HospitalInspections.org

Based on medical record reviews, observation, staff interview, review of patient handbook and facility policy, the facility failed to assure that all patients received Patients rights information on admission and that Patient Rights information was posted on all units.


Findings include:


During a facility tour on 10/30/2017 at 8:37 AM with the DON, the following was observed:
Detox unit -
No Patient Rights posted
Geriatric unit -
Patient Rights posted
Beacon West -
No Patient Rights posted
Beacon South -
No Patient Rights posted
Dual diagnosis unit -
Patient Rights posted

On 10/30/2017 at 10:25 AM the DON acknowledged that all units did not have Patient Rights posted.

Review of ten (10) medical records (#s 1, 2, 3, 4, 5, 6, 8, 9, and 10) revealed:
Seven (7- #s 1, 2, 3, 4, 5, 6, and 9) contained evidence that Patient Rights had been provided

Review of Patient Handbook revealed:
Patient Rights included:
1. You, your family, or legal guardian has the right to be fully informed about your rights as a patient. You will be given a copy of these rights, and a copy will be posted on the unit.
19. You do have the right to reasonable safety insofar as the hospital practices and environment are concerned.

Review of facility policy RI.005, Patient Rights, dated 1/10, reviewed/revised 1/17, revealed
Procedure:
I. Notification of Rights
A. At the time of admission, voluntary/involuntary patients or the parent or legal guardian of minor patients shall be provided a copy of the Patient ' s Bill of Rights form and a verbal explanation of those rights in their primary language. At the time of admission, each patient shall be given written information on the following.
1. A description of the facility, its services and its costs
2. Information as to how to seek conditional release or discharge
3. A statement of patient rights assured
4. A description of a patient grievance procedure.
B. If the patient does not understand English or is hearing impaired, staff shall contact an interpreter to explain the Patient ' s Bill of Rights in the patient ' s primary language
C. Staff shall ask the patient or the parent, or guardian to sign and date a statement of receipt of the Patient 's Bill of Rights form prior to admission to acknowledge the written and verbal explanation of those rights. The signed statement shall be filed on the patient 's medical record. If the patient is unable or unwilling to sign a brief explanation of the reason will be entered on the document.
D. A copy of the Patient 's Bill of Rights form shall be provided to the patient and to the patient ' s family or legal guardian prior to admission.
E. A copy of the Patient 's Bill of Rights form shall be displayed prominently at all times in patient common areas, and other areas frequented by persons receiving services.

Review of five (5) employee files revealed that all contained initial applications with references, job descriptions, background checks, had received annual trainings which included safe patient handling; had underwent competency testing and evaluations; and, had current BLS certifications.

Based on review of unit staffing, facility's staffing matrix, staff interview, and review of patient handbook, the facility failed to have adequate numbers of personnel to provide nursing care to all patients as needed.


Findings include:


Review of three weeks staffing for the Beacon South and Compass units versus the provided staffing grid revealed:
Beacon South, understaffed twenty-one (21) of sixty-three (63) shifts, as follows:
8/13/17 through 8/19/2017 -
· Understaffed on day shift 8/13/2017
· Understaffed on evening shift 8/16/2017 and 8/18/2017
· Understaffed on night shift 8/15/2017, 8/16/2017, 8/18/2017 and 8/19/2017
8/20/2017 through 8/26/2017 -
· Understaffed on day shift 8/26/2017
· Understaffed on evening shift 8/20/2017 and 8/26/2017
· Understaffed on night shift 8/20/2017
8/27/2017 through 9/2/2017
· Understaffed on day shift 8/29/2017 and 8/30/2017
· Understaffed on evening shift 8/28/2017, 8/31/2017, and 9/2/2017
· Understaffed on night shift 8/29/2017, 8/30/2017, 8/31/2017, 9/1/2017, and 9/2/2017
In addition to usual staffing requirements, the unit had one (1) one on one (1:1) resident on 8/31/2017, 9/1/2017, and 9/2/2017, which required an additional staff member to monitor.
Compass unit, understaffed six of sixty-three (63) shifts, as follows:
3/5/2017 through 3/11/2017 -
· Understaffed on day shift 3/5/2017
3/12/2017 through 3/18/2017 -
· Understaffed on evening shift 3/18/2017
10/22/2017 through 10/28/2017 -
· Understaffed on day shift 10/22/2017, 10/23/2017, 10/25/2017
· Understaffed on evening shift 10/24/2017

The director of nursing (DON) acknowledged the above findings on 11/2/2017 during telephone verification of staffing.

Review of Patient Handbook revealed:
Patient Rights included:
19. You do have the right to reasonable safety insofar as the hospital practices and environment are concerned.