Hutchinson Health

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47264 Based on interview, and document review, the facility failed to provide each patient notification of patient rights in advance of receiving care to three of ten patients (P1, P2, P3) reviewed when patients were provided care through the emergency department (ED). Findings include: Upon chart review on 4/29/25 at 1:37 p.m., it was identified the hospital does not offer information on patient rights to those who receive care in the ED; however, patients who were admitted to the hospital did receive information on patient rights. P1 was a 45-year-old male who presented to the ED on 2/26/25 at 4:13 p.m. via ambulance. P1 medical record did not indicate he was offered information on his bill of rights. P1 was transferred to an outside hospital via ambulance on 2/26/25 at 9:53 p.m. P2 was a 55-year-old female who presented to the ED on 6/28/24 at 9:11 a.m. via ambulance for concerns with erratic blood sugars and a pleuritic cough. P2’s medical record did not indicate she was offered information on her bill of rights. P2 was discharged in a stable condition on 6/28/24 at 10:27 a.m. P2 presented to the emergency room on 6/28/24 at 7:15 p.m. via ambulance for ambulance. P2’s medical record did not indicate she was offered information on her bill of rights. P2 was discharged in a stable condition on 6/28/24 at 8:49 p.m. P3 was a 61-year-old female who presented to the ED on 12/9/21 at 2:18 p.m. for evaluation of behavioral disturbances. P3’s medical record did not indicate she was offered information on her bill of rights. P3 was discharged in a stable condition on 12/9/21 at 7:23 p.m. During an interview at 4/24/25 at 2:27 p.m., the manager of the ED stated patient rights are provided to patients when they are admitted to the hospital for treatment or via the sign at the front entrance when they arrive at the ED. During an interview on 4/24/25 at 1:15 p.m., registered nurse (RN)-A stated patients are given a copy of their patient rights upon admission. During an interview on 4/24/25 at 1:48 p.m., RN-B stated patients are given a laminated copy of their patient rights upon admission by an RN. During an interview on 4/24/25 at 3:00 p.m., RN-C stated patients are told their rights when they are admitted to the hospital. During an interview on 4/29/25 at 4:13 p.m., the nurse manager of the ED stated ED patient rights are not discussed between the ED nursing staff and the patients. The nurse manager of the ED stated patient rights are reviewed with a patient upon inpatient admission. An undated policy titled “Patient Rights and Responsibilities,” indicated a copy of the patient bill of rights is provided to patients upon admission to inpatient or observation care. The policy indicated if the bill of rights is provided, it must be documented in the medical record. Based on interview, and document review, the facility failed to provide each patient notification of patient rights to three of ten patients (P1, P2, P3) reviewed when patients were provided care through the emergency department. Findings include: P1 was a 45-year-old male who presented to the ED on 2/26/25 at 4:13 p.m. via ambulance. P1 medical record did not indicate he was offered information on his bill of rights. P1 was transferred to an outside hospital via ambulance on 2/26/25 at 9:53 p.m. P2 was a 55-year-old female who presented to the ED on 6/28/24 at 9:11 a.m. via ambulance for concerns with erratic blood sugars and a pleuritic cough. P2’s medical record did not indicate she was offered information on her bill of rights. P2 was discharged in a stable condition on 6/28/24 at 10:27 a.m. P2 presented to the emergency room on 6/28/24 at 7:15 p.m. via ambulance for ambulance. P2’s medical record did not indicate she was offered information on her bill of rights. P2 was discharged in a stable condition on 6/28/24 at 8:49 p.m. P3 was a 61-year-old female who presented to the ED on 12/9/21 at 2:18 p.m. for evaluation of behavioral disturbances. P3’s medical record did not indicate she was offered information on her bill of rights. P3 was discharged in a stable condition on 12/9/21 at 7:23 p.m. During an interview at 4/24/25 at 2:27 p.m., the manager of the ED stated patient rights are provided to patients when they are admitted to the hospital for treatment, or via the sign at the front entrance when they arrive at the ED. During an interview on 4/24/25 at 1:15 p.m., registered nurse (RN)-A stated patients are given a copy of their patient rights upon admission. During an interview on 4/24/25 at 1:48 p.m., RN-B stated patients are given a laminated copy of their patient rights upon admission by an RN. During an interview on 4/24/25 at 3:00 p.m., RN-C stated patients are told their rights when they are admitted to the hospital. Upon chart review on 4/29/25 at 1:37 p.m., it was identified the hospital does not offer information on patient rights to those who receive care in the ED. During an interview on 4/29/25 at 4:13 p.m., the nurse manager of the ED stated ED patients are not discussed between the ED nursing staff and the patients. The nurse manager of the ED stated patient rights are reviewed with a patient upon inpatient admission. An undated policy titled “Patient Rights and Responsibilities,” indicated a copy of the patient bill of rights is provided to patients upon admission to inpatient or observation care. The policy indicated if the bill of rights is provided, it must be documented in the medical record.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 43080 Based on observation, interview, and document review, the hospital failed to ensure signage pertaining to the Emergency Medical Treatment and Active Labor Act (EMTALA) was posted in all areas likely to be noticed by patients entering the Emergency Department (ED). This had the potential to affect all patients presenting to the ED seeking care and treatment via the ambulance bay patient entrance. Findings include: On 6/14/24, at 9:43 a.m., a tour of the emergency department (ED) was conducted with the ED nursing director (EDND) and the patient relations representative (PRR). During the tour, EDND identified an entrance where patients who arrived via ambulance entered the facility. The ambulance bay, and the adjacent ambulance bay alcove, lacked EMTALA signage. EDND and PRR acknowledged there was no signage posted in either of these areas. An Emergency Medical Treatment and Labor Act Policy and Procedure, dated 6/11/24, identified its purpose was to outline the requirements for EMTALA compliance. The policy directed EMTALA signage was to be posted in “the Emergency Department as well as other areas where individuals may be waiting for examination and treatment for an emergency medical condition.” The policy lacked direction the facility must post EMTALA signage in areas likely to be noticed by all individuals entering the emergency department.”