HospitalInspections.org

Based on document review and interview, the facility failed to document that the notice of patient rights was provided to a patient or the patient's representative at the time of admission for 3 of 10 medical records (MR) reviewed (patient #'s 1, 2 & 4).

Findings include:

1. The policy/procedure Patient Rights and Responsibilities (approved 1-15) indicated the following: "The document outlining the patient rights and responsibilities shall be given to patients, family and/or guardian at the time of admission. The rights will be orally explained to the patient by the admission clerk at the time of admission and documented on the general patient consent form."

2. Review of the MRs for patient #1, #2 and #4 indicated that verbal consent was obtained for each patient admission and no MR entry indicated how or when a facility staff provided a copy of the notice of Patient Rights and Responsibilities to the patient's representative as indicated on the Consent for Treatment.

3. On interview on 8-23-16 at 1040 hours, the regional chief executive officer, staff A7 confirmed the MRs for patient #1, #2 and #4 failed to document the act of providing a copy of the notice of Patient Rights to the patient's representative at the time of admission and no other documentation was available.

Based on document review and interview, the facility failed to ensure each patient or the patient's representative was informed on admission of the facility's grievance process including an address and phone number for submitting a grievance with the State agency for 3 of 10 medical records (MR) reviewed (patient #'s 1, 2 & 4).

Findings include:

1. The policy/procedure Patient Rights and Responsibilities (approved 1-15) indicated the following: "The document outlining the patient rights and responsibilities shall be given to patients, family and/or guardian at the time of admission. The rights will be orally explained to the patient by the admission clerk at the time of admission and documented on the general patient consent form. Along with rights and responsibilities shall be included phone numbers which patient's family and/or guardians may call to ask for assistance in resolution of conflicts regarding admission, treatment, and/or discharge..."

2. Review of the Patient Rights and Responsibilities notice indicated the following: "...Be informed of advocacy services available to you...[and] ... Have access to the facility's grievance process..." and no other admission packet information indicated the name of a person, phone number, or process for lodging a grievance with the facility or the name, address, and phone number for lodging a grievance to the State Advocacy agency.

3. Review of the MRs for patient #1, #2 and #4 indicated verbal consent for treatment was obtained from a patient's representative at the time of admission and no MR entry indicated when or how the name, address and phone number of the State Advocacy agency was provided to the patient's representative at the time of admission.

4. On interview on 8-23-16 at 1045 hours, the regional chief executive officer, staff A7 confirmed the MRs for patient #1, #2 and #4 failed to document the act of providing the State Advocacy agency's name, address and phone number to the patient's representative at the time of admission and no other documentation was available.