HospitalInspections.org

Based on clinical record review, facility document review and staff interview, the facility staff failed to ensure each patient, or representative received notification of patient rights for three (3) of ten (10) patients included in the survey sample, Patient #1, 6 and 8.

The findings included:

Patient #1 was admitted to the facility on 9/15/21 and discharged on 10/13/21. When reviewing the clinical record on 11/9/21, the surveyor and navigator (Staff Member #18) were unable to locate evidence the patient or representative had been informed of the patient's rights during the hospitalization.

Patient #6 was admitted on 11/23/20 and discharged on 12/21/20. Review of the clinical record on 11/9/21 did not evidence the patient or representative were informed of the patients rights.

Patient #8 was admitted on 10/12/21 and discharged on 10/25/21 and did not have evidence, in the clinical record, that the patient or representative were informed of the patient's rights.

On 11/9/21 at 1:30 p.m., the surveyor requested further information regarding the documentation in the clinical record evidencing the patients (or representative) had received information regarding their Patient Rights. The Facility Staff Member #18, who was assisting the surveyor in navigating the patient records stated that because these were closed records, that admissions potentially could have the documents in the electronic record which they (Staff Member #18) were not able to access. The surveyor requested that this be investigated with the admissions personnel.

On 11/10/21 at 9:30 a.m., the surveyor was presented documents indicating all three patients did not have information concerning receipt of their patient rights. Staff Member #1 (CEO) stated at exit that the facility had changed to an different electronic system and that they think these documents did not carry over into the new system. "It is something we discussed and we will certainly check and be sure that all patients have documented information that they received and understand their rights."

The facility policy and procedure "Ethics and Patient Rights and Responsibilities" evidenced, in part: "Centra patients receive a copy of their "patient rights" at the time of registration. Patients are asked to review and sign a copy of the patient rights. A signed copy is scanned into the patient's medical record and a copy given to the patient..."