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Based on interview, observation, and record review, the facility failed to ensure that one of ten sampled patients (Patient 5) received information regarding his rights and responsibilities as a patient in a timely fashion. This failure had the potential to result in the violation of patient rights and inability of individuals to understand the care and treatment being provided.

Findings:

Patient 5's medical record was reviewed with the Director of Performance Improvement (DPI) on 3/10/15 at 2:35 pm.

Patient 5 had been transferred to this facility from another hospital on 3/3/15, with diagnoses that included fluid overload, congestive heart failure and severe chronic kidney disease.

The DPI confirmed that the Condition of Admission (COA) and the Patient Rights Acknowledgement were not present in Patient 5's electronic medical record, or the hard (paper)medical chart stored on the nursing unit.

The facility's policy titled, "Patient Registration/Admission Forms," dated 2/14, indicated the COA contained twenty topic items with detailed legal and informational elements. While all elements need to be reviewed with the patient, some topics require special attention and or signatures from the patient and the Admitting Representative... Follow up by the Admitting Department staff will occur frequently during the patient's hospital confinement to secure signatures, and ensure that the patient has copies of all signed documents.

During an interview with the Admitting Supervisor (AS) A on 3/11/15 at 3:30 pm, she reported that typically paperwork that is not signed upon admission is followed up on every three days. She verified that a staff member had last attempted to obtain signatures on 3/5/15. AS A reported that no patient rights information is left for the patient when they can not sign and their are no family members present. AS A was asked how does the facility ensure that a patient has been informed of all of their rights and responsibilities, she replied, "That is a very good question, without their signed acknowledgement there is really no way to demonstrate that."

AS A provided a document titled, "Signature Attempt Form," which indicated, that on 3/4/15 staff went to the patient's room and that he stated that he was too weak and confused to sign. No Family present. On 3/5/15 staff went to the nursing floor but was unable to wake the patient. On 3/10/15 staff went to the patient's room and was asked to come back later. This form indicates that the staff must follow-up each shift and everyday.

DPI acknowledged that although Patient 5 had stated he was too weak and confused to sign his admission paperwork on 3/4/15, he had signed a procedural consent form to have a peripherally inserted central catheter (a flexible tube that is inserted into a large vein) placed on 3/4/15.

Patient 5 was interviewed on 3/11/15 at 9:20 am, and had no recollection of ever being told about his rights or responsibilities as a patient when he arrived from the other hospital.

Patient 5's COA and Patient Rights Acknowledgement were signed by Patient 5 on 3/11/15 at 9:45 am, eight days after admission.

Based on interview and record review, the facility failed to ensure that one of ten sampled patients (Patient 5) had a properly executed informed consent prior to a procedure per facility policy. This failure could result in the inability of the patient to fully understand the care and procedure being provided.

Findings:

Patient 5's medical record was reviewed with the Director of Performance Improvement (DPI) on 3/10/15 at 2:35 pm.

Patient 5 had been transferred to this facility from another hospital on 3/3/15, with diagnoses that included fluid overload, congestive heart failure and severe chronic kidney disease.

Patient 5 required the placement a temporary dialysis catheter (a flexible tube that is inserted into a large vein) for dialysis treatments. Dialysis is the process of removing waste and excess water from the blood and is used primarily as an artificial replacement for individuals who have lost normal kidney function.

Patient 5's record contained a document, titled, "Consent for Surgery or Special Procedure," dated 3/6/15. This document was signed by two Registered Nurses (RNs) and indicated that verbal consent from the patient had been obtained for this procedure, and that the patient could not sign because he did not have his glasses.

The facility's policy titled, "Consent for Procedures," dated 11/13, indicates that if the patient/legal representative is physically incapable of writing his/her name, then the full name of the patient shall be written on the consent form and the patient/legal representative will place his/her "X" or mark beneath it. Two staff persons must witness this and sign the consent form.

During an interview and concurrent record review, with the DPI on 3/11/15 at 11:20 am, she acknowledged that Patient 5's consent form did not contain his "X" or mark per the facility's policy.