HospitalInspections.org

Based on document review, record review and staff interview it was determined the hospital failed to ensure patient rights information was provided to all patients in advance of furnishing care in eleven (11) of eleven (11) medical records reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11). This failure has the potential for patients to be unaware of their rights as a patient.

Findings include:

1. The Nurse Manager of the third floor nursing unit was interviewed on 8/11/15 at 9:40 a.m. and she stated the patient rights information is provided to the patients in writing at the time of the initial nursing assessment.

Upon request, the Nurse Manager provided a packet of information which is given to each patient at the time of the initial nursing assessment. Review of the packet revealed there are no patients' rights listed with the information.

2. The medical record was reviewed for patient #11, who was a current patient on the third floor nursing unit after being admitted through the Emergency Department (ED). There was no information in the medical record which indicated the patient rights information had been provided to the patient. The patient's visitor was interviewed on 8/11/15 at 9:50 a.m. and she provided all the written information which was located at the patient's bedside. There were no patients' rights listed in the packet of information.

3. The Registration Clerk at the main admissions desk was interviewed on 8/11/15 at 10:40 a.m. and she stated she gives a "Patient Services Handbook" to all patients who are admitted as a direct admit to the hospital if they present to the main admissions desk prior to admission. Review of the handbook revealed there are patients' rights listed.

The Director of Performance Improvement who was present at the time of the interview stated the majority of patients who are admitted are not direct admit and are admitted through the ED. The Registration Clerk stated the admissions personnel do no admit or provide patient rights information to the patients who are admitted through the ED.

4. The Admissions Clerk in the ED was interviewed on 8/11/15 at 10:45 a.m. and she stated she registers patients as they present to the ED for treatment. She stated that when patients are admitted from the ED, there is not a separate registration process for admission and she does not give any "Patient Services Handbook" to any patient who is treated in the ED or who is admitted through the ED. She stated written patients' rights are not provided to those patients.

5. The Director of Admissions was interviewed on 8/11/15 at 10:50 a.m. and she stated she was told the "Patient Services Handbook" is left at each patient's bedside by housekeeping. She stated the handbooks are not currently personally given to each patient who is treated through outpatient services or who is admitted through the ED. She stated she is not aware the patients' rights information is in any other form in the hospital other than in the "Patient Services Handbook."

6. Review of the medical record for patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 revealed all patients were admitted through the ED as inpatients. There was no documented evidence any patient had received written information about their rights as a patient.

The Director of Performance Improvement who was present during all interviews and record reviews concurred that not all patients are being given patient rights information.