The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST MARY'S SACRED HEART HOSPITAL, INC 367 CLEAR CREEK PARKWAY LAVONIA, GA 30553 April 19, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on medical record review, staff interview, review of the Patient Guide, and review of facility policies, the facility failed to ensure that medical records contained evidence that Patient Rights had been provided to ten (10) of ten (10) medical records reviewed.

Findings include:

Review of ten (10) medical records (#1-10) revealed:
#1 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#2 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#3 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#4 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#5 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#6 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#7 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#8 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#9 Did not contain evidence that Patient Rights had been provided to the patient or patient representative
#10 Did not contain evidence that Patient Rights had been provided to the patient or patient representative

Interview with the CNO (Chief Nursing Officer) on 4/18/16 at 2:00 PM in the conference room revealed that Patient Rights information was provided to patients by the registration staff when they checked into the hospital, but the record did not contain documentation of receipt of such. The CNO also stated that Advance Directive information was documented by registration staff in the medical record if the patient was able to state such on admission. If the patient was not able to speak on admission, the RN would obtain the information as soon as possible.

Review of the facility's 2014 version of the Patient Guide revealed information explaining Advance Directives, and rights concerning Personal Health Information.

Review of the facility's current version of the Patient Guide revealed Patient Rights Information which included receiving care in a safe setting, free from mental, physical, sexual and verbal abuse, neglect and exploitation.

Review of facility policy titled Patient Rights and Responsibilities, effective 10/2011, last revised 12/2014, revealed that all clinical patients would be informed of their rights and responsibilities by the health care system upon admission, and included:
4. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned.
8. Consent: The patient has the right to reasonably informed participation in decisions involving their health care. To the degree possible, this should be based on a clear, concise explanation of their condition and of all proposed technical procedures, including the possibilities of any risk of mortality or serious side effects, problems related to recuperation, and probability of success. The patient should not be subjected to any procedure without their voluntary, competent, and understanding consent or that of their legally authorized representative. The patient has the right to know who is performing the procedure or treatment.

Review of facility policy CM-301, Patient Rights, effective/revision date August 2011, retention date August 2014, revealed:
Patients and/or family members were to be involved in all aspects of their care, unless declared mentally incompetent and having a legal guardian, in which care the guardian or agent would be involved.