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Based on observation, interview, record review, and review of the Patient Rights and Responsibilities policy, it was determined the facility failed to inform all patients of their patient rights in the emergency department (ED). It was the practice of the hospital to only inform patients that were admitted to the hospital of their rights. Those patients that were treated and discharged from the ED were not informed of their rights.

The findings include:

Review of facility's policy titled Patient Rights and Responsibilities, revision date of May 2011, revealed patients are informed and provided a statement of their rights and responsibilities at the time of registration to the hospital. Review of the treatment consent form that patients sign prior to ED treatment revealed the body of the form stated, Patient Bill of Rights provided to patient or family member (inpatients only).

Observation of the ED, on 06/06/12 at 11:30 AM, revealed a Patient Rights sign posted outside the door to the walk-in entrance to the ED. Further observation revealed the ambulance entrance was located in a separate part of the ED. Continued observation revealed the only Patient Rights sign was in Spanish and posted outside the entrance to the ambulance entry doors. Observation of all ED exam rooms revealed no posted notice of Patient Rights.

1. Interview with Patient #2, on 06/06/12 at 11:40 AM, revealed the patient presented to the ED at approximately 10:30 AM, as a walk-in client with complaints of chest pain. The patient was immediately taken back to the exam room and placed on a monitor. The patient stated the chest pain had been relieved and could converse with the surveyor. When asked if the patient had received information regarding Patient Rights, the patient denied receiving any information. The patient stated the Patient Rights poster was not observed upon entrance to the ED because the only concern at that time was to seek immediate treatment for the chest pain.

Review of Patient #2's clinical record revealed the patient signed a consent to treat form with the Patient Bill of Rights not checked as provided. The patient left the ED at 1:50 PM against medical advice.

2. Interview with Patient #1, on 06/06/12 at 11:50 AM, revealed the patient walked into the ED at approximately 10:00 AM for symptoms of chest pain. Further interview with the patient revealed the patient had received a medical screening exam; however, neither the nurse nor the physician had talked about Patient Rights. The patient stated no information regarding Patient Rights had been provided by any staff.

Record review revealed Patient #1 was in the ED from 10:00 AM until 12:29 PM when the patient was admitted to the hospital for observation. Review of the consent to treat form revealed no documented evidence the hospital had provided the Patient Bill of Rights to Patient #1.

3. Observation of Patient #3, on 06/06/12 at 12:00 PM, revealed the minor sitting on an exam bed with the parent beside the minor patient. Observation revealed a registration clerk coming into the exam room and asking the parent for personal and insurance information. The parent was asked to sign the consent to treat form and privacy practices were discussed. However, the Patient Rights were not discussed and no written information was given to the parent.

Interview with the Registration Clerk, on 06/06/12 at 12:05 PM, revealed his job was to verify the emergency contact and insurance information. In addition, the consent to treat had to be signed and he would go over the privacy practices with the patient or parents of a minor. He stated he was not responsible for providing information regarding Patient Rights. He further stated the nurses completed that task. However, interview with the ED Nurse Director and the Director of Patient Access/Registration, on 06/07/12 at 9:35 AM, revealed patients are to be given verbal information regarding Patient Rights only. It was not the responsibility of the ED nurses to provide that information, the Registration Clerk was suppose to verbally inform the patient of their rights prior to obtaining the consent to treat. When asked how and when this was completed, the Directors could not give any specific information.

Review of Patient #3's medical record revealed the patient was treated and released without evidence the Patient Bill of Rights were provided.

4. Interview with Patient # 4's parent (minor child), on 06/06/12 at 12:20 PM, revealed they had been in the ED approximately two (2) hours and no staff had verbally informed them of any Patient Rights. In addition, the parent had not received any written information either. The parent brought the child through the walk-in entrance and did not notice any poster on Patient Rights.

Review of the medical record for Patient #4 revealed the parent signed a consent to treat form; however, there was no indication a Patient Bill of Rights was provided to the patient.

Interview with the Director of Compliance, on 06/06/12 at 1:00 PM, revealed if a patient is admitted to the hospital the patient receives a patient admissions guide booklet with the Patient Bill of Rights included. However, if a patient is treated and released from the ED, they are not given that booklet. She stated there were no posters in the individual exam rooms. She further stated the only notice those patients received was by reading the Patient Bill of Rights poster. However, the ambulance entrance did not have a poster in English and interview with the patients revealed the patients did not look at the Patient Rights poster upon entrance to the ED.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to obtain a written physician's order for Patient #12, on six (6) of the eighteen (18) days the physical restraints were applied.

The findings include:

Review of the facility's policy regarding Restraints, revised on 05/2011, revealed #2. Physician orders: C. Restraints must be reordered by the physician or LIP every 24 hours and #5. Orders for restraints will be written by a physician or Licensed Independent Practitioner (LIP) for clinical justification.

Observation of Patient #12, on 06/06/12 at 12:30 PM, revealed the patient had bilateral wrist restraints applied. The patient was semi-responsive, but restless, and had a tracheostomy, indwelling catheter tubing, multiple intravenous sites, and a rectal tube.

Review of the patient's clinical record revealed an admission diagnoses of sepsis and seizures. Continued review of Patient #12's restraint records revealed verbal orders had been obtained on 5/19, 5/20, 5/21, 5/22, 6/2, and 6/5/12; however, the physician had failed to sign the orders as required per policy.

Interview with the Intensive Care Unit RN, Team Leader, on 06/06/12 at 12:30 PM, revealed they usually place a sticker on the medical record to alert physicians that orders needed to be signed. The team leader stated they had been having problems with getting restraint orders signed by the physicians promptly and had identified this problem when auditing the restraints charts. However, review of Patient #12's restraint orders revealed the physician orders had not been signed, dating back to 05/19/12.

Interview with the Assistant Vice President of Nursing, on 06/06/12 at 12:45 PM, revealed the physician had 24 hours to sign restraint orders according to the facility policy and the facility was responsible for getting the orders signed.