2. Discuss the background of the Nursing Home Reform Act. 6. Identify the Joint Commission standards for patient and family rights (PFR), and patient

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1 Objectives 1. Define patient rights. 2. Discuss the background of the Nursing Home Reform Act. 3. Describe the criteria for the Nursing Home Reform Act. 4. Review patients rights. 5. Define the legal terminology associated with patient s rights. 6. Identify the Joint Commission standards for patient and family rights (PFR), and patient right (PR). 7. Describe the health care responsibilities and patient rights. 8. Understand the ramifications for not adhering to the Nursing Home Reform Act. Purpose The purpose of this 2 continuing education (CE) course is for the reader to understand that patient rights in health care has been at the forefront in the United States health care policy arena for over a decade (McClimans, Dunn, & Slowther, 2011). However, the Institute of Medicine (IOM) supports that patient-centered care is that of; respect, and responsiveness to individual patient preferences, needs and values, which is personalized care that gives patients the opportunity to exercise the degree of control they choose to have over their health care decisions (Committee on Quality of Health Care in America, Institute of Medicine, 2001). When health care policy makers evoke the language of patient-rights regarding his or her care; referring to respect and dignity, and the importance of individual values and needs, they invoke and deploy the language and concepts of ethics, and moral (McClimans, Dunn, & Slowther, 2011). 1

2 Patient Rights Defined In healthcare environment, patient (resident s) rights can be defined as the legal, social, or ethical principles of freedom or entitlement to make choices for themselves in accordance to; some legal system, social convention, or ethical theory (National Consumer Voice for Quality Long-Term Care, 2013). The health care team responsible for patient care encounter difficult choices concerning what is best care for their patients. Circumstances for patient choices can be interweaved in ethical dilemmas involving a series of choices from the patient, family and the health care provider. In essence the choices may not be the in agreement of what is best for the patient. Health care providers should take patient-rights seriously. McClimans, Dunn, & Slowther, (2011) explains that patient rights involves providing respectful, dignified and responsive care that is sensitive to patients values, then we also should be serious about how to fulfil these objectives. Substantiating the moral concepts underpinning the rhetoric relating to patients right can help to justify its status and content, and in turn help us to better evaluate it. Substantiating these concepts requires us to consider the nature of the obligations that we owe to each other. Background of the Nursing Home Reform Act The Nursing Home Reform Act (NHRA) was established to ensure that nursing home residents receive the highest practicable mental, physical, and psychosocial wellbeing. The Nursing Home Reform Act enforces quality care and the provision of certain services to nursing home residents. Additionally, it establishes a Bill of Rights for residents. The Nursing Home Reform Act is in place as a guideline for facilities that wish to receive state funding for Medicare and Medicaid services. Facilities receiving funding are required to meet the criteria set forth 2

3 by the Nursing Home Reform Act. The state is responsible for certifying nursing home facilities that substantially comply with these criteria. Therefore the entire health care team should understand the 1987 Nursing Home Reform Act requirements and reinforce them for excellent patient outcomes in the health care/nursing home settings. Under the federal 1987 Nursing Home Reform Law Reform Law, nursing homes are required to promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination. Nursing homes must meet federal residents' rights requirements if they participate in Medicare or Medicaid. Some states have residents' rights in state law or regulation for nursing homes, licensed assisted living, adult care homes, and other board and care facilities. A person living in a long-term care facility maintains the same rights as an individual in the larger community. Criteria for the Nursing Home Reform Act. Whenever an ethical decision is needed to be made regarding a resident, the entire health care team should be involved. The team should not loose site of the patient rights. Understanding that the collaboration of the team can result in great problem-solving efforts that can resolve the ethical predicament. Residents Rights are guaranteed by the federal 1987 Nursing Home Reform Law, and provides residents with the right to: Privacy Accommodation of physical, mental, and psychosocial needs Communicate freely Be treated with dignity Be free from mistreatment, abuse, and neglect 3

4 Exercise self-determination Voice grievances without facing reprisal or discrimination Be free from physical restraints Participate in family and resident groups Participate in their own care plan, including advance notice of changes in treatment, care, or facility status Patient Rights Because elderly individuals constitute a special group in our society, they are considered vulnerable and present unique health care conditions their right should be respected. Elderly residents/ patients expect to be respected and they do not want to be effected by anytime of medical interventions without consent when they are in need of specialized care. Additional rights that falls under the federal 1987 Nursing Home Reform Law are: The Right to Be Fully Informed of Available services and the charges for each service Facility rules and regulations, including a written copy of resident rights State survey reports and the nursing home s plan of correction Advance plans of a change in rooms or roommates Assistance if a sensory impairment exists Residents have a right to receive information in a language they understand (Spanish, Braille, etc.) Right to Complain Present grievances to staff or any other person, without fear of reprisal and with prompt efforts by the facility to resolve those grievances To file a complaint with the state survey and certification agency 4

5 Right to Participate in One's Own Care Receive adequate and appropriate care Be informed of all changes in medical condition Participate in their own assessment, care-planning, treatment, and discharge Refuse medication and treatment Refuse chemical and physical restraints Review one's medical record Be free from charge for services covered by Medicaid or Medicare Right to Privacy and Confidentiality Private and unrestricted communication with any person of their choice During treatment and care of one's personal needs Regarding medical, personal, or financial affairs Rights During Transfers and Discharges Remain in the nursing facility unless a transfer or discharge: (a) is necessary to meet the resident s welfare; (b) is appropriate because the patient (residents) health has improved and s/he no longer requires nursing home care; (c) is needed to protect the health and safety of other residents or staff; (d) is required because the resident has failed, after reasonable notice, to pay the facility charge for an item or service provided at the patient (residents) request Receive thirty-day notice of transfer or discharge which includes the reason, effective date, location to which the resident is transferred or discharged, the right to appeal, and the name, address, and telephone number of the state long-term care ombudsman Safe transfer or discharge through sufficient preparation by the nursing home Right to Dignity, Respect, and Freedom To be treated with consideration, respect, and dignity To be free from mental and physical abuse, corporal punishment, involuntary seclusion, and physical and chemical restraints 5

6 To self-determination Security of possessions Right to Visits By a resident s personal physician and representatives from the state survey agency and ombudsman programs By relatives, friends, and others of the residents' choosing By organizations or individuals providing health, social, legal, or other services Residents have the right to refuse visitors Right to Make Independent Choices Make personal decisions, such as what to wear and how to spend free time Reasonable accommodation of one's needs and preferences Choose a physician Participate in community activities, both inside and outside the nursing home Organize and participate in a Resident Council Manage one's own financial affairs National Consumer Voice for Quality Long-Term Care (2013). Retrieved from Nursing Home Reform Act (. (OBRA 87) (2013). 20 Years of History. United States Senate Special Committee on Aging. United States Senate. Retrieved from 6

7 Define the Legal Terminology Associated with Patient s Rights Liability - an obligation one has incurred or might incur through any act or failure to act Negligence - (Breach of duty) is the failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance. Failure to provide care Malpractice - Refers to the behavior of a professional person s wrongful conduct, improper discharge of professional duties, or failure to meet the standards of acceptable care, which results in harm to another person. Failure to provide care and injury results Assault - stated intent to touch a person in an offensive, insulting, or physically intimidating manner. Battery - The touching of another person without the person s consent. False imprisonment - occurs when patients are made to believe they cannot leave a place. Includes use of restraints (physical or chemical) and seclusion. Autonomy - The principle of self-determination, freedom to make own choices Invasion of Privacy /Confidentiality - State laws respect the privilege doctrine guaranteeing that no one will reveal confidential information without the patient s permission. Violation of HIPP. Beneficence - The duty of morality and to avoid harm, respectful, compassionate Non-maleficence - The duty not to invoke harm, not treated as a means to an end Right-to-Know Right of the informed consent principle 7

8 Veracity Maintaining ones integrity Defamation - occurs when information is communicated to a third party that causes damage to someone else s reputation, either in writing (libel) or spoken (slander). Fidelity - The making and keeping of promises Fraud - results from a deliberate deception intended to produce unlawful gain. For example; obtaining and using false credentials, falsifying medical records, and illegal billing practices. (Hamblet, 1994; Doğan, & Değer, 2004). Residents/Patient Safety The health care team should remain vigilant and must act as reasonably prudent persons, equivalent with education and experience, when performing nursing duties. When employed as caregivers, it is important to perform only those tasks that they are competent to perform, as stated in a job description. Care givers should severe as an advocate and always respect the cultural values, beliefs, and practices of those in their care. Joint commission Patient and Family Rights (PFR), Patient Right (PR) The Joint commission Joint Commission for the Accreditation of Healthcare Organizations (2013),and the International Accreditation Standards for hospitals (2014) clearly correlates with the federal 1987 Nursing Home Reform Law. The standard includes: Standard PFR.1 The health care organizations are responsible for providing processes that support patients and families rights during care. 8

9 Standard RI.1 Requires that the health care organizations to address ethical issues in providing patient care the standard includes: a. The patient's/residents right to reasonable access to care. b. The patient's/residents right to security and personal privacy and confidentiality of information; c. The issue of designating a decision maker in case the patient is incapable of understanding a proposed treatment or procedure or is unable to communicate his or her wishes regarding care. d. The health care organization method of informing the patient of these issues identified in the intent. e. The hospital's method of educating staff about patient rights and their role in supporting those rights; and include in the training the patient's right to access protective services. Standard PFR.1.1 The health care organizations seeks to reduce physical, language, cultural, and other barriers to access and delivery of services. Standard PFR.1.2 The health care organizations provides care that is respectful of the patient s personal values and beliefs and responds to requests related to spiritual and religious beliefs. Standard PFR.1.3 The patient s rights to privacy and confidentiality of care and information are respected. 9

10 Standard PFR.1.5 Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities. Standard PFR.2 The health care organizations supports patients and families rights to participate in the care process. Standard PFR.3 The hospital informs patients and families about its process to receive and to act on complaints, conflicts, and differences of opinion about patient care and the patient s right to participate in these processes. Standard PFR.4 All patients are informed about their rights and responsibilities in a manner and language they can understand. The above joint commission standards are very important for local and international health care organization accreditation processes. Additional standards that health care organizations should familiarize themselves regarding patients/ residents rights can be found in the April 2014 Joint Commission International Accreditation Standards for Hospitals at Mar2014.pdf. Accreditation Survey Activity Guide for Health Care Organizations at 10

11 Case Study: Mr. B. is a 21 year old patient who was admitted to a long term care facility after being treated in a nearby hospital for multiple gunshot wounds. He was treated and was sent to your long term care facility for rehabilitation. During the term of Mr. B s rehabilitation he refused to be turned every 2 hours, and refused to get out of bed. Each time the caregiver would offer to turn him, he refused. Two weeks had passed and an agency Certified Nurses Aid was assigned to Mr. B. After receiving report, she decided that no matter what Mr. B. said she was going to turn him, massage his bony prominences, and provide the care that was in her scope of practice. Upon turning the patient she noted that he had a grades 2 and 3 ulceration to his coccyx and lateral hip. Although Mr. B had the right to refuse care and the health care team they tried to respect his patient rights, no one documented that he refused the care that they tried to provide. Failure to document that the patient refused care; although he had the right to refuse resulted in grave consequences for the staff and the patient. It is important to remember that the patient is entrusting you with their care and although we have to respect their rights, refusal of care should be discussed on an administrative and interdisciplinary level. The consequences/outcomes of refusal should also be discusses with the patient, physician, and the family then documented in the patients chart. Summary Within the content domain of healthcare ethics, ethical theories are of great significance for almost all healthcare professional (Aveyard, Edwards, and West, 2005). It is imperative to understand solutions for ethical dilemmas in the context of healthcare ethics. The context of healthcare ethics should include educational activities that will set ethical theories into practice 11

12 composed of consequentialism, deontology and utilitarianism, justice, or contract-based approaches, including virtue ethics and the ethics of care (Monteverde, 2014). Health care organizations would benefits from reinforcing an adopting ethical theories designed to meet their organizational needs because, respecting patient rights in health care can be very challenging. Providing respectful, dignified and responsive care can also be ethically challenging. It important to make sure that the patient remain fully informed regarding their care, As long as the patient is in sound mind he or she can make decisions for themselves. The health care team would benefit from an understanding of consequentialism. Consequentialism contends that the rightness or wrongness of an action is based upon the consequences. If the consequences serve some intrinsic good, that is, a good that is good in and of itself independent of any further consequences, then the action is considered ethical (Stahl, 1996). 12

13 References Aveyard, H., Edwards, S., & West, S. (2005). Core topics of health care ethics. The identification of core topics for interprofessional education. Journal of interprofessional Care,9, Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Doğan, H., & Değer, M. (2004). Nursing care of elderly people at home and ethical implications: an experience from Istanbul. Nursing Ethics, 11(6), Hamblet, J.L. (1994). Ethics and the pediatric perioperative nurse. Todays OR Nurse, 16(2), Joint Commission for the Accreditation of Healthcare Organizations. (2013). Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission Resources. Joint Commission International. (2014). International Accreditation Standards for hospitals. Retrieved from Standards-Only-Mar2014.pdf. McClimans, L., Dunn, M., & Slowther, A.M. (2011). Health policy, patient-centered care and clinical ethics. Journal of Evaluation in Clinical Practice 17, Monteverde, S. (2014). Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nursing Ethics, 21(4), National Consumer Voice for Quality Long-Term Care. (2013). Retrieved from 13

14 Nursing Home Reform Act (2013). OBRA 87, 20 Years of History. United States Senate Special Committee on Aging. United States Senate. Retrieved from Stahl, D. (1996). Subacute care: creating alternatives. Ethics in subacute care -- part 1. Nursing Management, 27(9), Stanford Encyclopedia of Philosophy. (2005). Rights. Retrieved from Tuckett, A. G. (2005). Residents' rights and nurses' ethics in the Australian nursing home. International Nursing Review, 52(3), Woods, M. (2005). Nursing ethics education: are we really delivering the good(s)? Nursing Ethics, 12,