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Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of the patient's rights in advance of furnishing care as 1 of 5 inpatient medical records reviewed did not contain admission forms signed by the patient which include receipt of the Patient Bill of Rights which resulted in an incomplete record and the patient being uninformed regarding his patient rights.

The findings were:

Electronic medical records were reviewed on the afternoon of 9/18/18 with the assistance of the quality review coordinator, staff #1. The record of patient #10 did not contain signed admission forms which included receipt of the Patient Bill of Rights. The record of patient #10 contained a nurses' note dated 8/28/18 1910 which reflected in part "Received patient transfer from [another hospital] per stretcher by ambulance. Pain free, hemodynamically stable, alert oriented. Placed in hospital bed, oriented to place, time and person."

The facility policy entitled "Procedure for Direct Admissions" #PARA.PP.PTAC.015 dated 1/14 reflected in part "Policy: Registration of direct admission patients will be performed bedside after receiving medical clearance from the attending nurse or physician." The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights."

In an interview with the director of patient access, staff #8 on the afternoon of 9/18/18 in the conference room, staff #8 stated in the case of direct admission, Patient Access staff will go the patient's room to get admission forms signed. Staff #8 stated that no admission forms were found in the medical record. Staff #8 stated that the usual procedure would be for Patient Access staff to return at another time to the patient's room to get the forms signed if the patient was unavailable. Staff #8 stated that the Patient Access staff should have obtained the patient's signature on the admission forms.

Based on review of documentation and interviews with facility staff, the facility failed to inform 1 of 5 inpatients reviewed of a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization as the Important Message from Medicare form in the medical record of patient #10 was documented by staff that the patient was unable to sign, but the medical record reflected that patient #10 was alert and oriented upon admission.

The findings were:

Electronic medical records were reviewed on the afternoon of 9/18/18 with the assistance of the quality review coordinator, staff #1. The medical record of patient #10 contained an Important Message from Medicare form which reflected "Pt [patient] unable to sign" dated 6/28/18 2110 witnessed by patient access staff #14 and 15. The record of patient #10 contained a nurses' note dated 8/28/18 1910 which reflected in part "Received patient transfer from [another hospital] per stretcher by ambulance. Pain free, hemodynamically stable, alert oriented. Placed in hospital bed, oriented to place, time and person."

In an interview with the director of patient access, staff #8 on the afternoon of 9/18/18 in the conference room, staff #8 was asked about the date 6/28/18 on the Important Message from Medicare form as patient #10 was admitted on 8/28/18, and staff #8 stated the staff signing the form must have recorded the date wrong. Staff #8 stated that the usual procedure would be for Patient Access staff to return at another time to the patient's room to get the forms signed if the patient was unavailable. Staff #8 was told that the medical record reflected that patient #10 was alert and oriented on admission and staff #8 stated that the patient access staff should have had patient #10 sign the Important Message from Medicare form.

The facility policy entitled "Procedure for Direct Admissions" #PARA.PP.PTAC.015 dated 1/14 reflected in part "Policy: Registration of direct admission patients will be performed bedside after receiving medical clearance from the attending nurse or physician." The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Additional forms are required in the following situations: Important Message from Medicare ...if the patient is a Medicare or Managed Medicare Inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission ...In addition, the patient's or patient's representative's signature is required."

Based on review of documentation and interviews with facility staff, the facility failed to determine upon admission if 1 of 5 inpatients reviewed had formulated advanced directives as the admission forms documenting the advanced directive statements were not completed by patient #10 upon admission which resulted in an incomplete record and the facility being unaware if patient #10 had an advanced directive.

The findings were:

Electronic medical records were reviewed on the afternoon of 9/18/18 with the assistance of the quality review coordinator, staff #1. The record of patient #10 did not contain signed admission forms which included completion of the advanced directives statements in the Conditions of Admission form. The record of patient #10 contained a nurses' note dated 8/28/18 1910 which reflected in part "Received patient transfer from [another hospital] per stretcher by ambulance. Pain free, hemodynamically stable, alert oriented. Placed in hospital bed, oriented to place, time and person."

The facility policy entitled "Procedure for Direct Admissions" #PARA.PP.PTAC.015 dated 1/14 reflected in part "Policy: Registration of direct admission patients will be performed bedside after receiving medical clearance from the attending nurse or physician." The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...The Advanced Directives statements are contained within the Parallon standard COA (Conditions of Admission) and COS (Consent for Outpatient Services) forms ...Only one of three applicable PSDA (Patient Self Determination Act) statements is initialed or marked by the patient or legally authorized/legally empowered representative."

In an interview with the director of patient access, staff #8 on the afternoon of 9/18/18 in the conference room, staff #8 stated in the case of direct admission, Patient Access staff will go the patient's room to get admission forms signed. Staff #8 stated that no admission forms were found in the medical record. Staff #8 stated that the usual procedure would be for Patient Access staff to return at another time to the patient's room to get the forms signed if the patient was unavailable. Staff #8 stated that the Patient Access staff should have obtained the patient's signature on the admission forms.

Based on review of documentation and interviews of facility staff, the facility failed to inform the patient of Privacy Practices and obtain Authorization for Release of Information as 1 of 5 inpatient medical records reviewed did not contain admission forms signed by the patient which include the Authorization for Release of Information form and the Notice of Privacy Practices form which resulted in an incomplete record and the patient being uninformed of confidentiality rights.

The findings were:

Electronic medical records were reviewed on the afternoon of 9/18/18 with the assistance of the quality review coordinator, staff #1. The record of patient #10 did not contain signed admission forms which included Authorization for Release of Information and the Notice of Privacy Practices. The record of patient #10 contained a nurses' note dated 8/28/18 1910 which reflected in part "Received patient transfer from [another hospital] per stretcher by ambulance. Pain free, hemodynamically stable, alert oriented. Placed in hospital bed, oriented to place, time and person."

The facility policy entitled "Procedure for Direct Admissions" #PARA.PP.PTAC.015 dated 1/14 reflected in part "Policy: Registration of direct admission patients will be performed bedside after receiving medical clearance from the attending nurse or physician." The facility policy entitled "Procedure for Registration Forms and Signatures" #PARA.PP.PTAC.038 dated 5/15 reflected in part "The Patient Access department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based on patient circumstance ...Standard forms required at time of Pre-Registration or Registration ...2. The Conditions of Admission is obtained for all other types of Registrations (Emergency, Observation, Surgery, Inpatient and Newborn) ...3. Authorization for Release of Information. 4. Patient Bill of Rights ...Procedure: Responsible Party, Patient Access. Action, Notice of Privacy Practices. The patient or legally authorized/legally empowered representative or family member initials this section to acknowledge receipt of the Notice of Privacy Practices."

In an interview with the director of patient access, staff #8 on the afternoon of 9/18/18 in the conference room, staff #8 stated in the case of direct admission, Patient Access staff will go the patient's room to get admission forms signed. Staff #8 stated that no admission forms were found in the medical record. Staff #8 stated that the usual procedure would be for Patient Access staff to return at another time to the patient's room to get the forms signed if the patient was unavailable. Staff #8 stated that the Patient Access staff should have obtained the patient's signature on the admission forms.