Patients' Rights
Patient Safety
Restraints & Seclusion
Complaints & Grievances
Elements of Performance
100
A written instruction under state law relating to the provision of healthcare when the individual is incapacitated.
What is the patient's right to have an advance directive?
100
The use of 4 HUG's tags that are placed on the infant's wrist and ankle, the mother's wrist, and the wrist of one support person; "pink" ID badges for employees who can take the infant; the use of ID badges for all employees
What are the security efforts in place to protect newborn and infant safety?
100
The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.
What is the definition of seclusion?
100
An oral or written complaint or dispute expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested
What is the definition of a grievance?
100
The patient's needs, complexity of patients, any special needs of individualized patients, competence of nursing personnel, qualifications of nursing personnel, education of nursing personnel, and experience of nursing personnel.
What are the considerations necessary when making staff assignments?
200
Shutting doors / curtains during personal hygiene activities, during medical / surgical treatments, and when requested as appropriate
What is the patient's right to personal privacy?
200
Physical, mental, sexual, verbal.
What are the forms of abuse?
200
Any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement.
What is the definition of a restraint?
200
Issues and concerns expressed verbally: resolved PRIOR to the complainant leaving the hospital; received post-hospitalization either in person or on the telephone and can be be dealt with IMMEDIATELY; or unrelated to quality of care or violation of patient rights.
What is the definition of a patient complaint?
200
Medications where greater flexibility in the timing of their administration is permissible; a longer or shorter interval of time since the prior dose does not significantly change the medication’s therapeutic effect or otherwise cause harm
What is the defintion of non-time-critical scheduled medications?
300
Ensuring physical safety through infection control and security and emotional safety through respect, dignity and comfort.
What is the patient's right to receive care in a safe setting?
300
The use of security and infection control measures.
What are the procedures in place to protect patient safety?
300
May be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
What is the time that restraints or seclusion may be used?
300
Written information is in the Patient Guides and given to patients at the outpatient registration and during the inpatient admission. "Patient Rights" posters are displayed prominently at major entrances and all nursing units.
What is the process of informing patients of their right to file a grievance?
300
Category of medications for which an early or late administration of greater than 30 minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect.
What are time-critical scheduled medications?
400
Informing the client of his or her health status, involving the client in care planning and treatment, and allowing the client to request of refuse treatment.
What is the patient's right to make informed decisions about his or her care?
400
Inform the manager or supervisor immediately, so that he or she can take action. Report to Child Protective Services (CPS) or Adult Protective Services (APS) as appropriate.
What are the steps for reporting SUSPECTED abuse or neglect?
400
Providing the option to go to a room or patio for a fresh air break, offering fluids / snacks, one to one counseling, diversion type activities, PRN medication as appropriate.
What are examples of non-physical intervention skills that may be utilized to redirect a patient in order to avoid the use of restraints?
400
May be submitted in-person, via phone (RCRMC Hospital Patient Advocate [HPA], RCRMC Compliance and Privacy Hotline, & California Department of Public Health Services) or written.
What are the options a patient has for submitting a complaint or grievance?
400
Antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents, pain medication, medications prescribed more frequently than 4 hours.
What are examples of time-critical scheduled medications?
500
Communicating rights to each patient and utilizing a certified translator as needed.
What is the patient's right to be informed of their rights?
500
Call Security Law Enforcement Officers immediately, inform the manager or supervisor, and file an incident report.
What are the actions you take if you WITNESS abuse or neglect?
500
To preserve the patient's safety and dignity when restraint or seclusion is used, discontinue restraint or seclusion as early as possible after it has been implemented, provide education to staff about how restraint or seclusion may be perceived by the patient, prohibit the use of restraint or seclusion for the purpose of coercion, discipline, convenience, or retaliation, and prevent, reduce, and strive to eliminate the behavioral restraint and/or seclusion by promoting the use of non-physical interventions.
What is the hospital's behavioral restraint or seclusion policy?
500
Route the completed grievance form to HPA without delay, HPA shall acknowledge the grievance within 2 business days, the HPA shall send a written response to the patient within 7 business days.
What is the hospital's grievance resolution process?
500
The right patient, medication, dose, route, and time.
What are the patient's 5 rights of medication administration?
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