HospitalInspections.org

Based on document review and interview, the facility failed to document that the Notice of Patient Rights was provided to patents or the patient's representative prior to receiving care for 8 of 11 medical records (MR) reviewed.

Findings:

1. The policy/procedure Patient Rights and Responsibilities (approved 5-12) indicated the following: "You shall receive information at the time of admission about the hospitals Patient Rights policy." The policy/procedure failed to indicate a process for providing the Notice of Patient Rights to outpatients and inpatients.

2. Review of 5 MR patient registration "face sheets" for patients 24, 25, 26, 27 and 29 lacked an entry under the heading Miscellaneous Required Questions (item 4) for documenting receipt of the Notice of Patient Rights. Review of 5 MR "face sheets" for patients 35 (dated 9-17-12 and 9-20-12) and patient 37 (dated 4-27-12, 11-30-12 and 12-05-12) lacked an entry in the area for documenting receipt of the Notice of Patient Rights.

3. During an interview on 3-05-13 at 1102 hours, the registration manager staff A7 confirmed that the MR patient registration "face sheet" entry area for documenting that the Patient Rights were provided to the patient or the patient's representative has not been completed by the patient or registration staff for several years.

4. During an interview on 3-05-13 at 0945 hours, staff A2 indicated that at the time of inpatient admission, nursing staff document that a patient booklet/folder is provided to the patient including the Notice of Patient Rights under the heading Patient Education in the nursing Admission History Assessment.

5. The MR for patient 37's admission assessment entries dated 4-27-12 and 11-30-12 and the MR for patient 35's admission assessment entry dated 9-20-12 under the heading Patient Education lacked documentation to indicate that a patient booklet/folder including the Notice of Patient Rights was provided to the patient or patient's representative.

6. The MR for patients 24, 25, 26, 27 and 29 admission assessment entries under the heading Patient Education lacked documentation to indicate that a patient booklet/folder including the Notice of Patient Rights was provided to the patient or patient's representative.

7. During an interview on 3-05-13 at 1525 hours, staff A2 and A4 confirmed that the open MR for patient 29 lacked documentation that the Patient Rights were provided to the patient or the patient's representative.

8. During an interview on 3-05-13 at 1555 hours, staff A2 confirmed that the closed MR for patients 24, 25, 26, 27 and 35 lacked documentation that the Patient Rights were provided to the patient or the patient's representative.

Based on document review and interview, the outpatient notice of Patient Rights & Responsibilities failed to provide the patient or the patient's representative with notice of how to file a grievance with the Indiana State Department of Health (ISDH) including a phone number and address.

Findings:

1. The Lutheran Health Network Patient Rights & Responsibilities notice provided on request failed to indicate an effective date or date of approval by the facility and failed to indicate notice of how to file a grievance with the Indiana State Department of Health (ISDH) including a phone number and address.

2. During an interview on 3-05-13 at 1102 hours, the registration manager staff A7 indicated that the current Patient Rights & Responsibilities notice was effective 12-12-12, confirmed the current notice lacked an effective date of approval by the facility and confirmed that the document lacked the required information of how to file a grievance with the Indiana State Department of Health (ISDH) including a phone number and address.

Based on document review and interview, the facility lacked documentation to indicate the governing board reviewed and resolved grievances and lacked documentation to delegate in writing the responsibility to review and resolve grievances to a committee of more than one person.

Findings:

1. On 3-04-13 at 1530 hours, staff A1 and A2 were requested to provide documentation indicating that the grievance process is reviewed and resolved by the governing board or delegated in writing to a grievance committee (of more than one person) and requested to provide documentation of grievance committee minutes. No documentation was provided prior to exit.

2. Review of the Governing Board bylaws (reviewed 4-12) failed to indicate a provision for reviewing and resolving grievances and failed to indicate a provision for delegating the grievance process to a grievance committee.

3. During an interview on 3-05-13 at 1245 hours, staff A1 confirmed that no documentation of Governing Board review of complaints and grievances was available and no documentation indicating that the grievance process was delegated to a grievance committee was available.

4. Review of the policy/procedure Patient Complaint/Grievance Management (approved 5-12) and The Customer Concern Investigation Report (revised 3-04-13) failed to indicate the same process to forward the Customer Concern Investigation Report and failed to assure that a grievance committee of more than one person was responsible for reviewing and resolving all grievances at the facility.

5. During an interview on 3-05-13 at 1300 hours, staff A2 confirmed that the policy/procedure Patient Complaint/Grievance Management and Customer Concern Investigation Report process did not agree.