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Based on staff interviews, policy and procedure review, and review of the facility's Conditions of Admission, the facility failed to inform every emergency department patient of their rights.

Findings:

During an interview with a registration clerk working in the emergency department (ED) on March 22, 2011, the clerk informed the survey team that each patient who entered the facility through the ED was provided a consent for treatment (Conditions of Admission) and privacy information.

On March 23, 2011 the facility's Patient Access Manager was interviewed. She stated that all patients entering the facility through the ED were asked to sign the Conditions of Admission form which allowed the facility to treat that patient and bill their insurance company if necessary. She acknowledged that after an ED patient was admitted to the facility, a patient access employee provided the patient with an admission packet. The admission packet was reviewed and included a list of Patient Rights and Responsibilities.

On the same day the facility's policy and procedure entitled, "Patient Rights and Responsibilities Plan" was reviewed. The policy stated the purpose was, "To provide a hospital-wide policy on patients (infant, pediatric, adult, and geriatric) rights and responsibilities, and to define those rights, including both inpatients and outpatients."

The facility's Conditions of Admission, a five page form signed by each patient registered in the facility was reviewed on March 23, 2011. On page five under "Patient Self Determination Act" the form stated in part, "I have also been furnished with written information regarding patient rights and responsibilities and other information related to my stay."

The Patient Access Manager, VP of Quality and CNO acknowledged that patients who entered the facility via the ED and who were later discharged through the ED (without being admitted) were not being informed of their patient rights and responsibilities. The CNO added that outpatients who entered the facility via other departments (i.e. radiology, outpatient surgery, etc...) were being provided their patient rights and responsibilities and said that the disconnect was only with the ED.