Bringing transparency to federal inspections
Tag No.: A0117
Based on a review of facility policy, medical record (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that a patient was informed of their rights in a timely manner for one of one medical record reviewed (MR1).
Findings include:
A review of the facility policy, "Patient Rights and Responsibilities" last revised January 17, 2013, revealed, "Patients may expect to be informed of their rights as early as possible during the course of their hospitalization ... ."
A review of facility policy, "Management of Patient Complaints/Grievances" last revised November 8, 2012, revealed, "As part of the admission process, each patient will be given a copy of the Patient Rights and Responsibilities brochure (included in the 'Welcome' admission folder). Information regarding initiating a complaint is also posted throughout each campus. "
A review on July 11, 2014, of MR1 revealed that the patient was admitted to the hospital on June 25, 2014. A "Patient Acknowledgement Form" signed by the patient's wife and EMP3 dated June 25, 2014, revealed a "No" checked next to "Patient Rights Brochure Copy given to patient". Further review of MR1 did not reveal documentation that the "Patient Rights Brochure" had been given to the patient's family during this admission.
An interview conducted on July 11, 2014, at 10:30 AM with EMP3 confirmed that the patient had been admitted through the Emergency Department and that the patient's family was not given a copy of the "Patient Bill of Rights" at that time.
An interview conducted on July 11, 2014, at 10:45 AM with EMP1 revealed that the facility did not have a procedure to ensure that patients received a copy of the Patient Bill of Rights in a timely manner, if it were not provided to them on admission.
An interview conducted on July 11, 2014, at 3:30 PM with EMP1 confirmed that the facility had not followed their policy to provide the patient's family with a copy of the Patient Bill of Rights on admission.