HospitalInspections.org

Based upon record review and interview, the facility failed to implement the Patient Rights policy and ensure patients are informed of all patient rights at time of admission including the process for addressing patient complaints concerning the quality of care.

Review of a patient admission packet revealed on admission, the patient is given a tri-fold brochure titled "Your Rights as a Patient". Review of this brochure revealed sections titled "Informed Consent", "Directives to Physicians", "Durable Power of Attorney for Health Care", "Legal Aspects of Advance Directives". The brochure did not contain any other patient rights. Further review of the admission packet revealed a form titled "Universal Consent for Treatment". The consent contained a paragraph with a title of "PATIENT RIGHTS" that contained the following statement: "I have received a copy of the Advance Directive Information. Upon request I will be provided telephone #s to file a complaint."

Review of the facility's administrative policy #1102 titled "Patient Rights and Responsibilities" revealed a more thorough listing of patient rights but did not include the complaint process and restraints/seclusion.

Further review of the facility's administrative policy #1112 titled "Notification to the Patient on Admission-Patient Complaint Process" revealed information about advance directives and completing a Patient Satisfaction Survey, and contacting a Discharge Planner if any needs regarding discharge planning and follow-up care. The policy contained one statement regarding complaints and concerns as follow: "Notify a nursing supervisor of any concerns or complaints regarding your care or services during your hospital stay. We will make every attempt to handle your concerns promptly."

An interview was conducted with Staff #9 in the registration office on 2/2/10 at 10:00 am. Staff #9 confirmed that the tri-fold brochure titled "Your Rights as a Patient" and the Advance Directives booklet were what was given to patients on admission.

Based upon record review and interview, the facility failed to implement the Patient Rights policy and ensure patients are informed of all patient rights at time of admission including the process for addressing patient complaints concerning the quality of care.

Review of a patient admission packet revealed on admission, the patient is given a tri-fold brochure titled "Your Rights as a Patient". Review of this brochure revealed sections titled "Informed Consent", "Directives to Physicians", "Durable Power of Attorney for Health Care", "Legal Aspects of Advance Directives". The brochure did not contain any other patient rights. Further review of the admission packet revealed a form titled "Universal Consent for Treatment". The consent contained a paragraph with a title of "PATIENT RIGHTS" that contained the following statement: "I have received a copy of the Advance Directive Information. Upon request I will be provided telephone #s to file a complaint."

Review of the facility's administrative policy #1102 titled "Patient Rights and Responsibilities" revealed a more thorough listing of patient rights but did not include the complaint process and restraints/seclusion.

Further review of the facility's administrative policy #1112 titled "Notification to the Patient on Admission-Patient Complaint Process" revealed information about advance directives and completing a Patient Satisfaction Survey, and contacting a Discharge Planner if any needs regarding discharge planning and follow-up care. The policy contained one statement regarding complaints and concerns as follow: "Notify a nursing supervisor of any concerns or complaints regarding your care or services during your hospital stay. We will make every attempt to handle your concerns promptly."

An interview was conducted with Staff #9 in the registration office on 2/2/10 at 10:00 am. Staff #9 confirmed that the tri-fold brochure titled "Your Rights as a Patient" and the Advance Directives booklet were what was given to patients on admission.

In order to provide patient safety, drugs and biologicals shall be controlled and distributed in accordance with applicable standards of practice, consistent with federal and state laws. Outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for patient use.

Based upon observation and interview with staff, the facility failed to provide drugs packaged in multi dose bottles in the emergency department with labels consistent federal and state laws.

During a walk through of the emergency department on 02/02/10 at 10:00 AM, a brown bottle, half full of white liquid, was discovered in a small closed drawer with a white label on the bottle reading " Maalox/Donnotal " . Two (2) tubes of 2% lidocain were observed to have been opened and no date was found on the tubes, finally a brown bottle half full labeled mineral oil had no date. An interview with the Emergency Department supervisor confirmed they do not date multi use containers when they open them. Review of the facilities policy and procedures indicate that a 28 day date of expiration is expected for all opened multi dose bottles.