HospitalInspections.org

Based on review of policies/procedures, hospital documents, and interview with staff, it was determined the hospital failed to inform the patient or the patient's representative of patient's rights upon admission.

Findings include:

Patient #2 was admitted on 02/19/13 with acute and chronic respiratory failure, pulmonary fibrosis, Cor pulmopnale secondary to severe pulmonary hypertension and toxic metabolic encephalopathy due to hypoxemia.

At the time of admission, nurses documented the daughter who has Medical Power of Attorney (MPOA) was with the patient. Physician #2 admitting the patient instructed the nurses not to allow the patient to sign consents. Nurses documented this in the nursing notes.

The form titled Conditions of Treatment and Admission included the name of an emergency contact, with a phone number. It also included the signature of the "patient or legally authorized representative," his daughter/MPOA. The form was not witnessed, dated or timed, however, documentation in the nurses notes on 02/19/13, indicate the daughter/MPOA signed the form upon admission at 2000 hours.

At the bottom of the form it reads: "Initial the Following Options that Applies: I hereby acknowledge receipt of the Patient Rights and the Patient and Family Handbook._____Init...." This area was blank and no initial was present indicating receipt of those items.

The hospital policy titled Consent: Informed for Medical Treatment required: "...Inpatient/resident Admission-each patient/resident/legal representative seeking admission shall sign the admission consent for treatment form. By signing the bottom of this form, it indicates that they received all the following items: a. Patient/resident Rights...c. Patient/resident/Family Education Handbook...."

The Director of Quality confimed on 11/15/13 at 1400 hours, that the Conditions of Treatment and Admission form did not indicate the MPOA or patient received information on Patient Rights or the Family Education Handbook. Addtionally, the hospital did not have a policy regarding Patient Rights that met the requirements of the R9-10-209.A.4. through R9-10-209.A.5.