HospitalInspections.org

Based on observation, interviews and record review, the hospital failed to provide two patient's (P)1 and P2's representatives with the patient rights of a sample size of three, when they were treated in the Emergency Room (ER). The hospital did not have an effective process in place to ensure all patients or representatives have the information necessary to exercise their rights.

Findings include:

1) Reviewed the Facility Grievance log for the period of 10/01/2024 to 11/12/2024, and identified a complaint made by P1's Patient Representative (PR)1 regarding patient rights. Review of the complaint summary revealed P1 presented to the Emergency Room for care on the evening of 10/24/2024. The issue description on the summary read: "PR1 upset at not knowing when his daughter will be transferred to another facility. Additional areas of concern included wait time, information about medical condition/plan of care and willingness to answer questions. Patient Relations was notified by phone message, and returned the call on 10/28/2024 at 10:52 AM. The summary documented "Patient registration stopped by (P1's room) to deliver Rights and Responsibilities, RN (registered nurse) will provide upon their (parents) return to the hospital. The complaint was closed and a follow up letter was sent to PR1. The follow up letter dated November 6, 2024 included. "In our conversation, you expressed worries about your daughter's patient rights given her status. I immediately informed the Behavioral Health Department of your concerns. As I mentioned, the Behavioral Health Team assured me that they would respond to any questions or issues you had later that day."

2) P1 was a 17 year old female that was taken to the hospital by her parents on October 24, 2024, following an intentional ingestion of ibuprofen. She had a history of major depression with past suicidal attempts and was under the care of a psychiatrist. P1 was seen by the behavioral health team in the ER, who determined it unsafe to discharge her, and recommended inpatient psychiatric care. She was held in the ER until a bed became available at a hospital with inpatient adolescent psychiatry, at which time she was transferred.
P1's parents did not receive a copy of the Patient Rights at the time she was admitted to the ER. They were provided after requested, four days late.

On 11/12/2024 at 03:30 PM, during an interview with Patient Relations, she said she received a phone message from PR1, and contacted him on 10/28/24. She said it was clear PR1 did not get a copy of the Patient Rights and Responsibilities, so she immediately contacted ER Registration and asked them to deliver a copy to him.

3) The facility admission/registration process includes providing all inpatients, outpatients and Emergency Room (ER) patients with a glossy printed handout/brochure (8 1/2 inches x 11 in) that includes information on Notice of Privacy Practices, Patient Rights & Responsibilities and Proficiency of Language Assistance Services. The information on Patient Rights & Responsibilities was two pages and included topics of Respectful and Supportive Care, Nondiscrimination, Right to Treatment, Information about Treatment, Participation in Care Planning, Cultural and Religious Beliefs, Pain Management, Advance Directives, Restraints, Research, Billing Information, Communication, Confidentiality of Health Medical Information, Visitation Rights, Protective Services, Ethical Issues Care at the End of Life and Concerns & Complaints.

In addition to receiving the brochure, all patients/PR's sign the form (carbonless duplicate) titled "Terms and Condition of Services," during the registration process. This form provides is the consent to treat and additional information on disclosure of Information for Payment Purposes, Information to Other Providers, and Privacy practices. Section 9, of this form validated the patient/PR received the patient rights, and read "I acknowledge I have received my Rights and Responsibilities as a patient as well as information regarding nondiscrimination and language access services."

4) On 11/14/2024 at 09:30 AM, observed an ER Registrar (ERR)1 greet a person who presented to ER registration with her child. Toward the end of the registration process, ERR1 asked if the patient representative would like a copy of the patient rights, and held out the informational brochure. After the PR did not respond, ERR1 told the PR "some people opt out of taking it." At that time the PR said she'd "opt out." Observed multiple copies of the brochure available at the Registration work area.

On 11/14/2024 interviewed ERR2, who was a lead registrar, training ERR1. Asked what the practice was for providing patient rights, and she confirmed several patients will "opt out" of taking the informational brochure. She said they do not review or discuss the patient rights with them, and do not make a notation on the consent form indicating the information was offered and refused.