HospitalInspections.org

Based on review of facility policies, review of medical records and interview, the facility failed to inform each patient of the patient's rights, in advance of furnishing patient care whenever possible.

Findings included:

Facility policy titled "Patient Rights Texas" stated in part, "Procedure: Intake Coordinator: Shall provide all patients and family (when applicable) with a written copy of the Patient's Bill of Rights ... Shall orally review the Patient Rights with the patient and family/parent or conservator of a minor (when applicable) and have the patient sign the "Acknowledgment of Rights" form ..."

Review of patient #5's medical record revealed no "Acknowledgment of Rights" form. This was confirmed with the facility Administrator on the afternoon of 11/22/16.

One of ten patient medical records reviewed had no evidence the Patient Rights were reviewed and received by the patient.

Based on review of facility documents and interview, the facility failed to maintain and demonstrate evidence of its QAPI (Quality Assurance and Performance Improvement) program for review.

Findings included:

Request of QAPI meeting minutes were made twice on the morning of 11/22/16. The facility administrator provided a copy of April 2016 meeting minutes and stated, "This is all I have."

In an interview with the Director of Quality on the afternoon of 11/22/16, she stated, "I just took this job over in October. The only meeting minutes I can find is the one on ShareDrive [which was provided by the Administrator]."

The above was confirmed with the facility Administrator in an interview on the afternoon of 11/22/16.