HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure that each patient or their representative is informed of their rights in advance of providing or stopping care. Three of three outpatient ( #'s 21, 24 & 25) and four of four inpatient ( #'s4, 10, 18, & 25) electronic surgical records reviewed did not have evidence that each patient had been informed of their rights in advance of providing or stopping care.

Findings:

1. Hospital staff verified on 10/22/10 in the afternoon that there was no evidence in the closed electronic patient records that the patients had been informed of their rights in advance of care or before stopping care.

2. Hospital staff stated that discharged patients' records are scanned and entered into the hospital's information system.

Based on record review and interviews with hospital staff, the hospital does not ensure that all entries into the medical record are legible. Seven of seven ( #'s 4, 6, 8, 17, 21, 24 & 25 ) outpatient procedure electronic records which had a short stay record handwritten by the physician were illegible. Hospital staff verified on 10/21/10 and 10/22/10 in the afternoon that the records were not legible.