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.
|INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL||2401 UNIVERSITY AVE MUNCIE, IN 47303||June 27, 2019|
|VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS||Tag No: A0117|
|Based on document review and interview, the facility failed to ensure the adult representative of each minor patient was informed of the patient's rights at the time of admission to the facility for 10 of 14 medical records (MR) reviewed (Patient's #1, 2, 3, 4, 5, 6, 7, 8, 9 & 10).
1. Review of the policy/procedure Patient Rights and Responsibilities, Complaints and Grievances (revised 6-18) indicated the following: "For the purpose of this policy, the term "patient" shall also include the patient's authorized representative, as applicable...It is the policy of Indiana University Health to inform all patients an outline of Patient Rights and Responsibilities are available...Patient Rights and Responsibilities information will be readily available for patient upon admission or registration."
2. Review of the MRs for patient's #1, 2, 3, 4, 5, 6, 7, 8, 9 & 10 lacked documentation indicating how and when the adult representative or legal guardian of each minor patient was notified and informed of the patient's rights and/or provided with a copy of the facility's notice of Patient Rights and Responsibilities and/or receipt of notification obtained at the time of admission to the facility.
3. On 6-27-19 at 1005 hours, the Accreditation and Compliance Specialist, A6 confirmed the MRs for patient's #1, 2, 3, 4, 5, 6, 7, 8, 9 & 10 lacked documentation indicating the adult representative or guardian for each minor patient was notified and informed of the patient's rights at the time of admission and no other documentation was available.
|VIOLATION: PATIENT RIGHTS: INFORMED CONSENT||Tag No: A0131|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review and interview, the facility failed to ensure a consent for treatment was obtained from the adult representative of each minor patient admitted to the facility for 1 of 14 MR (medical records) reviewed (Patient #6).
1. Review of the policy/procedure Legal Health Care Consent (Adult and Minor) - Informed Consent (revised 7-18) indicated the following: "Consents are to be signed and witnesses by an adult. An adult is defined as an individual 18 years of age or older. An individual not an adult is referred to as a minor."
2. Review of the MR for patient #6 indicated the [AGE] year old patient was admitted to the facility on on [DATE] and indicated that family members FM20 and FM21 were listed as the nearest relatives (parents) and adult representatives.
3. Review of the MR for patient #6 indicated the document titled Consent for Treatment and Payment Responsibility, was signed by the patient on 12-12-18 and no other documentation indicated a valid consent for treatment was signed by an adult representative of the minor patient during the hospital stay.
4. On 6-27-19 at 0900 hours, the Accreditation and Compliance Specialist, A6 confirmed the MR for patient #6 lacked documentation indicating on 12-12-18 a consent for treatment was signed by an adult representative of the minor patient upon admission to the facility and no other documentation was available.