HospitalInspections.org

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Based on interview and document review, the hospital failed to ensure that all patients presenting to the hospital for services were given written notice of their patient rights for 2 of 9 medical records reviewed (Patient #106 and Patient #107).

Failure to ensure that all patients receive a copy of their patient limits a patient's ability to exercise those rights.

Findings included:

1. Document review of the hospital's policy titled, "Notice of Patients' Rights and Responsibilities on Admission, 390.00," PolicyStat ID 10140777, last revised 07/21 showed the following:

a. Each patient or their legal representative is asked to sign the Notice and Acknowledgment of Patient Rights/Responsibilities at registration or admission and offered a written copy of the hospital's Patient Rights and Responsibilities.

b. Patient Access/Registration staff is responsible for providing the patient or legal representative with the site specific "Patient Rights/Responsibilities - Notice and Acknowledgement" form. The patient or legal representative is asked to read, acknowledge, and sign that they have received the information.

c. Staff must document on the acknowledgement form if the information is not provided due to the patient's condition or if the legal representative is not immediately available.

2. On 07/17/24 at 10:28 AM, the investigator and the Intensive and Progressive Care Clinical Manager (Staff #117) reviewed the medical records of 7 inpatients and 2 outpatients. Record review showed the following:

a. On 07/07/24, Patient #106 was admitted to the hospital. The investigator could find no evidence that Patient #106 or their legal representative had read or signed acknowledgment of the receipt of their written patient rights or that Patient #106's condition prevented them from signing the acknowledgment.

b. On 07/10/24, Patient #107 was admitted to the hospital. The investigator could find no evidence that Patient #107 or their legal representative had read or signed acknowledgment of the receipt of their written patient rights or that Patient #107's condition prevented them from signing the acknowledgment.

3. On 07/17/24 at 10:28 AM, Staff #117 confirmed the investigator's finding of the missing required patient rights documentation.
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