36C26219R0026-015.pdf

DEPARTMENT OF VETERANS AFFAIRS HEALTHCARE SYSTEM Long Beach, California

HEALTHCARE SYSTEM POLICY No. 003-04

ISSUE DATE: October 5, 2012

PATIENTS’ RIGHTS, RESPONSIBILITIES AND CONDUCT

1. MAJOR POLICY CHANGES: Incorporates patient’s rights related to visitation and federal regulations that prohibit the practice of banning disruptive, threatening, and violent patients from VHA facilities.

2. PURPOSE:

a. To define policies and procedures for ensuring patient’s rights.

b. To define patient’s responsibilities and conduct.

3. POLICY: All patients treated at any facility within the VA Long Beach Healthcare System (VALBHS) will receive considerate, respectful care at all times and under all circumstances, with recognition of personal dignity, in a humane environment that affords appropriate privacy, and reasonable protection from harm. Patients have reasonable access to care and have a right to receive, to the extent provided for by their eligibility, prompt and appropriate treatment for any physical or mental disability within the least restrictive conditions necessary to achieve treatment purposes. When planning the provision of health care service, clinical staff will recognize and take into consideration the patient’s psychosocial, spiritual, and cultural values that impact the patient’s responses to the care provided.

It is prohibited to ban disruptive, threatening and violent Veteran patients from receiving care at the

VALBHS.

The medical center respects the patient’s rights to make decisions about his or her care, treatment and services, and to involve the patient’s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker. The medical center allows a family member, friend or other individual to be present with the patient for emotional support during the course of stay. The medical center 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. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

4. DEFINITIONS:

a. Family: ‘Family’ is defined as a group of two or more persons united by blood or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as significant other, friend or caregiver) whom the individual considers to be a family. A family member may be the surrogate decision-maker, as defined in VHA Handbook 1004.02, if authorized to make care decisions for the individual, should he or she lose decision-making capacity or choose to delegate decision making to another.

5. PROCEDURES:

a. Patients’ Rights

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(1) All patients have the right to be free from neglect, exploitation, and verbal, mental, physical, or sexual abuse.

(2) At the time of admission for inpatient purposes or during enrollment, the registration specialist will inform the patient or other responsible party that the admission packet or enrollment packet contains the “Patient and Nursing Home Resident Rights and Responsibilities,” “Health Care Benefits Overview,” “Family Member Rights & Responsibilities (IB 10-235),” and “VALBHS Honors Your Life and Your Health Care Choices.”

(3) Special Care Units: Psychiatric Inpatients: Patients admitted to Psychiatry inpatient units will additionally receive a copy of “Rights for Individuals in Mental Health Facilities” as admitted under the Lanterman Petris Short Act by the California Department of Mental Health. The patients sign for receipt of this booklet.

(4) Long Term Care Patients: Long term care patients, or a responsible party such as the next-of-kin or a conservator, will be given a copy of the information booklet (VA Form 10-7991a) as a part of the “Orientation Handbook for Nursing Home Care Unit.” The patient or responsible person will be asked by nursing personnel to acknowledge receipt of the information booklet by signing.

(5) SCI/D Patients: SCI/D patients, or a responsible party such as the next-of-kin or a conservator, will be given a copy of the SCI patient handbook which has a listing of patient’s rights. The patient or responsible person will be asked by nursing personnel to acknowledge receipt of the information booklet by signing.

(6) Other Areas: Outpatients: A copy of “Patient and Nursing Home Resident Rights and Responsibilities” will be posted in key outpatient waiting areas.

b. Limits on Patient’s Rights

(1) When it is recommended that a limitation be placed on an individual patient’s rights of movement, the Disruptive Behavior Committee is to be involved with the recommendation and the Chief of Staff is required to concur with the limitation. The reason used to limit the movement of a patient must be related to a specific behavior, threat, or violation.

(2) If the limitation requires that a patient have police accompany them while they are obtaining their health care, the provider will need to obtain written consent from the patient on the Release of Information form number 10-5345a which can also be found in IMED under Administrative Consents. If the patient is denying consent and requires treatment at that time, if their rights to privacy are violated by the presence of the police escort, then the provider will notify the Privacy Officer as soon as possible and on the same day.

(3) The patient will be notified of any limitations that are part of the condition of care at the VALBHS and will receive a letter from the Director’s office specifically outlining the limitations and the reasons for the limitations.

c. Patient Conduct

(1) A patient who has received an irregular discharge may be readmitted when the patient has satisfied the admitting authority that he/she will conform to expected standards of behavior.

(2) A capacitated patient has the right to refuse or deny any form of treatment. Any refusals of care will not jeopardize the patient’s right to obtain health care at the VALBHS.

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(3) The Disruptive Behavior Committee has the responsibility for reviewing patient conduct and making recommendations for any limitations of a patient while on the grounds of the

VALBHS.

(4) All recommendations for discharges resulting from unacceptable behavior will be referred to the Disruptive Behavior Committee, the Chief of Staff, and the Director. The committee will submit a recommendation for the Director and Chief of Staff’s review and they must concur on any limitations and/or recommendations prior to a patient’s early discharge. An early discharge will require a written plan for follow-up care to be given to the patient prior to discharge.

6. RESPONSIBILITIES:

a. Every Healthcare System employee and volunteer is responsible for knowing and respecting the rights of patients and ensuring that patients are free of any type of abuse, exploitation, and neglect.

b. Human Resources Management (HRM) will provide all new employees information about patient’s rights as part of New Employee Orientation. The information will include, but will not be limited to, a copy of “Information Booklet on Patient and Nursing Home Resident Rights and Responsibilities” (VA Form IB-10-88) and “Code of Patient Concern” (VA Form 10-7991).

c. The Veterans and Family Assistance Service will be the primary point of distribution of information about patient’s rights at the time of patient admission unless patients are being admitted from other areas.

d. Nursing personnel are responsible for advising patients of appropriate rules of conduct to include those applicable to a particular ward as soon as the patient’s condition permits.

e. The physician or a team composed of the charge nurse, social worker and patient’s physician, is delegated authority for minor infractions to impose restrictions such as refusal to authorize absences, revocation or restriction of privileges, and denial of attendance at recreational activities. Corrective measures must take into consideration the patient’s physical abilities and mental capacity.

f. If there are patient’s rights issues/concerns that have been addressed at the Health Care Group level but are not resolved, the patient/family will be referred to the Patient Advocate Office.

g. The Ethics Consult Team will act in an advisory capacity to the Chief of Staff, Medical Executive Council, the Director, staff members, patients, surrogates, or patient’s family members on ethical issues.

7. REFERENCES:

a. DUSHOM Memo, Visitation Policy Outreach, February 8, 2012

b. 38 U.S.C. 501, § 17.106, VA Response to Disruptive Behavior of Patients

c. Joint Commission on Accreditation of Healthcare Organizations, Rights and Responsibilities of the Individual Chapter, RI.01.06.03

d. DUSHOM Memo, New Federal Regulations Prohibit the Practice of Banning Disruptive, Threatening, and Violent Patients from Veterans Health Administration (VHA) Care, February 28,

e. VA Form 10-88 Patient and Nursing Home Resident’s Rights and Responsibilities

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8. RESCISSION: HSP 06-02, Patients’ Rights, Responsibilities and Conduct, dated April 7, 2010.

9. REVIEW AND FOLLOW UP RESPONSIBILITY: This policy will be reviewed annually by the Policy Coordinator and the Organizational Excellence Board. This policy will be recertified and reissued on or before October 5, 2017.

10. POLICY COORDINATOR: The Patient Centered Care Coordinator is responsible for the contents of this document.

Isabel Duff, MS Healthcare System Director

Attachment

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Attachment A

PATIENT AND NURSING HOME RESIDENT RIGHTS AND RESPONSIBILITIES

The Veterans Health Administration (VHA) is pleased you have selected us to provide your healthcare.

We want to improve your health and well-being. We will make your visit or stay as pleasant for you as possible. As part of our service to you, to other Veterans and to the Nation, we are committed to improving healthcare quality. We also train future healthcare professionals, conduct research, and support our country in times of national emergency. In all these activities, our employees will respect and support your rights as a patient. Your basic rights and responsibilities are outlined in this document.

Please talk with VA treatment team members or a patient advocate if you have any questions or would like more information about your rights.

I. Respect and Nondiscrimination

You will be treated with dignity, compassion, and respect as an individual. Your privacy will be protected. You will receive care in a safe environment. We will seek to honor your personal and religious values.

You or someone you choose has the right to keep and spend your money. You have the right to receive an accounting of any VA held funds.

Treatment will respect your personal freedoms. In rare cases, the use of medication and physical restraints may be used if all other efforts to keep you or others free from harm have not worked.

As an inpatient or nursing home resident, you may wear your own clothes. You may keep personal items. This will depend on your medical condition.

As an inpatient or nursing home resident, you have the right to social interaction and regular exercise. You will have the opportunity for religious worship and spiritual support. You may decide whether to participate in these activities. You may decide whether or not to perform tasks in or for the medical center.

As an inpatient or nursing home resident, you have the right to communicate freely and privately.

You may have or refuse visitors. You will have access to public telephones. You may participate in civic rights, such as voting and free speech.

As a nursing home resident, you can organize and take part in resident groups in the facility. Your family also can meet with the families of other residents.

In order to provide a safe treatment environment for all patients or residents and staff, you are expected to respect other patients, residents and staff and to follow the facility's rules. Avoid unsafe acts that place others at risk for accidents or injuries. Please immediately report any condition you believe to be unsafe.

II. Information Disclosure and Confidentiality

You will be given information about the health benefits you can receive. The information will be provided in a way you can understand.

You will receive information about the costs of your care, if any, before you are treated. You are responsible for paying your portion of any costs associated with your care.

Your medical record will be kept confidential. Information about you will not be released without your consent unless authorized by law (an example of this is State public health reporting). You have the right to information in your medical record and may request a copy of your medical records. This will be provided except in rare situations when your VA physician feels the information will be harmful to you. In that case, you have the right to have this discussed with you by your VA provider.

You will be informed of all outcomes of care, including any potential injuries. You will be informed about how to request compensation for any injuries.

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III. Participation in Treatment Decisions

You, and any persons you choose, will be involved in all decisions about your care. You will be given information you can understand about the benefits and risks of treatment. You will be given other options. You can agree to or refuse treatment. You will be told what is likely to happen to you if you refuse treatment. Refusing treatment will not affect your rights to future care but you take responsibility for the possible results to your health.

Tell your provider about your current condition, medicines (including over-the counter and herbals), and medical history. Also, share any other information that affects your health. You should ask questions when you do not understand something about your care. Being involved is very important for you to get the best possible results.

You will be given, in writing, the name and title of the provider in charge of your care. As our partner in healthcare, you have the right to be involved in choosing your provider. You also have the right to know the names and titles of those who provide you care. This includes students, residents and trainees. Providers will properly introduce themselves when they take part in your care.

You will be educated about your role and responsibilities as a patient or resident. This includes your participation in decision-making and care at the end of life.

If you believe you cannot follow the treatment plan, you have a responsibility to notify your provider or treatment team.

You have the right to have your pain assessed and to receive treatment to manage your pain.

You and your treatment team will develop a pain management plan together. You are expected to help the treatment team by telling them if you have pain and if the treatment is working.

As an inpatient or nursing home resident you will be provided any transportation necessary for your treatment plan.

You have the right to choose whether you will participate in any research project. Any research will be clearly identified. Potential risks of the research will be identified and there will be no pressure on you to participate.

You will be included in resolving any ethical issues about your care. You may consult with the Medical Center's Ethics Consultation Service and/or other staff knowledgeable about healthcare ethics.

If you or the medical center believes that you have been neglected, abused or exploited, you will receive help.

IV. Complaints

You are encouraged and expected to seek help from your treatment team or a patient advocate if you have problems or complaints. You will be given understandable information about the complaint process. You may complain verbally or in writing, without fear of retaliation.