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 record review and interviews, the hospital failed to ensure each patient was informed of the patient's rights prior to furnishing patient care as evidenced by failure to have the patient initial/sign his acknowledgement of the receipt and explanation of the patient rights for 1 of 5 sampled patients (#5). Findings:

Review of the hospital's "Conditions of Admission", page 2 of 2, revealed, in part, "...Acknowledgement Of Notification Of Rights: I, _______, have received in writing with an explanation and do understand: (line for initials) 1.) The procedures for requesting release from this facility. (line for initials) 2.) The availability of counsel. (line for initials) 3.) The rights listed in Revised Statute 28:171. (line for initials) 4.) Information about the Mental Health Advocacy Service. (line for initials) 5.) The rules and regulations applicable to or concerning my conduct while a patient in this treatment facility. (line for initials) 6.) The facility uses surveillance cameras for safety purposes. (line for initials) 7.) Right to report any alleged abuse to Police and/or regulatory body. ________ Signature of Patient ________ and/or Signature of Parent or Legal Guardian...".

Review of patient #5's "Conditions of Admission" revealed no documented evidence of Patient #5's initials or signature acknowledging his notification of rights. Further review revealed no documented evidence of the date, time, and signature of a witness.

Review of the hospital form titled "Comprehensive Assessment High Risk Notification Alert Form" revealed one of the listed items able to be checked was "patient unable to sign admission paperwork. need follow-up to obtain signatures". Further review revealed a line for the signature of the assessment staff completing the form, a line for the signature of the unit staff receiving the form, and a line for the time. Review of Patient #5's medical record revealed no documented evidence of the presence of this form in the record.

In a face-to-face interview on 03/10/11 at 11:30am with S2 DON (director of nursing) and S10 Risk Manager/QAPI (quality assurance performance improvement) present, S2 DON indicated the admission paperwork was signed by the patient/caregiver when the patient arrived in admissions. She further indicated the admission staff would usually go to the unit the next day, if the paperwork did not get signed at the time of admission. S10 confirmed Patient #5's medical record did not have evidence that he was informed of his rights, and there was no evidence of the "Comprehensive Assessment High Risk Notification Alert Form" in his record.

Review of the hospital's policy titled "Patient Rights And Restriction Of Rights", submitted by S10 Risk Manager/QAPI as their current policy on patient rights, revealed, in part, "...Upon admission, patient/his or her family member/or representative receives and acknowledges receipt of "Patient Rights". ...Patient is informed of his/her right to make decisions in collaboration with physician involving patient's health care...".

Review of the hospital policy titled "Admission Of Patients", submitted by S10 Risk Manager/QAPI as their current policy on patient admission, revealed, in part, "...The Admission and Referral Department (A&R) and/or the unit nurse is responsible for obtaining the initial Physician's Order to admit a person and for completing the legal documents required to accept an individual as admitted to River Oaks Hospital. ... A Hand Off Form is used to facilitate communication being relayed from A&R to Nursing Staff. ... For children and adolescents, patient and family, if available, are brought to the unit by program staff or Admission and Referral staff... If parents not available on admit, Tour will be given on visitation and referral to A&R to complete any necessary paperwork...".