patient rights or the grievance process.

7. Interview with Patient #21 on 06/21/12, at 10:55 AM, revealed the patient walked into the ED at approximately 10:00 AM, for evaluation/treatment. Further interview with the patient revealed neither the nurse nor the physician had informed the patient of his/her patient rights and stated he/she had not received information from any other staff person regarding patient rights.

8. Interview with Patient #20 on 06/21/12, at 11:05 AM, revealed the ambulatory patient presented to the ED at approximately 9:00 AM, and denied receiving information related to patient rights. The patient stated he/she did not receive the Patient & Visitor Information Guide booklet and did not know who to contact if he/she had any concerns regarding care.

9. Observation of Patient #22 on 06/21/12, at 11:15 AM, revealed the patient lying in a bed on the Observation Unit. Interview with the patient revealed he/she presented to the ED on 06/20/12, at approximately around 10:00 PM, and denied receiving any information regarding patient rights. A review of the paperwork provided by the facility to the patient revealed no information regarding patient rights. The patient did not know the facility's process for reporting concerns and/or grievances.

10. Interview with Patient #29 on 06/21/12, at 3:45 PM, revealed the patient came to the ED the previous night for treatment and stated he/she did not receive a booklet or any other form of communication regarding patient rights.

11. Interview with Patient #28 on 06/21/12, at 4:00 PM, revealed the patient was treated in the ED and then admitted to the 4th Floor for IV (intravenous) antibiotic treatment. The patient stated she did not receive any information regarding patient rights in the ED or when admitted to the floor.

12. Observation of Patient #27 on 06/21/12, at 4:10 PM, revealed the patient sitting up in bed and the patient's family member was at bedside. Interview with the patient and family member revealed the patient did not receive any information regarding patient rights. The family member stated the patient had been at this hospital before and had received the patient rights booklet, however, that information was not provided at this admission.

13. Interview with Patient #30 on 06/21/12, at 4:20 PM, revealed the patient was admitted from the ED to the 4th Floor. The patient stated he/she did not receive the patient rights booklet in the ED or when admitted to the unit.

Interview with the Patient Access Coordinator for the evening shift and the Director of Quality on 06/21/12, at 4:50 PM, revealed the Patient & Visitor Information Guide booklets were to be provided to patients during general registration and/or through the ED. The interview revealed the "Patient Access" receptionists were to offer each patient a patient rights booklet upon admission to the ED or at the first available opportunity. The Patient Access Coordinator stated patients were required to sign a consent form for treatment and stated the consent form contained a section where the patient signed acknowledgment of receipt of the patient rights booklet.

Review of the Conditions of Admission and Authorization for Treatment form revealed under Section V. Hospital Rules: there was a general statement that indicated, as the patient, "I acknowledge receipt of the Patient Information Booklet which includes the information on patient rights." However, the statement was observed to be co-mingled among other information related to the hospital rules. In addition, the patients interviewed on the day of the investigation reported they did not receive the information and/or the booklet that contained the information related to patient rights. The Director of Quality acknowledged in interview the patient rights booklet was not being provided to all patients on a consistent basis.