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Based on staff interviews, medical record reviews and policy and procedure reviews, the facility failed to inform emergency room patients who were not admitted to the hospital of their patient's rights.

Findings:

During an interview with the Director of the Emergency Department (ED) on October 19, 2010, the director stated an employee from Patient Access/Patient Registration provided ED patients with their patient's rights information during the bedside registration process.

The Director of Patient Access was interviewed on October 20, 2010 and stated the registration clerks do register ED patients at the bedside and at times in the waiting room. During this registration, the clerks obtained a consent and provided patients a pamphlet regarding financial aide and a pamphlet regarding the Privacy Act if necessary, based on whether the patient had received one within the permitted timeframe. She said an IM (An Important Message from Medicare About Your Rights) was also provided to Medicare patients. She stated the registration clerks obtained a signature from the patient on both the consent and the IM if the patient's condition allowed them to sign. The Director denied providing information on patient's rights during registration and stated it was her understanding that patient's rights information was provided by clinical staff.

Medical records were reviewed on both October 19, 2010 and October 20, 2010. Within each record reviewed, a consent and IM was found. The one page consent contained three paragraphs, one regarding "Release of Information and Assignment of Insurance Benefits", another regarding "Guaranty of Account", and a third labeled "Personal Valuables". The two paged IM (An Important Message From Medicare About Your Rights) contained information for Medicare Inpatients. It informed them of their right to receive Medicare covered services ordered by their doctor while in the hospital and after being discharged if necessary, to know about those services, who would pay, and where to obtain those services. It stated they had the right to be involved in decisions regarding their hospital stay and who would pay for it. The IM provided information on how to report any concerns about quality of care to the Quality Improvement Organization (QIO) along with a phone number. Lastly, the IM included the patient's Medicare Discharge Rights with instructions on what to do if the patient felt they were being discharged too soon. The instructions included the patient's right to appeal along with step by step information on how to file an appeal. There were no other patient's rights noted on the IM.

The facility's patient right's policy was reviewed on October 19, 2010. The facility provided a six-page policy named "Patient Care Services Ch 01: Patient Rights and Responsibilities," with an approval date of 07/07/2009. The policy reads in part, "We communicate patients' rights through the patient handbook." On October 20, 2010, the Patient Handbook was reviewed. Patient's Rights were found on pages 12 - 15.

During an interview the ED's Unit Manager and ED Director in the afternoon of October 20, 2010, the Unit Manager indicated the Patient Handbook is provided to patients when they were admitted to the facility. She stated the admitting nurse, on the unit the patient was admitted to, provided the Patient Handbook as part of the admission assessment. When asked how patients who were seen in the ED were informed of their rights if they were not admitted to the facility, the manager did not know. She stated the Patient's Rights and Responsibilities were posted on the wall within the ED. She added that when an ED patient was transferred to the Admissions Unit, the computer program prompted the admission nurse to inform the patient of their rights. The ED Director added no further information on how ED patients who were discharged from the ED were informed of their rights.

The Senior Vice President Patient Care Services/CNO and the Senior Vice President, Operations were informed of findings on October 20, 2010 in the afternoon. The Senior Vice President, Operations stated that Patient Rights and Responsibilities were posted on the wall in the ED.