HospitalInspections.org

Based on document review, medical record (MR) review and interview, 11 of 19 MRs (Patient's #2 - #12) lacked documentation that the patient and/or their representative were provided with a copy of the "Patient's Bill of Rights" as required by New York State regulation in Title 10 New York Codes, Rules and Regulations (NYCRR) 405.7. This lack of notification does not ensure the patient and/or representative had received the information necessary to exercise their rights.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "Patient's Rights & Responsibilities," last revised 10/2019, indicated in order to assure that patients are made aware of, understand, and can exercise their rights and responsibilities the hospital shall: Provide for each patient or patient's representative a copy of the "Patient's Bill of Rights and Patient Responsibilities."

-- Review of MRs for Patients #2 - #12 revealed, each lacked documentation that the patient and/or their representative were provided a copy of the "Patient's Bill of Rights."

-- During interview of Staff C, Emergency Department (ED) Nurse Manager on 2/7/2020 at 12:05 pm, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, 13 of 17 MRs of patients greater than 18 years of age (Patients #1 - #9 and #13 - #16), lacked documentation that advance directive (AD) information was provided when the patient presented to the Emergency Department (ED) or if the patients had executed an AD. This lack of documentation could lead to a patient's wishes concerning their provision of care to not be followed.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "Advance Directives, Consents and Medical Decisions Management Plan," last revised 12/2019, indicated the following actions are to be taken on admission or in a reasonable time frame: determine if the patient has a signed Health Care Proxy, living will or other prior instructions regarding treatment and include copies in the MR. The Department of Health publication titled, "Your Rights as a Hospital Patient in New York State," dated 3/2019, should be provided to patients/families.

-- Review of Patient #1's MR revealed, she presented to the ED on 10/18/2019 at 8:32 pm, there was no documentation indicating whether she had executed an AD or that the patient was provided or accepted AD information.

The same lack of documentation indicating whether patients had executed an AD or that the patients were provided or accepted AD information was noted in the MRs for Patients #2 - #9 and #13 - #16.

-- During interview of Staff D, Director of Quality Management and Regulatory Affairs on 2/7/2020 at 11:00 am, he/she acknowledged the above findings.