HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure that each patient was informed of his rights by providing a copy of the Patient 's Bill of Rights for four of eight medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

A review on May 15, 2012, of facility policy "Respecting Patient Rights," effective June 2007 revealed "Procedure: Upon admission, all patients or their representatives will be given a copy of MHMC's [Montgomery Hospital Medical Center] "Patients Bill of Rights and Responsibilities". The "Patients Rights and Responsibilities" will be explained to the patient upon admission. This explanation will be in a language he/she can reasonably be expected to understand. Documentation of the patient's receipt of the "Patient Rights and Responsibilities" will be made by the patient and placed in their medical record...."

A review on May 15, 2012, of MR1, MR2, MR3, and MR4, revealed no documented evidence that the patient's received a copy of the facility's Patient Rights and Responsibilities.

An interview conducted on May 15, 2012, at approximately 11:30 AM with EMP2 confirmed that MR1, MR2, MR3, and MR4, did not contain documentation that the patients received a copy of the facility's Patient Rights and Responsibilities.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to inform each patient, or when appropriate, the patient's representative of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for five of six Medicare patients records reviewed (MR1, MR2, MR5, MR6, and MR7).

Findings include:

A review on May 15, 2012, of facility document "Important Message from Medicare [IMM]," no date revealed "...1. Registration will obtain the initial notice to the patient and have them sign it. A copy will be sent with the admission paperwork and placed in the admission section of the chart...2. A second notice must be provided to the patient if the patient's length of stay is longer than 2 days....3. Case Management will have the patient sign the second notice (added signature and date on the first notice). This needs to be given within 2 days of discharge or at discharge if not given two days prior (this could be because we didn't know the patient was going home)..."

A review on May 15, 2012, of MR1, MR2, MR5, MR6, and MR7, revealed no documented evidence that the Medicare recipients received the second IMM notice.

An interview conducted on May 15, 2012, at approximately 11:00 AM with EMP3 confirmed that MR1, MR2, MR5, MR6, and MR7, did not contain documentation that the patients received the second IMM notice.