HospitalInspections.org

Based on review of the facility's policy/procedure, documents, observations on tour, and interviews, it was determined that the facility failed to require that the Notice of Patient Rights were provided to patients at the time of registration at the Mayo Clinic Hospital for the following areas: Admitting, Emergency Department, and Diagnostic Imaging. This deficient practice poses a risk to the health, and safety of the patients, when the hospital cannot ensure that patients are informed of their rights while receiving medical care and/or services.

Findings include:

Policy titled "Patient Rights and Responsibilities" (Current Version, AZ, 04/29/2019) revealed: "...applies to Mayo Clinic Hospital (MCH) personnel...to provide instructions for personnel for notifying patients of their rights, and responsibilities to participate in their care...at time of registration or admission, patients are informed of their rights, and responsibilities, including but not limited to providing information, asking questions, following instructions, accepting consequences, following rules, and regulations, showing respects, and consideration, acknowledging when he or she does not understand the treatment course of care decision ...."

Document titled "Mayo Clinic, Conditions of Admission" (Form #MC0072-98, 2018) revealed: "...Patient Rights and Responsibilities...the patient/guarantor was provided with a copy of the hospital's statement of Patient Rights, and Responsibilities...detailed information is located in the Mayo Clinic Hospital Handbook and/or Patient and Visitor Guide...."

Document titled "Mayo Clinic, Your Information, Your Rights, Our Responsibilities" (Form #MC5256-01, revised 08/2018) revealed: "...this notice describes how medical information about you may be used, and disclosed by Mayo Clinic, and how you can get access to this information...."

Document titled "Mayo Clinic Patient, and Visitor Guide" (revised 03/2019) revealed no documented evidence of Patient Rights and Responsibilities.

Observation on tour conducted 10/15/2019 (1145), revealed that a copy of the Patient Rights and Responsibilities was posted in the hospital's main lobby, behind a glass enclosure, to the right of the elevators. Additionally, the document was revised 06/18/2014.

Observation on tour conducted 10/16/2019 (1330), revealed that no copy of the Patient Rights and Responsibilities was posted in the Emergency Department lobby.

Personnel #39 confirmed during an interview conducted 10/15/2019 (1150), that the registration/admitting staff used to give patients a booklet, that listed the Patient's Rights and Responsibilities, but when the computer systems switched from Cerner to Epic in October 2018, the registration/admitting staff stopped providing the patients with the booklet , and handed the patients the "Mayo Clinic Patient, and Visitor Guide", and a document titled "Mayo Clinic, Your Information, Your Rights, Our Responsibilities." Additionally, Personnel #39 revealed the required Patient Rights and Responsibilities is not listed in the above documents currently being given to patients at the time of registration or admission.

Personnel #38, and Personnel #146 both confirmed during an interview conducted 10/15/2019 (1155), that the document titled "Mayo Clinic, Conditions of Admission" reads that the patient/guarantor was provided with a copy of the hospital's statement of Patient Rights and Responsibilities, but that the only documents currently handed to the patient/guarantor are the "Mayo Clinic Patient, and Visitor Guide", and the "Mayo Clinic, Your Information, Your Rights, Our Responsibilities." Personnel #38, and Personnel #146, revealed that the required Patient Rights and Responsibilities is not listed in the above documents currently being given to patients at the time of registration or admission. Additionally, Personnel #38 revealed that at the time of registration or admission, all patients are given the document titled "Mayo Clinic, Complaint and Grievance Process".

Personnel #77, and Personnel #78 both confirmed during an interview conducted 10/16/2019 (1335), that during the registration or admitting process, the only documents given to the patient are the "Mayo Clinic Patient, and Visitor Guide", and the "Mayo Clinic, Your Information, Your Rights, Our Responsibilities", and that a copy of the Patient Rights and Responsibilities is not provided to the patient. Additionally, Personnel #77, and Personnel #78 both revealed that at the time of registration or admission, all patients are given the document titled "Mayo Clinic, Complaint and Grievance Process."

Personnel #145 confirmed during an interview conducted 10/17/2019 (1153), that during the registration process, the only documents given to the patient is the "Mayo Clinic Patient, and Visitor Guide", and the document titled "Mayo Clinic, Your Information, Your Rights, Our Responsibilities", and that a copy of the Patient Rights and Responsibilities is not provided to the patient.

Personnel #1 confirmed during an interview conducted 10/18/2019 (0930), that the computer system conversion from Cerner to Epic took place on 10/06/2018.