HospitalInspections.org

Based upon record review and interview, the facility failed to ensure that patients were informed of their rights related to complaints/grievances and restraint/seclusion. The facility also failed to ensure that patient's rights were provided and explained in a language that the patient can understand.

Review of the patient rights brochure revealed the following statement: "Receive, at the time of admission in a language or method that the patient understands, information about the patient rights policy and the mechanism for initiation, review, and when possible, resolution of patient complaints." The brochure did not contain the mechanism for initiation, review, and resolution of patient complaints.

Further review of the Patient Rights brochure given to patients on admission revealed no rights related to restraint/seclusion. Review of facility policy "10.02 Patient Rights" revealed no mention of rights related to use of restraint/seclusion.

Review of the Admission, Outpatient, and Clinic Consent Form revealed the following statement: "I have been provided with copies of the Notice of Privacy Practice, Patient's Rights and Responsibilities, and Information about Advanced Directives. Review of three admission packets utilized by the admissions department revealed the Admission, Outpatient, and Clinic Consent Form was only provided in english.

An interview was conducted with an admissions clerk (Staff #31) on 1/8/10 at 11:00 am in the admissions area. The admissions clerk reported that when a patient is admitted, they are given the consent form and told it was the consent for treatment and authorization to bill insurance company and then patient signs the form. The admissions clerk reported the patient is given the brochures of Patient's Rights and Responsibilities, Notice of Privacy Practice, and Information about Advance Directives but they are not explained or read to the patient.

Based upon record review and interview, the facility failed to ensure that patients were informed of their right to be free from restraint or seclusion.

Review of the Patient Rights brochure given to patients on admission revealed no rights related to restraint/seclusion. Review of facility policy "10.02 Patient Rights" revealed no mention of rights related to use of restraint/seclusion.

An interview was conducted with the Director of Quality on 1/8/10 at 10:00 am in the conference room. The Director of Quality reviewed the Patient Rights Brochure and the facility policy titled 10.02 Patient Rights and confirmed there was no mention of rights related to use of restraint/seclusion.

Based upon record review and interview, the facility failed to ensure there were written policies and method of communication between outpatient service departments to corresponding inpatient services.

Review of policies and procedures revealed there were no written policies for the outpatient services. Further review revealed there was no established method of communication between outpatient and inpatient services to ensure continuity of care to its patients.

An interview was conducted on 1/5/10 at 2:30pm in the conference room with the Chief Operating Officer(COO). The COO confirmed there were no written policies and procedures for the provision of outpatient services.