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Based on observation, interview and record review, it was determined that there was deficient practice in the area of patient rights for 15 of 15 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15)

Findings include:

The surveyors requested a list of patients who presented to the emergency room (ER) during the months of February and March of 2012 and a list of patients admitted to the hospital during March of 2012. The surveyors chose a sample of 10 ER patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10)

Medical records for patients 1 through 10 were reviewed on 3/21/12 for evidence that the patients had been informed of their patient rights. For 10 of 10 records reviewed, there was no documented evidence that the patients had received notice of their patient rights.

In an interview with the Admissions Supervisor (AS) for the emergency department (ED) conducted on 3/21/12, she stated that patients were given a Notice of Privacy Practices at the same time the Consent to Treat was signed at the window before the patients were seen in the emergency room. The AS provided the surveyors with a copy of the Notice of Privacy Practices; it was a 4-page fold-out with a 2-page insert titled "Patient Rights", which had a list of the patient rights. Through interview and/or observation of patients 11, 12, 13, 14, and 15, it was revealed that the Notice of Privacy Practices with the Patient Rights insert was not given to 5 out of 5 patients prior to being seen in the ER, as required. This conflicted with what the AS stated in the interview.

Based on observation, interview and record review, it was determined that there was deficient practice in the area of patient rights for 15 of 15 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15)

Findings include:

The surveyors requested a list of patients who presented to the emergency room (ER) during the months of February and March of 2012 and a list of patients admitted to the hospital during March of 2012. The surveyors chose a sample of 10 ER patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10)

Medical records for patients 1 through 10 were reviewed on 3/21/12 for evidence that the patients had been informed of their patient rights. For 10 of 10 records reviewed, there was no documented evidence that the patients had received notice of their patient rights.

An interview was conducted with the hospital chief quality officer (CQO) on 3/21/12 at 9:35 A.M. The surveyor asked the CQO where the patient record evidenced that the patients had received notice of their patient rights. The CQO stated that patient rights were included on the Consent to Treatment form, in section 7, which was titled "Notice of Privacy Practices." The CQO pointed paragraph 7 out to the surveyors on a blank copy of the Consent to Treatment form. When the surveyor stated that this statement appeared to be a statement that patients had received their HIPAA privacy notice rather than patient rights information, the CQO stated that they had always used it as confirmation that the patients had been informed of their patient rights.

The form "Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment" was reviewed on 3/21/12. The form contained 11 categories:
1. Assignment of Insurance Benefits/Promise to Pay
2. Nursing Care
3. EMTALA
4. Private Room Difference (Inpatient)
5. Personal Valuables
6. Weapon/Explosives/Drugs
7. Notice of Privacy Practices
8. General Consent for Tests, Treatments, Photo, Video, and Services
9. Advance Directive Acknowledgement
10. Research Studies
11. Smoking Cessation Information

Except for the advance directive acknowledgement section, the form did not include any information regarding patients rights information. Item 7 on the form, "Notice of Privacy Practices," stated, "Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA) I acknowledge that I have received a copy of the Facility's Notice of Privacy Practices that provides information about how the Facility may use and disclose my protected health information." Number 7 only addressed HIPAA privacy issues. A complete list of patient rights was not in the information provided by the hospital.

In an interview with the Admissions Supervisor (AS) for the emergency department (ED) conducted on 3/21/12, she stated that patients were given a Notice of Privacy Practices at the same time the Consent to Treat was signed at the window before the patients were seen in the emergency room. The AS provided the surveyors with a copy of the Notice of Privacy Practices; it was a 4 page fold-out with a 2-page insert titled "Patient Rights", which had a list of the patient rights. Through interview and/or observation of patients 11, 12, 13, 14, and 15, it was revealed that the Notice of Privacy Practices with the Patient Rights insert was not given to 5 out of 5 patients prior to being seen in the ER, as required. This conflicted with what the AS stated in the interview.

On 3/21/12 at 1:50 P.M., the surveyor observed the Admission Clerk (AC) admit patient 14. Patient 14 presented to the ED window to be seen after falling on the playground at school. Patient 14 was accompanied by her mother. Patient 14's mother was asked to sign a Consent to Treat form. No other paperwork was given at that time. Patient 14 was brought back to a room and triaged by the nurse. After observing the nurse and physician, the surveyor asked the mother of patient 14 if anyone had talked to her about patient rights and if she had received any paperwork on patient rights, in which she stated no. The nurse went through the discharge instructions with the mother and patient 14, the mother signed the discharge instructions, and then she told the nurse that no one had taken her insurance information. A few minutes later the AC came in with some paperwork. The AC took patient 14's demographic and insurance information and handed her some paperwork. The surveyor looked over the paperwork and saw no evidence that a copy of patient rights was given to patient 14 or her mother.

On 3/22/12 at 10:30 A.M., the surveyor asked to interview a patient that had been through the admission process, in which the nurse stated that room 3 (patient 11) was ready to be discharged and should have all the admission paperwork. The surveyor interviewed patient 11. When asked if anyone had talked to her about her patient rights, she stated, "No, I was just mentioning to my husband that they haven't got any of my insurance information or name band." Patient 11 stated she signed a consent form when she first arrived, but that was it. The surveyor checked with patient 11 at 10:50 A.M., and the AC had brought in some paperwork. The surveyor looked over the paperwork and found that the patient had been given a Notice of Privacy Practices with a copy of the patient rights insert inside, after treatment had occurred. Patient 11 stated that the AC went over her patient rights with her.


On 3/22/12 at 10:35 A.M., the surveyor interviewed patient 12 and asked if anyone had talked to her about her patient rights, in which she stated yes. The surveyor asked to review the paperwork given to patient 12. There was a Notice of Privacy Practices with a copy of the patient rights insert inside. The surveyor asked if she received the patient rights information before or after they started treatment, in which she stated it was after she saw the nurse.

On 3/22/12 at 10:45 A.M., the surveyor observed the AC admit patient 13. Patient 13 had just come back from receiving an x-ray. The AC went over the demographics and insurance information, left a copy of the Notice of Privacy Practices, which had the patient rights insert; however, it was after treatment had begun. The AC asked patient 13 if she had any questions about either, in which she stated no.

On March 22, 2012, the surveyor observed a patient rights sign which was posted on the wall outside the emergency room window, with one patient rights sign in Spanish on the right, and one patient rights sign in English directly behind the patient window.

An interview was conducted with the hospital Chief Executive Officer (CEO) on 3/22/12 at 2:00 P.M. The CEO stated that their hospital was part of a corporation of many hospitals, and that the corporation position was that by posting Patient Rights in both English and Spanish in the entrance to the hospital emergency room, it fulfilled the hospital's responsibility regarding informing patients of their patient rights. The surveyor asked, "What about patients who can't read? What about patients who don't speak English or Spanish? How do you make sure all patients have read and understood the patient rights information?" The CEO stated that he hadn't thought of those possibilities and that it made sense to him what the surveyors were saying.