It is the policy of Rutherford Regional Health System to admit and to treat all patients without regard to race, color, sex, national origin, disability or age in compliance with the 45 CFR Parts 80, 84 and 91 respectively. The same requirements for admission are applied to all patients whose needs are reasonable for the facility to meet and patients are assigned within this facility without regard to race, color, sex, national origin, disability or age. Each patient must be admitted to the facility as ordered by a licensed physician. It is the policy of the facility not to retain a patient who requires services beyond those for which the facility is licensed or has the functional ability to provide. There is no distinction in the eligibility for, or in the manner of providing any patient service provided by the facility or by others in or outside of the facility. The services of this facility are available without distinction to all patients and visitors regardless of race, color, sex, national origin, disability or age. All persons and organizations having occasion either to refer patients for admission or to recommend to the facility are advised to do so without regard to the patient’s race, color, sex, national origin, disability or age.
Right to Quality Care
The patient shall be accorded the right to quality medical care regardless of race, sex, national origin, diagnosis, disability, political affiliation, sexual preferences, veteran status, religion, age, ability to pay, or source of payment. The hospital’s code of ethical business and professional behavior protects the integrity of clinical decision making regardless of hospital compensation or financial risk. To avoid compromising the quality of care, clinical decisions, including tests, treatments, and other interventions, are based on identified patient health care needs.
The patient has the right to expect that within its capacity, mission statement, and applicable laws and regulations, the hospital will make a reasonable response to their request for services. The hospital shall provide evaluation, service and/or referrals as indicated by the urgency of the patient’s case. The patient has the right to have a family member or representative of his/her choice and his or her own physician notified promptly of his/her admission to the hospital.
Respect and Dignity
The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of personal dignity. The patient has the right not to be awakened by hospital staff unless it is medically necessary, to be free from needless duplication of medical and nursing procedures, and to medical and nursing treatments that avoid unnecessary physical and mental discomfort.
The patient has the right to know the identity and professional status of individuals providing services for them, and to know which physician or other practitioner is primarily responsible for the patient’s care. This includes the patient’s right to know of the existence of any professional relationship among individuals who are treating him, as well as the relationship to any other health care or educational institutions involved in his care. Participation by patients in clinical training programs or in the gathering of data for research purposes should be voluntary. Healthcare provider identity is given to the patient at the point of entry, at the time of admission or as/when requested by the patient or representative.
1. The patient has the right to obtain from his/her physician information concerning his/her diagnosis, treatment and
prognosis to the degree known. Such information should be communicated in terms that the patient can reasonably be
expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to the legal next of kin or to the person the patient has trusted to make decisions for him/her when
unable to make decisions for him/herself.
2. The patient has the right to participate in the development and implementation of his/her plan of care.
3. Each patient has a right of access to inspect and obtain a copy of his/her PHI in a designated record set, for as long as the PHI is maintained in the designated record set, except for:
a. Psychotherapy notes;
b. Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and
c. PHI maintained by the organization that is:
1) Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S. C 263a, to the extent the provision of access to the patient would be prohibited by law; or
2) Exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR 493.3(a)(2)
4. The patient has the right to amend his/her medical record. A patient has the right to have PHI or a record about the patient in a designated record set, amended for as long as the PHI is maintained in the designated record set.
5. The patient has the right to request an accounting of disclosures related to the organization’s uses and disclosures of the patient’s medical record or other PHI, for reasons other than treatment, payment, payment, or health care operations.
The patient has the right to receive from his/her physician information necessary for giving informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include, but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved and the probable duration of incapacitation and probability of success. Where medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information. The patient should not be subjected to any procedure without his/her voluntary, competent, and understanding consent or the consent of his/her legally authorized representative.
Refusal of Treatment
The patient may refuse treatment to the extent permitted by law and has the right to be informed of the medical consequences of this action. When refusal of treatment by the patient or his/her legally authorized representative prevents the provision of appropriate care in accordance with ethical and professional standards, the relationship with him/her, the patient, may be terminated upon reasonable notice.
The patient has the right to receive information concerning advance directives such as a living will and a health care power of attorney. These documents express the patient’s choices for treatment or designate someone to represent the patient in the event he/she is unable to communicate his/her wishes. The advance directive will be respected to the extent permitted by law. The patient may ask his/her nurse, his/her case manager, or call the Patient Representative at 828.286.5505 for more information concerning advance directives.
Privacy and Confidentiality
The patient has the right to personal and informational privacy, within the law, as shown by the right to:
1. Refuse to talk with or see anyone not officially connected with the hospital, including visitors, or persons officially connected with the hospital but not directly involved in his/her care.
2. Have his/her PHI used by or disclosed only to individuals directly involved in his/her treatment, payment for such treatment, or the monitoring of its quality, and by other individuals only on written authorization of the patient or that of his/her legally authorized representative, as legally required.
3. Expect that all communication and other PHI be available only to those directly concerned with his/her care unless the patient gives specific permission for access by another.
4. Be placed in protective privacy when considered necessary for personal safety.
5. To wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment.
6. To be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy. This includes the right to have a person of one’s own sex present during certain parts of a physical examination, treatment, or procedure - performed by a health professional of the opposite sex and the right not to remain disrobed any longer than is required for accomplishing the medical purpose for which the patient was asked to disrobe.
7. To expect that any discussion or consultation involving his/her case will be conducted discreetly and that individuals not directly involved in his/her care will not be present without his/her permission.
8. To expect all communications and other PHI pertaining to his/her care, including the source of payment for treatment, to be treated as confidential.
9. To request transfer to another room if another patient or a visitor in the room is unreasonably disturbing him/her by his/her actions.
10. To request that an alternative means of communication between the organization and the patient be used if disclosure of the communication would in some way harm the patient (confidential communication).
a. The organization will accommodate reasonable requests by patients to receive communications of PHI by alternative means or at alternative locations, if the patient clearly states that the disclosure of all or part of that information could endanger the patient. The request must be in writing.
b. The organization may refuse to accommodate a request if the patient has not provided information as to how payment, if applicable, will be handled, or if an alternative address or method of contact has not been specified.
c. The organization will not require an explanation from the patient as to the basis for the request as a condition of providing communications on a confidential basis.
The patient may not be transferred to another facility unless he/she or the legally authorized representative has received a complete explanation of the need for the transfer, the alternatives, risks and benefits of such a transfer and the patient or their legal representative have consented to the transfer. The transfer must be acceptable to the receiving agency or organization.
Continuity of Care
The patient has the right to be informed by the doctor or his/her designee of any need for care following the patient’s discharge from the hospital.
Ethical Issues/Care at the End of Life
The patient has the right to participate in the consideration of ethical issues that arise in his/her care. The designated representative also has this right. Decisions about care at the end of life will be handled with respect and sensitivity. The hospital shall provide a mechanism to consider ethical issues utilizing an ethics committee. An ethics consult can be obtained by calling the Patient Representative at 828.286.5505.
Cultural and Religious/Spiritual Beliefs
The patient has the right to express spiritual beliefs and cultural practices, as long as they are not detrimental to his/her medical care and do not harm others. Religious, spiritual and cultural beliefs and values will be honored to the best of our ability. The nursing department has a number of resources available (including the Volunteer Chaplains Program) to attend to spiritual and cultural needs.
The patient has the right to appropriate assessment and management of pain when admitted to the hospital and throughout his/her hospitalization. The hospital plans, supports, and coordinates activities and resources to assure that every patient’s pain is recognized and addressed appropriately.
The patient has the right to be free from chemical or physical restraint and seclusion except as authorized by a physician or in an emergency when necessary for medical treatment and/or to protect the patient or others from injury. If restraints are indicated, the least restrictive method will be used in accordance with Hospital policy.
The patient has the right to effective communication including the use of a teletex typewriter or text telephone (TTY), or foreign and sign language interpreters. The TTY can be used as a regular telephone by reading the text on the display. This unit is also used for VCO (Voice Carry Over) which is people who cannot hear but wish to speak for themselves. They use this TTY to read what the person types back to them. Also HCO (Hearing Carry Over) is available for people who can hear but are speech impaired. They listen and type their conversations. If any form of communication is withheld, including visitors, mail or telephone calls, the patient or his/her legal representative will be involved in that decision.
The patient has the right of access to people outside the facility by means of visitors and by verbal and written communication. When the patient does not speak or understand the predominant language of the community, he should have access to an interpreter. Language Line Services are available 24 hours per day via AT&T Language Line. This service is available upon patient request at no cost to the patient. A Teletext Typewriter or Test Telephone (TTY) is also provided for those who are hearing impaired. This device is located in the Emergency Registration area, and can be used at any telephone extension in the hospital if an AC power connection is available.
The patient has the right to be advised if the facility proposes to engage in or perform human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in such research projects without fear of retribution.
The patient has the right to be free from abuse, or harassment and has the right to access protective services.
The patient has the right to expect safety in the Hospital environment and in the procedures performed at the Hospital. We continuously strive to identify and correct any safety issues.
Hospital Rules and Complaints
The patient should be informed of hospital rules and regulations that apply to his/her conduct as a patient and the mechanism for the initiation, review and when possible, resolution of a complaint concerning the quality of care. Patients are entitled to file a complaint about care without fearing retribution. Patients can file a complaint by calling the Hospital Patient Representative at 286-5505 or contacting the North Carolina Division of Health Service Regulation, by phone at 1.800.624.0004 (within NC) or 919.855.4500 or in writing at 2711 Mail Service Center, Raleigh, NC 27699-2711.
According to Accreditation Participation Requirement (APR) standard APR.09.01.01, organizations need to update their notice instructing patients on how to contact The Joint Commission with the following information about reporting safety concerns:
- At www.jointcommission.org, using the "Report a Patient Safety Event" link in the "Action Center" on the home page of the website
- By Fax to 630.792.5636
- By Mail to The Office of Quality and Patient Safety (OQPS), The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181.
Report of patient safety events to The Joint Commission must include the health care organization's name, street address, city and state.
You have the right to file a complaint of discrimination on the basis of disability with the U.S. Dept. of Health and Human Services, Office for Civil Rights in writing at US DHHS, Sam Nunn Atlanta Center, Suite16T70, 61 Forsyth St. SW, Atlanta, GA 30303-8909 or by phone at 1-800-368-1019 or TDD at 1-800-537-7697.
Hospital Charges/Billing Explanation
Regardless of the source of payment for his/her care, the patient has the right to request and receive an itemized and detailed explanation of his total bill for services rendered in the hospital. The patient has the right to timely notice prior to termination of this eligibility for reimbursement by any third party payer for the cost of his care.
The patient has the right to receive visitors designated by the patient, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. Also included is the right to withdraw or deny such consent at any time.
Health Care Decision Making
The patient has the responsibility to participate in his/her own health care decisions and to be as accurate and complete as possible when providing their medical history and treatment information to the physicians and clinical staff.
The patient or his/her designated representative has the responsibility to assure that a current copy of the patient’s
Advance Health Care Directive is provided to the Hospital if the patient should have one.
The patient has the responsibility to follow his/her physician’s advice regarding health care requirements. The Patient has the responsibility to ask questions of his/her physician or nurse if he/she has questions or concerns regarding treatment, medical information, medical words or instructions. The patient is responsible for notifying his/her physician or other health care provider if he/she feels the designated treatment plan cannot be followed.
Rules and Regulations
The patient, his/her family and friends have the responsibility to follow the hospital’s rules and regulations which include limiting visitors, controlling noise, following smoking regulations and refraining from using the telephone, television or lights in a way that will disturb others. The carrying of weapons is prohibited on hospital property. The use of alcohol or drugs not prescribed by a physician is not permitted.
The patient, his/her family and friends have the responsibility to behave considerately and appropriately with hospital personnel. If a patient is intentionally disruptive, verbally or physically, the patient may be referred elsewhere for non-urgent care, once his/her treatment is completed.
The patient is responsible for keeping follow-up appointments and for participating actively in his/her continued care after leaving the hospital. The patient should know when and where to get further treatment and should ask questions about this matter.
The patient has the responsibility to cooperate with the Hospital by providing complete, timely insurance information and making payment arrangements on any balances.
The patient has the responsibility to advise his/her nurse, physician, and/or the patient representative of any dissatisfaction he/she may have regarding his/her care.
RIGHTS AND RESPONSIBILITIES OF PARENTS AND GUARDIANS OF PEDIATRIC PATIENTS
Neonates, children, and adolescents are entitled to the same patient rights as other patients. It is the responsibility of the involved Rutherford Regional Medical Center staff to ensure that the family or responsible adult is involved in treatment and care decisions outside the authority of a minor.
Course of Treatment
Parents and guardians have the right and responsibility to participate in the treatment process. The treatment process includes planning the course of treatment, remaining informed of the progress of treatment, and physically participating in the delivery of certain types of care and treatment. Parents and guardians have the responsibility to ensure that their child follows the agreed upon course of treatment.
Each minor patient has the right to attend school, take part in recreational and outdoor activities, and receive help in letter-writing and making telephone calls, except when restricted for therapeutic reasons.