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Based on the review of policies and procedures, documents, medical records, and interviews, the Department determined the hospital failed to ensure that patients who were court-ordered to the facility acknowledged receipt of their patient rights. This deficient practice poses a potential risk of the patient not knowing what his/her rights are pertaining to receiving care.

Findings include:

Policy titled "Steward - Patient's Rights and Responsibilities" revealed: " ...Policy ...The complete and up-to-date Patient Rights and Responsibility document ...is provided to patients on admission, or upon request ...Procedure 1. The hospital shall inform (hand out ...as noted above) each patient, or when appropriate, the patient's surrogate decision-maker of the patient's rights and responsibilities ...."

Document titled "Patient Rights and Responsibilities" revealed: " ...You are entitled to these rights ...The following statement of Patient Rights has been adopted by the medical staff. As a patient, you have the right to ...."

The medical record for Patient #20 revealed the signature line on the Patient Rights and Responsibilities listed ACOT-Involuntary, with no patient signature. Care Assessments - Psych Legal Status dated 11/08/2021, identified the " ...Notice of Rights Given and reviewed by MD or Nurse ...No ...Patient Rights Review Comment ...Patient will be given notice of rights after arrival, the patient is a {sic} involuntary, direct admit ...."

The medical record for Patient #25 revealed the signature line on the Patient Rights and Responsibilities listed ACOT-Involuntary, with no patient signature.

The medical record for Patient #27 revealed the signature line on the Patient Rights and Responsibilities listed ACOT-Involuntary, with no patient signature.

Employee #7 confirmed during an interview/medical record review on 01/19/2022, that for Patient #20, #25 and #27, there was no documented evidence that the patient received a copy of his/her patient rights.

Based on the review of policies and procedures, medical records, and interviews, the Department determined the hospital failed to ensure that patients who were placed in a physical or chemical restraint or seclusion legally authorized representative were notified of the episode. This deficient practice poses a potential risk of the patient's representative not knowing about changes in the patient's condition.

Findings include:

The policy titled "Restraint and Seclusion- Rights and Responsibilities" revealed: " ...1. Each patient and/or each patient's LAR (legally authorized representative), if any, will be informed of the facility's policy related to the use of restraint and seclusion upon admission. The policy notification may be a summary of the facility's policy. If the patient has a LAR but he/she cannot be notified, the facility shall document the reason in the individual's medical record.

Policy titled "Steward - Patient's Rights and Responsibilities" revealed: " ...Policy ...The complete and up-to-date Patient Rights and Responsibility document ...is provided to patients on admission, or upon request ...Procedure 1. The hospital shall inform (hand out ...as noted above) each patient, or when appropriate, the patient's surrogate decision-maker of the patient's rights and responsibilities ...."

A review of Patient #13's medical record on 01/19/2022, revealed a physical hold occurring on 10/06/2021, and no guardian notification documentation.

A review of Patient #14's medical record on 01/19/2022, revealed a chemical restraint and a physical hold occurring on 11/19/2021, and no guardian notification documentation.

A review of Patient #16's medical record on 01/19/2022, revealed a chemical restraint and a physical hold and seclusion occurring on 11/19/2021, 11/21/2021, and on 12/02/2021, and no guardian notification documentation.

Employee #6 confirmed during an interview and medical record review conducted on 01/19/2022, that for Patient #13, Patient #14, and Patient #16 there was no documented evidence that the patient's legally authorized representative was informed of the restraint and/or seclusion episodes.