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.

Based on observation and staff interview, the facility failed to ensure the patients' private information was not visible to other patients and visitors in the patient care areas. Facility census was 48. Findings are:

A. Observation on 8/24/11 at 11:20 AM on 2 East inpatient care area found a TV monitor 46 inches in size which contained the patient's room number, initials, age, physician, admitting diagnosis, isolation type and under "Comments" information about discharge plans. One patient was identified with the admitting diagnosis documented as "suicidal" another with "cellulitis of scrotum". The screen was visible to patients or visitors standing in the public hallway facing the nursing desk. Observations on 8/24/11 further revealed the same information visible to the public on screens in the ICU and OB floors.

B. Staff interview with the 2 East Charge Nurse Registered Nurse (RN)-A on 8/24/11 at 11:20 AM confirmed the information is visible to patients/visitors standing at the nurses desk.
Staff interview with the Vice President of Quality on 8/24/11 at 12 Noon confirmed the same information including patient's admitting diagnosis with initials and room number is on the monitor screens housewide. 3 West inpatient area also has 46 inch monitor with Observation patient area, Obstetrics and Intensive care having 32 inch monitors. The emergency room has a 46-inch monitor with the same information displayed. The monitors went up with the information in December of 2009. The facility failed to ensure the patient's private information could not be discovered by other patients or visitors who were near the nurses desk.
Based on record review and interviews, the facility failed to ensure the copy of patient rights provided to patients on admission was inclusive of all the required rights. This would have the potential of affecting all past patients since development of the current patient rights provided, current patients and future patients. Facility census was 48. Findings are:

The facility provided a copy of the patient rights form given to patients on admission in a notebook format titled "Your Rights as a Patient" and a copy of a folded brochure also provided titled "Patient Rights and Responsibilities". Review of the 2 types of written information given to patients listing patient rights found the information on rights was not inclusive. The list of rights on the forms did not include the following:
a. The patient has the right to participate in the development and implementation of his or her plan of care.
b. The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives.
c. The patient has the right to receive care in a safe setting.
d. The patient has the right to be free from all forms of abuse or harassment.
e. The patient has the right to access information contained in his or her clinical records within a reasonable time frame.
f. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

On 8/24/11 at 9:10 AM an interview was initiated with the Patient Advocate (PA), and the Director of Performance and Clinical Outcomes (DPCO). The form titled "Your Rights as a Patient" was reviewed together. The list of rights identified 36 patient rights (not numbered but bulleted). Neither PA nor DPCO could find the above identified missing rights (a through f) on the list. They confirmed those 6 rights were not specified in the list they currently provide patients. The PA revealed they had revised the rights to try to make them more understandable and readable across multiple cultures and socio-economic groups that are served in their community. The current list of rights had been provided to patients for several months, but were new this year. The brochure provided patients was also reviewed and also failed to contain the rights identified as a, b, c, d, e and f above. Both PA and DPCO confirmed this. When the facility revised the rights they reworded them to the point these 6 rights were no longer recognizable or were no longer present on the form.