HospitalInspections.org

Based on staff interview, medical record reviews, and facility documentation review, it was determined the facility staff failed to ensure that two (2) of eleven (11) patients in the survey sample (Patients #9 & #10), were informed of their patient's rights.

The findings included:

Patient #9 was admitted to the facility on 9/27/21 with diagnoses that included but not limited to, cirrhosis of the liver, refractory ascites, and renal failure. Patient #9 died at the hospital on 9/28/21 therefore a closed record review was conducted.

On 10/7/21 at 12:50 p.m. an electronic medical record review was conducted with the Regulatory Coordinator (Staff #7). The review revealed the admission H&P dated 9/27/21 at 5:19 a.m. included that Patient #9 was alert and oriented.

Review of the consents obtained by staff during Patient #9's admission included verbal consents from Patient #9's wife on 9/27/21 for a paracentesis and a blood transfusion. There was no signed or verbal "Authorization for Healthcare Services" form which includes, but not limited to, information about Advanced Directives, Release of Information, and acknowledgement that the patient (or representative) received the Privacy Notice, and Bill of Rights and Responsibilities.

On 10/7/21 at 1:30 p.m., the Vice President of Regulatory Affairs (Staff #1) stated, "Per HIM (health information management) there's no signed consent."

Review of facility policy titled "Patient Rights and Responsibilities" with an effective date of 6/4/2018 included:
"Policy A. (Name of Health System) recognizes and respects the rights of all patients. Patients receiving any health care services at (Name of Health System) are informed of these patient rights as well as their responsibilities..."
"Procedure 1. Notification of Patient Rights and Responsibilities
...1.3. Each patient/legal representative is asked to sign the Patient Bill of Rights and Responsibilities section of the Condition for Health Care Services form at initial registration and annually thereafter, and at each admission. The patient/legal representative is asked to read, acknowledge and sign that he/she has received this information. The Inpatient Guide, which contains the Patient Bill of Rights and Responsibilities, is distributed upon admission..."

On 10/7/21 at approximately 4:00 p.m. the Chief Operating Officer, Staff #1, Staff #7, and Staff #21 were informed of the findings.

Patient #10 was admitted to the facility on 8/28/21 with diagnoses that included but not limited to, mantle cell lymphoma, pancytopenia, and acute leukemia. Patient #10 died at the hospital on 8/30/21 therefore a closed record review was conducted.

On 10/7/21 at 9:35 a.m. an electronic medical record review was conducted with the Regulatory Coordinator (Staff #7).
There was no signed or verbal "Authorization for Healthcare Services" form which includes, but not limited to, information about Advanced Directives, Release of Information, and acknowledgement that the patient (or representative) received the Privacy Notice, and Bill of Rights and Responsibilities.

On 10/7/21 at 1:30 p.m., the Vice President of Regulatory Affairs (Staff #1) stated, "Per HIM (health information management) there's no signed consent."

Review of facility policy titled "Patient Rights and Responsibilities" with an effective date of 6/4/2018 included:
"Policy A. (Name of Health System) recognizes and respects the rights of all patients. Patients receiving any health care services at (Name of Health System) are informed of these patient rights as well as their responsibilities..."
"Procedure 1. Notification of Patient Rights and Responsibilities
...1.3. Each patient/legal representative is asked to sign the Patient Bill of Rights and Responsibilities section of the Condition for Health Care Services form at initial registration and annually thereafter, and at each admission. The patient/legal representative is asked to read, acknowledge and sign that he/she has received this information. The Inpatient Guide, which contains the Patient Bill of Rights and Responsibilities, is distributed upon admission..."

On 10/7/21 at approximately 4:00 p.m. the Chief Operating Officer, Staff #1, Staff #7, and Staff #21 were informed of the findings.