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Based on interview, record review, and review of hospital documents, the hospital failed to provide evidence that prior to treatment, the patient was provided or informed of the required "Patients' Bill of Rights and Responsibilities" for 4 of 4 sampled patients (#1, 2, 3 & 4).

Findings:

1. Patient #1's record reflected that she was admitted to the hospital's emergency department (ED) on 11/18/21 and later admitted as an inpatient to the hospital. Patient #1's chief complaint was stroke alert symptoms. The patient's record did not contain any evidence of consent for treatment and admission information given to the patient and informed of their Patient Rights and Responsibilities prior to treatment.

2. Patient #2's record reflected that she was admitted to the hospital's ED on 11/18/21 for cardiac complications. Patient #2' record did not contain any evidence of consent for treatment and admission information and informed of their Patient Rights and Responsibilities prior to treatment.

3. Patient #3's record reflected that she was admitted to the hospital's ED on 11/18/21 for chief complaint of Headache. Patient #3's record did not contain any evidence of consent for treatment and admission information and informed of their Patient Rights and Responsibilities prior to treatment.

4. Patient #4 was a current patient admitted to the hospital ED on 1/11/22 with Covid symptoms and positive Covid test. Patient #4's record did not contain any evidence of consent for treatment and admission information and informed of their Patient Rights and Responsibilities prior to treatment.

On 1/12/22 at 12 PM, the ED Patient Access Assistant Manager related patients come in for treatment and are not given their Patient Rights information in paper form or through patient access information. He said it was decided that because the ED posted Patient Rights signage on their walls, it was felt that they were informed of their rights. He related when the patients are admitted, they are again visited by Patient Access to gain further information and if they chose, they can have a copy of their Rights at that time, and it also will be in their patient portal. The Patient Access Assistant Manager related he did not know who made the decision about not supplying or informing the Patient Rights information to each patient and could not remember when it was done.

On 1/12/22 at 12:45 PM, with Risk Manager (RM) A, the Senior Director of Patient Access confirmed the process stated by the Patient Access Assistant Manager/ED. She also verbalized she did not know where the decision came from regarding not giving or informing each patient on admission to the ED their Patient Rights, as signage is posted to inform them. The Senior Director and RM both stated with the new electronic health record, there was no area for patient access to document in the record that the Patient Rights information was provided to the patients.

The hospital polity entitled "Patients' Rights and Responsibilities #1480", revised 11/2019, read "It is the policy of [Hospital name] to protect the basic human rights of its patients for independance of expression, decision, action, human relationships and personal dignity to the extent consistent with sound medical care and the rights of other patients and hospital employees." There was no further documentation observed in the policy that explained how the Patient Rights and Responsibilities would be given or how the patient would be informed of them by the hospital staff.

Based on interview and review of medical records, the hospital failed to notify a family member/representative of a patient's acute change of health status and change in condition for 1 of 4 sampled patients (#1). Failure to notify family/representative of the patient's health status results in the inability of the family/representative to be informed of the patient's status and to be involved in decisions for treatment and care planning when the patient is unable.

Findings:

Patient #1's record reflected she was admitted to the hospital Emergency Department (ED) on 1/18/21 and was immediately placed on stroke alert precautions. The patient was later admitted as an inpatient on 11/19/21. Documentation revealed the patient's family was at the bedside in the ED. The patient underwent testing and diagnostics including a Computerized Tomography (CT) scan and a Magnetic Resonance Imaging (MRI). The patient's record contained a physical exam by an Advanced Practice Registered Nurse on 11/19/21 at 3:30 AM. It read that the patient was alert and oriented to all spheres with a Glasgow Coma Scale (GCS) of 15, representing her cognitive status, as cognitively alert.

Patient #1's record reflected that she returned from having an MRI on 11/19/21 at 5 AM. A nurse's note read, "Pt [patient] returned from MRI-hallucinating and was only able to complete a portion of MRI due to pulling wires." A hospital event report revealed on 11/19/21 at 5:45 AM, the patient was found by a nurse and had an unwitnessed fall which resulted in a fracture. The nurse's note reflected that the patient had confusion and her GCS decreased to 14.

Patient #1's record did not contain any documentation that the patient's family/representative was contacted to inform them of the patient's fall and the changes in her cognitive status. The patient continued to receive treatment and the family was unable to participate or contribute to her care because they were unaware of the change in her cognitive status. The patient's medical record showed six different contact names and numbers under "Emergency Contacts" the hospital staff should have contacted to inform them of the cognitive changes.

On 1/12/22 at 2:10 PM, Risk Manager C and the ED Nurse Manager stated it is expected that if a patient has a change of condition, fall and mental status changes, and are not oriented, and not able to make decisions, a family member/representative is contacted soon after the event. Risk Manager C and the ED Nurse Manager agreed patient #1's record did not contain documentation that a family member or representative had been contacted post her fall and change in cognitive status.