Developed / Edited By: UNION HOSPITAL Reviewed By: Approved By: Policy Number: AG-245 Elkton, Maryland Effective Date: 11/2009 Hospital Policies and Procedures Patient Rights and Responsibilities Departments Affected: Hospital Wide Elizabeth Money Director of Oncology and Palliative Date: 11/2014 Bioethics Committee Vice President, Medical Affairs Katie Boston Leary Senior Vice President Patient Care Services/ CNO Reviewed Dates: 10/1996, 02/1997, 06/1999, 01/2003, 03/2006,11/2014 Revised Dates: 0819/99, 10/2003, 03/2006, 11/2009,11/2014 Date: 11/2014 Date: 11/2014 Established Date: January, 1993 POLICY It is the policy of Union Hospital to support and inform each patient of his/her rights and responsibilities. These rights are extended to each patient regardless of the patient's age, sex, race, creed, national origin, ethnic group, religion, economic, or cultural background or source of payment. Patients are informed of their rights, as appropriate - inpatients, pediatrics, adult day care, and psychiatric rights. Union Hospital understands that communication and information are important areas of rights and respect for patients. It is the policy of Union Hospital to provide patients with unrestricted access to all forms of communication. Sometimes, however, it may be necessary to restrict visitors, mail, telephone calls, or other forms of communication as a component of a patient s care (for example, to prevent injury or deterioration in the patient, damage to the environment or infringement on the rights of others). PURPOSE To ensure patients, their families, or their designee, are aware of their rights and responsibilities. Statement of Inpatient/Outpatient Rights Our mission at Union Hospital is to meet the health and wellness needs of our community in collaboration with other providers and to ensure that services reflect high quality, compassion, and value. Care, treatment, and services will be provided in a respectful manner that fosters patient dignity, autonomy, maintaining patient rights. This commitment is evidenced through the care we provide in accordance with the following patient rights. Patient has a right to: 1. Medical care and services without discrimination based upon race, color, religion, sex, sexual preference, national origin, source of payment, or disability.
Patient Rights and Responsibilities (Continued) Page 2 of 9 2. Care that is considerate and respectful of his or her personal values and beliefs and the right to express those values and beliefs which do not harm others or interfere with medical therapy. 3. Know the name and professional status of the physician who has primary responsibility for his or her care, as well as other physicians and nonphysicians involved in providing care. 4. Be informed about his or her responsibilities related to his or her care, treatment, and services. 5. Receive information in a manner tailored to the patient's age, language, and ability to understand. 6. Be provided interpreting and translation services, as necessary. 7. Receive communication with the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient's needs. 8. Participate in making decisions about his or her care, treatment, and services, including the right to have his or her own physician promptly notified of his or her admission to the hospital. 9. Refuse care, treatment, and services including leaving against medical advice and be respected of this decision. 10. Give or withhold informed consent. 11. Give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care. 12. Be informed of the risks, benefits, alternatives, and procedures to be followed if experimental treatment or research is being proposed; the patient has the right to refuse to participate in such treatment or research without limiting his or her access to care and services. 13. Receive respect for his or her rights during research, investigation, and clinical trials. 14. Receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services. 15. Address patient decisions about care, treatment, and services received at the end of life. 16. Formulate advance directives and to have the hospital staff comply with these directives.
Patient Rights and Responsibilities (Continued) Page 3 of 9 17. Be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse. 18. Be in an environment that preserves dignity and contributes to a positive self-image. 19. File a complaint and to expect prompt referral to appropriate hospital administrative personal for resolution. The patient also has the right to file a complaint with state and federal advocacy and licensing groups, as well as accreditation agencies. 20. Access protective and advocacy services. 21. Be free from restraints and seclusion of any kind that is used as a means of coercion, discipline, convenience, or retaliation by staff. 22. Be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse. 23. Confidentiality of his or her care and clinical records and the right to access information contained in his or her records within a reasonable time frame. *All records are confidential except as otherwise provided by law or third-party contractual arrangements. 24. Be informed of unexpected as well as expected outcomes resulting from care provided. 25. Have his/her pain managed effectively through ongoing assessment and timely responsive interventions. Patients can expect to receive information about pain relief measures, as appropriate, and to be involved in decisions related to their pain management. 26. Receive quality care and clinical decisions regarding care based on health care needs, not financial incentives. 27. Obtain consultation with another physician at the patient s request and expense. 28. Obtain knowledge of any professional and/or business relationships that may exist between individuals, other organizations or health care services, or educational institutions involved in his/her care. 29. Receive referrals based on patient choice, after receiving information, including disclosure of any relationships that may exist. 30. Admission and continued hospitalization that is based on clinical need, medical necessity, and a collaborative plan with physician and not based on insurance company recommendations or decisions that may inappropriately restrict or limit care. 31. When a transfer to another hospital is necessary, the patient has the right to receive information and an explanation concerning the reason, risks, and alternatives.
Patient Rights and Responsibilities (Continued) Page 4 of 9 32. The patient s presence in the hospital and condition may be released to those requesting the information, unless the patient has stipulated otherwise or unless you are admitted for treatment of Psychiatric illnesses. In cases that are reportable to public authorities, the patient s identity, the nature of the illness or injury and the patient s condition may be released without the patient s consent. 33. The right to expect a response to any reasonable requests within the hospital's capabilities, this may include requests for room changes. 34. The right to request and receive a detailed explanation of the hospital bill and to receive information and counseling on the availability of known financial resources for health care. 35. Dying is a natural part of life. Patients have the right to be made as comfortable as possible, and treated with dignity. All of the patient s symptoms and discomforts should be treated aggressively and effectively, including the management of pain. All of the patient s psychological, social, emotional, spiritual, and cultural needs and concerns should be addressed. Statement of Patient Responsibilities The care patients receive depends partially on the patient. Therefore, in addition to these rights, patients have certain responsibilities. These responsibilities are presented to patients in the spirit of mutual trust and respect. These responsibilities include, but are not limited to: 1. Providing accurate and complete information concerning the patient s present complaint, past medical history, and other matters pertaining to the patient s health. 2. Reporting any changes in the condition. 3. Asking questions if directions and/or procedures are not understood. 4. Actively participating in the management of pain, including asking questions regarding what to expect for pain and pain management, options available, asking for pain medication when pain first begins, and reporting when pain has not been relieved. 5. Following the treatment plan prescribed by the physician, including the instructions of nurses and other health care providers as the physician's orders are carried out. 6. Keeping appointments and notifying the hospital and the physician when unable to do so. 7. The patient is responsible for his/her own actions if the patient chooses to refuse treatment or to not follow the physician's orders. 8. Assuring that the patient s financial obligations for the care provided are fulfilled as promptly as possible.
Patient Rights and Responsibilities (Continued) Page 5 of 9 9. Following hospital policies and procedures. 10. Being considerate of the rights of other patients and hospital personnel. 11. Being respectful of the patient s own personal property and that of others in the hospital. Pediatric Rights and Responsibilities In addition to the rights of adult patients, children and their parents/guardians shall have the following rights: 1. Respect for each child and adolescent as a unique individual and respect for the caretaking role and individual response of the parent 2. Provision for normal physical and physiological needs of a growing child to include: nutrition, rest, sleep, warmth, activity, and freedom to move and explore. 3. Consistent, supportive, and nurturing care which meets the emotional and psychosocial needs of the child fosters open communication and relationships. 4. Provision for self-esteem needs which will be met by attempts to give the child: a. the reassuring presence of a caring person, especially a parent b. freedom to express feelings or fears with appropriate reactions c. as much control as possible, over both self and situation d. opportunities to work through experience before and after they occur, verbally, in play or in other appropriate ways e. recognition and reward for coping well during difficult situations 5. Provision for varied and normal stimuli of life which contributes to cognitive, social, emotional, and physical developmental needs, such as play, educational and social activities essential to all children and adolescents. Family Responsibility Parents/family shall have the responsibility for continuing their parenting role to the extent of their ability, being available to participate in decision-making and providing staff with knowledge of parents/family whereabouts. Psychiatric Patient Rights An individual admitted on a mental health unit has their own unique set of rights. Those rights are presented to each patient on admission to our Psychiatric Unit as per Maryland Title 10 - Subtitle 7A Rights of Mentally Ill Individuals in Facilities@ Each patient has the following rights: 1. Receive appropriate humane treatment and services that restrict the individuals liberty only to the extent necessary and consistent with the individual s treatment needs and applicable legal requirements. 2. Be free from restraints and seclusion except:
Patient Rights and Responsibilities (Continued) Page 6 of 9 - In an emergency where the individual presents a danger to the life and safety of an individual or of others; or - To prevent serious disruption of the therapeutic environment. 3. Be free from mental abuse and be protected from harm and physical and sexual abuse. 4. Subject to the applicable provisions of law, have access to the individual s medical records and have medical records kept confidential. 5. Have access to the resident grievance procedure that has been established at the facility. 6. Have reasonable access to writing materials and postage, and to have mail sent out promptly and, except at the direction of the addressee, without being opened, unless limited for medical reasons. 7. Have reasonable access to a telephone to call anyone who has not given written notice of being unwilling to be called, unless limited for medical reasons. 8. At all reasonable hours patients may visit and have private conversations with a lawyer or clergy of choice. 9. Unless limited for medical reasons Union Hospital allows a family member, friend or other individual to be present with the patient for emotional support during the course of a stay. Union Hospital allows for the presence of a support individual of the patient s choice, unless the individual s presence infringes on others rights or safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient s surrogate decision-maker or legally authorized representative. Union Hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual preference 10. Patient has the right to receive, hold, and dispose of personal property, however, access to personal property may be restricted for medical and/or security reasons. 11. Receive treatment in accordance with an individualized treatment plan; participate in the development and periodic updating of the treatment plane, and be told, in appropriate terms and language of : - The content and objectives of the plan, - The nature and significant possible adverse effects of recommended treatments - The name, title, and role of the persons responsible for carrying out the treatment, and - When appropriate, alternative treatments or mental health services that are available. 12. Refuse to participate as a subject in physically intrusive research conducted at the facility. 13. The right to refuse medication used for the treatment of a mental disorder except when: - The medication is ordered by a physician in an emergency where the individual
presents a danger to the life or safety of the individual or of others, or - The individual is hospitalized involuntarily or by order of a court, and medication is approved by a clinical review panel.
Patient Rights and Responsibilities (Continued) Page 7 of 9 14. An aftercare plan in accordance with Health-General Article 10-809, before being discharged. If a minor in a residential state facility, be placed in a unit for minors, unless the individual treatment plan provides otherwise. Involuntary Psychiatric Admissions An individual who has entered a facility on the basis of certificates for involuntary admission has the right to: 1. An administrative hearing to be held within 10 days of initial confinement to determine if the individual will be involuntarily admitted or released; the hearing may be postponed for good cause for no more than 7 days, and the postponement shall be on the record. 2. Apply to a court of competent jurisdiction for a writ of habeas corpus to determine the cause and legality of detention 3. Petition the court for a judicial release from the facility so that a judge or jury can determine if the individual has a mental disorder necessitating inpatient care or treatment for the protection of the individual or others. All Psychiatric Admissions All psychiatric patients have the right to consult with an attorney of choice. If the individual is unable to afford an attorney, the Office of the Public Defender shall provide legal representation at the commitment hearing. If the individual does not have an attorney, the individual may contact the Legal Aid Bureau, Lawyer Referral Services, Maryland Disability Law Center or other agencies that exist for the referral of individuals who need legal counsel. Each individual shall be given the opportunity to call or write a lawyer or a referral agency or to have someone do so on behalf of the individual. Adult Day Care Participants An individual participating in our Adult Day Care Program has the following unique rights: 1. The right to be treated as an adult, with consideration, respect, and dignity, including privacy in treatment and in care for personal needs. 2. The right to participate in a program of services and activities designed to encourage independence, learning, growth, and awareness of constructive ways to develop one s interests and talents. 3. The right to self-determination within the day care setting, including the opportunity to: a. Participate in developing one s plan for services and any changes therein b. Decide whether or not to participate in any given activity c. Be involved to the extent possible in program planning and operation d. Refuse treatment and be informed of the consequences of such refusal
Patient Rights and Responsibilities (Continued) Page 8 of 9 e. End participation in the Adult Day Care Center at any time 4. The right to be cared about in an atmosphere of sincere interest and concern in which needed support and services are provided. 5. The right to a safe, secure, and clean environment. 6. The right to confidentiality and the requirement for written consent for release of information to persons not authorized under law to receive it. 7. The right to voice grievances without discrimination or reprisal with respect to care or treatment that is (or is not) provided. 8. The right to be fully informed, as evidenced by the participant s written acknowledgment of these rights, of all rules and regulations regarding participant conduct and responsibilities. 9. The right to be free from harm, including unnecessary physical or chemical restraint, isolation, excessive medication, abuse, or neglect. 10. The right to be fully informed, at the time of acceptance into the program, of services and activities available and related charges. 11. The right to communicate with others and be understood by them to the extent of the participant s capability. PROCEDURE 1. Notification: A copy of the rights and responsibilities is provided to each patient, or the patient's surrogate, at the time of admission or upon request in outpatient settings, along with information about advance directives. 2. Patient Access to Communication: a. Any restrictions on communication are fully explained to the patient and family and are determined with their participation. b. Communication restrictions are explained in a language the patient understands. c. For an unemancipated minor or patient under guardianship, applicable law determines who is legally able to act in the patient s best interest. d. Clinical justification of restrictions must be documented in the medical record. e. The continued need for restriction shall be reassessed every 24 hours and documented in the medical record 3. Outpatients: Outpatient are informed of their Patient Rights through posted materials in all outpatient waiting/registration areas, both on-site and off-site. All posting will contain a listing of Local and State Advocacy and Protective Service Agencies, including:
Patient Rights and Responsibilities (Continued) Page 9 of 9 Equal Access Compliance Unit Delmarva Foundation Discrimination Complaints Medicare/Medicaid Program 1-410-767-6592 1-800-492-5811 Dept of Health & Mental Hygiene State Patient Advocacy Office Licensing & Certification 1-877-261-8807 1-410-402-8000 1-410-528-1840 State Health Insurance Assistance Program Medicare Fraud Control Unit Medicare Right & Complaints - Dept of Aging 1-410-576-6521 1-800-243-3425 1-410-767-1100 Domestic Violence Hotline TDD 1-410-767-1083 1-410-996-0444 Department of Social Services Adult Protective Services 1-410-996-0100 Child Protective Services 1-410-996-0500 REFERENCES: Joint Commission CAMH 2010 State of Maryland Law Federal Regulations, Federal Register - Patient Rights for Medicare COP