Bringing transparency to federal inspections
Tag No.: A0216
Based on a review of the hospital patient rights information, the patients' right to 1) visitation, to withdraw visitation, and the right to deny visitation is not delineated in the document , and 2) there was no documentation identifying that the patients have a right to designate a support person.
The hospital "Visitation Policy" (February 2015) states "The hospital informs the patient (or support person, where appropriate) of his or her visitation rights." Review of the hospital "Guide to Patient Rights and Responsibilities" pamphlet found no information that is given to patients regarding the right to have visitors, the right to withdraw consent to have visitors, or the right to deny visitation. Further, no information was found regarding the patient's right to designate a support person. Therefore, while the hospital has an appropriate visitation policy, the hospital failed to convey the rights of visitation to its patients.
Tag No.: A0438
Based on a review of 8 open and 5 closed medical records, it was determined that an intraoperative record for patient #1 on 12/13/2015 contained inaccurate information regarding the time of the anesthesiologist's presence in the operating room.
An intraoperative record for patient #1 who was undergoing an emergency caesarian section revealed that the anesthesiologist was present at 0930. However, other documentation revealed that the anesthesiologist was not in attendance until 1006. Therefore, there were inaccuracies and inconsistencies in the medical record.