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.

MAIN LINE HOSPITAL PAOLI 255 WEST LANCASTER AVENUE PAOLI, PA 19301 Oct. 30, 2016
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0020
Based on review of facility policies, review of medical records (MR) and interview with staff (EMP) and patients, it was determined the facility failed to conform to all applicable Federal regulations.

The facility was found to be non-compliant with the following Federal regulation:

482.13 (a) (1) A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible.

This is not met as evidenced by:

Based on review of facility policy, review of medical record (MR), interview with staff (EMP) and interview with a patient, it was determined the facility failed to follow their policy that required all patients be informed of their patient rights for MR1.

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed March 2016 revealed, "All patients, inpatient and outpatient, must be informed of their rights as hospital patients. ... There are established mechanisms to ensure that these rights and responsibilities will be observed and communicated. ... The hospital must inform each patient, or when appropriate, the patient's representative as allowed by State law, of the patient rights. ... ."

Review of MR1 failed to reveal evidence that the patient had been given a copy of or was informed of the Patient Bill of Rights while in the Emergency Department (ED).
An interview conducted on October 28, 2016, at 1:30 PM with EMP22 revealed that they were not aware that ED patients were to be informed of their "Patient Rights" prior to receiving care in the ED. Further interview revealed that if a patient asked about their rights they would be directed to look at the posting on the wall next to the Registration area.

An interview conducted on October 28, 2016, at 1:45 PM with EMP1 confirmed that the facility did not follow their policy "Patient Rights and Responsibilities" for all ED patients as they do not inform patients of the "Patient Bill of Rights" prior to furnishing care or provide a copy during their ED stay. Further interview confirmed that they did not have a process to provide ED patients with their "Patient Bill of Rights" nor did they have copies of the "Patient Bill of Rights" to give patients, if they requested a copy.
A tour of the ED on October 28, 2016, at 1:00 PM with EMP1 and EMP20 revealed there were only five "Patient Bill of Rights" posters posted in the ED - one on the wall next to the Registration area, one in Snack area, and one in the two ED pods and Fast Track on hallway walls. No copies of the "Patient Bill of Rights" were available to be given to ED patients.

An interview conducted on October 28, 2016, at 2:00 PM with ED patient in Pod B room A3 revealed that they were not given a copy of the "Patient Bill of Rights" nor had they been informed of their patient rights during their ED stay.