HospitalInspections.org

Based on interview, medical record review and document review, it was determined the facility failed to provide evidence that two (2) patients were informed of their patient's rights.

Findings:

The facility's policy titled, Patient Rights and Responsibilities, was reviewed and reads, in part: "... B. [Name of health system] Responsibilities. The [name of health system] facilities shall use all reasonable efforts to ensure that patients are aware of their rights and can exercise their rights effectively. Each [name of health system] facility will: 1. Provide to each patient or his/her representative a summary of the rights set forth in this policy...". The policy was last reviewed, revised and effective on 6/27/2023.

During the review of Patient #4 and Patient #5's medical record on 4/9/24, the surveyor requested to see documentation that the patients signed the facility's patient rights and responsibilities form acknowledging they were informed of their patient rights. The form could not be located in either Patient #4 or Patient #5's medical record.

On 4/9/24 at approximately 10:15 a.m. and again at 11:10 a.m., the surveyor spoke with Staff Member #7 via telephone regarding the missing forms. Staff Member #7 said there was a note on Patient #5's chart indicating the patient access representative was unable to obtain the patient rights and responsibilities form because "they saw a note from a nurse that the patient was under moderate sedation". Patient #4's chart contained a note that the patient access representative was unable to obtain the form, but did not contain any documentation to explain why.

Staff Member #7 said the patient access representatives in the emergency department (ED) only have contact with the patient while in the ED. Any error or missed form related to billing and insurance would cause the account to "pop-up" in a work que so a representative can follow-up on it. Staff Member #7 said no one is assigned to "work the que" daily and acknowledged "we work it as we have time". Staff Member #7 was unable to speak on the process for follow-up on missing forms once the patient is admitted.

On 4/9/24 at 1:05 p.m., the surveyor spoke with Staff Member #10 via telephone. Staff Member #10 said there are patient access representatives who cover the inpatient areas and can follow-up on any missing forms. Staff Member #10 acknowledged that follow-ups should occur "within 24 hours". The patient access department uses hospital account record (HAR) for documentation. Any follow-up conducted or attempted on an account should be documented in HAR. Patient access should continue to conduct follow-ups until the missing forms are completed. If the follow-up is unsuccessful, a HAR note should document why.

Staff Member #1 confirmed that neither Patient #4 or Patient #5's medical record contained HAR notes documenting that any follow-up was attempted or conducted to complete the patient rights and responsibilities form.