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Based on policy review, record review, and interview, the Hospital failed to ensure it informed each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care for 1 of 3 sampled patients (Patient 1) This deficient practice places any patient at risk of not understanding their individual rights as required per regulation requirements 42 CFR §482.13(a)(1).

Findings Include:

Review of Hospital Policy titled "Provision of Patient Rights" no date showed "Policy: All staff members will observe the rights of each patient. All patients will be informed of their rights and responsibilities as part of their orientation to the rehabilitation program. Procedure: 1. The rehabilitation nurse or social worker/case manager will review the Patient's Rights and Responsibilities document with the patient or family member at the time of admission. The staff member reviewing the rights of the patient will document in the medical record that the rights were reviewed and with whom. 2. The patient/family member will be given a copy of the Patient Rights and Responsibilities."

Patient 1

Review of Patient 1's medical record showed a 82-year-old female admitted on 01/05/24 at 9:38 PM with a diagnosis of severe sepsis (infection that causes organ damage) secondary to Klebsiella (bacteria) pneumonia, Urinary Tract Infection (UTI), acute renal failure (when kidneys suddenly can't filter waste from the blood) requiring dialysis (treatment for people who kidneys are failing) in the setting of chronic kidney disease related to absence of kidney. Patient 1 had a past medical history uncontrolled diabetes mellitus with hyperglycemia (too much sugar in the blood).

Review of Patient 1's medical record failed to show a signed Patient Rights.

During an interview on 02/08/24 at 9:22 AM Staff A, Director of Nursing (DON) stated, "Patient Rights are done the next business day. Patient 1 did not get patient rights since she came in on a Friday and left on a Sunday."

During an interview on 02/08/24 at 1:25 PM Staff B, Director of Marketing and Business Development stated, "When the patient arrives to the hospital, they sign consent to treat by the nursing department. Admissions has them sign Patient Rights, sometimes it's the same day but most of the time it's the next day. If patient arrives over the weekend, it's the next business day."