Quality & Patient Safety
Patient Rights and Responsibilities
Do you know your rights as a patient?
As a patient in a Texas hospital, you have the right to make decisions concerning your medical care. We hope these rights will provide better patient care and greater satisfaction for you, your physician, and Wise Regional Health System.
These rights can be exercised on the patient’s behalf by a designated surrogate or proxy decision maker if the patient lacks decision-making capabilities, is legally incompetent, or is an unemancipated minor.
Patient Rights
Wise Regional Health System is committed to protecting and promoting each patient’s basic rights. 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. The purpose of this document is to notify each patient of such rights and the recourse available to the patient in the event the patient has concerns regarding these or other rights.
1. The hospital has established policies and procedures to provide a reasonable response to the patient’s requests and needs for treatment or service, within the Hospital’s capacity, it’s stated mission and applicable law and regulation. Patients have the right to medical services whenever and wherever the emergency arises. The patient has the right to receive accommodation for a disability.
2. The patient has a right to considerate and respectful care at every health care facility by every health care provider that shall include effective pain management, consideration of the psycho-social, spiritual and cultural variables that influence the perceptions of illness.
3. The dying patient has a right to considerate and respectful care that optimizes the comfort and dignity of the patient through:
a. treating primary and secondary symptoms that respond to treatment as desired by the patient or surrogate decision maker;
b. effectively managing pain; and
c. acknowledge the psycho-social and spiritual concerns of the patient and the family regarding dying and the expression of grief by the patient and family.
4. The patient has the right, in collaboration with his/her physician to make decisions involving his/her health care, and to participate in the development and implementation of his or her plan of care and to make informed decisions regarding his or her care including:
a. the right to choose the right doctor for the right type of care;
b. the right to receive written information as to rights under state law to accept or refuse treatment and formulate advance directives;
c. the right to accept medical care or to refuse treatment to the extent permitted by law and to be informed of medical consequences of such refusal;
d. the right to formulate advance directives and appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by law; and
e. the right to know all medical options, no matter how much they cost
f. the right to have a family member or representative and his or her own physician notified promptly of admission to the hospital.
g. the right to personal privacy, to receive care in a safe setting, and be free from all forms of abuse or harassment.
h. the right to access a support person during their care provided that it does not interfere with the rights of other patients or interfere with the care process.
5. With regard to advance directives:
a. The hospital has established a mechanism to ascertain the existence of and assist in the development of advance directives at the time of the patient’s admission;
b. the hospital shall not condition the provision of care on the existence of an advance directive; and
c. an advance directive shall be in the patient’s medical record (if there is one) and shall be reviewed periodically with the patient or surrogate decision maker; and
d. the right to have hospital staff and practitioners who provide care in the hospital comply with these directives.
6. The patient has the right to information necessary to enable him/her to make decisions that reflect his/her wishes based on the hospital’s policy on informed decision making consistent with all legal requirements.
7. The patient has the right to receive at the time of admission, the information about the hospital’s patient’s rights policies and mechanism by which the patient can express concerns about the quality of care received and how to take action when that care is inadequate. The procedure requires the timely review of every written or oral concern brought to the attention of the hospital as well as a report to the person who registers the concern on the results of the review. Should you desire to bring a concern to the attention of the hospital, please contact the Administrator or the Director of Nursing.
8. The patient or the patient’s designated representative has a right to participate in the consideration of ethical issues that arise in the care of the patient. The hospital shall develop and have in place a mechanism for the consideration of ethical issues arising in the care of patients and shall develop and have in place a mechanism to provide education to care givers and patients on ethical issues and health care.
9. The patient has the right to be informed of any human experimentation or other research or educational progress affecting his/her care or treatment and to refuse to participate in any such activity.
10. The patient has the right, within the limits of law, to personal privacy and to know his/her medical records are confidential and only used for legitimate purposes.
11. The patient or patient’s legally designated representative has the right of access to information contained in the patient’s medical records, within the limits of the law, and within a reasonable time frame.
12. The patient’s guardian, next-of-kin, or legally authorized responsible person has the right to exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient:
a. has been adjudicated incompetent in accordance with the law;
b. is found by his/her physician to be medically incapable of understanding the proposed treatment or procedure;
c. is unable to communicate his/her wishes regarding treatment;
d. or is a minor.
13. Each patient has rights with respect to the use of restraints for acute medical and surgical care, which include:
a. to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. The term restraint includes either a physical restraint or a drug that is being used as a restraint.
b. that a restraint can only be used if needed to improve the patient’s well-being and less restrictive interventions have been determined to be ineffective.
c. that the use of a restraint be selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm and must be in accordance with the order of a physician or other licensed independent practitioner permitted by the State of Texas and the hospital to order a restraint.
d. that the use of a restraint be in accordance with a written modification to the patient’s plan of care, implemented in the least restrictive manner possible, in accordance with safe and appropriate restraining techniques and ended at the earliest possible time.
e. that the condition of the restrained patient be continually assessed, monitored, and reevaluated according to hospital policies and procedures.
14. Each patient has rights with respect to the use of restraints for behavior management, which include:
a. to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff. The term restraint included either a physical restraint or a drug that is being used as a restraint. The term seclusion means the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.
b. that seclusion or a restraint can only be used in emergency situations if needed to ensure the patient’s physical safety and less restrictive interventions have been determined to be ineffective.
c. that a restraint can only be used if needed to improve the patient’s well-being and less restrictive interventions have been determined to be ineffective.
d. that the use of a restraint be selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm and must be in accordance with the order of a physician or other licensed independent practitioner permitted by the State of Texas and the hospital to order a restraint.
e. that a physician or other licensed independent practitioner see and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention, and that each written order for a physical restraint or seclusion be limited to four hours for adults; two hours for children and adolescents ages nine to seventeen/ or one hour for patients under nine.
f. that the use of a restraint be in accordance with a written modification to the patient’s plan of care, implemented in the least restrictive manner possible, in accordance with safe and appropriate restraining techniques, and ended at the earliest possible time.
g. that a restraint and seclusion not be used simultaneously unless the patient is continually monitored face-to-face by an assigned staff member or continually monitored by staff using both video and audio equipment.
h. that the condition of the restrained patient be continually assessed, monitored, and reevaluated. Should any patient desire to file a complaint against the hospital in addition to or instead of bringing the concern to the attention of the hospital, he or she may do so by contacting: Hospital Licensing Section, Texas Department of Health, Health Facility Licensing Division, 1100 West 49 Street, Austin, TX 7875603199, Telephone: (512) 834-6648, Fax: (512) 834-6714.
Patient Responsibilities
1. A patient or his or her parent or legal designated representative has the responsibility to provide, to the best of his knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his health. He or she has the responsibility to report unexpected changes in his condition to the responsible for making it known whether he or she clearly comprehends a contemplated course of action and what is expected of him or her.
2. A patient or his or her parent or legal designated representative is responsible for following the treatment plan recommended by the practitioner primarily responsible for his care. This may include following the instructions of health care personnel as they carry out the coordinated plan of care and implement the responsible practitioner’s orders, and as they enforce the applicable department or facility rules and regulations. This also includes the patient or legal representative’s participation in the formulation of the plan of care/treatment plan and goals. The patient is responsible for keeping appointments and, when unable to do so for any reason, for notifying the responsible practitioner or department/facility.
3. The patient or his or her parent or legal designated representative is responsible for his actions if he refuses treatment or does not follow the practitioner’s instructions. If the patient cannot follow through with the treatment, he is responsible for informing the physician.
4. The patient or his or her parent or legal designated representative is responsible for assuring that the financial obligations of his health care are fulfilled as promptly as possible. The patient is responsible for providing information for insurance.
5. The patient or his or her parent or legal designated representative is responsible for following department/facility rules and regulations affecting patient care conduct.
6. The patient or his or her parent or legal designated representative is responsible for being considerate of the rights of other patients and personnel, and for assisting in the control of noise, smoking, and number of visitors. The patient is responsible for being respectful of the property of other persons and of the department/facility.
7. A patient’s health depends not just on their care, but, in the long term, on the decisions he or she makes in his or her daily life. He or she is responsible for the effects of their lifestyle on their personal life.
8. The patient or his or her parent or legal designated representative is responsible for reporting safety concerns to the Health care provider.
Grievance Procedure
The staff at Wise Regional Health System is dedicated to providing the finest quality care available to those being served. In the event you are not satisfied with our services, we would like to suggest that three steps be taken in the following order:
1. STAFF NURSE/SUPERVISOR
a. A Registered Nurse or Licensed Vocational Nurse is on duty at all times. Please address any concerns, problems, or complaints directly with this individual. He/she will make every effort to correct any problems that exist.
2. NURSING HOUSE SUPERVISOR
a. If the nurse is unable to resolve your problem, please ask to see the Nursing House Supervisor and address any problem to that individual.
3. DIRECTOR OF NURSING/ADMINISTRATOR
a. If you feel that your concern still has not been addressed, please ask to see the Director of Nursing or the Administrator. If the patient has a language barrier or hearing impairment the patient has the right to language assistance or interpreter services at no cost the patient. If the patient is a minor, is incapacitated, or has a designated advocate the parent, legal guardian, surrogate decision-maker or legally authorized representative has the right to language assistance or interpreter services at no cost the patient.
Privacy, Confidentiality and HIPAA
Wise Regional Health System values protection of the private health information of our patients. We understand that medical information about you and your health is personal.
Privacy and confidentiality mean that patients have the right to control who will see their protected and identifiable health information. This means that communications with or about patients involving patient health information will be private and limited to those people who need such information in order to provide/conduct treatment, payment, and healthcare operations.
A new federal law known as HIPAA (Health Insurance Portability and Accountability Act of 1996) mandates that all covered entities comply with regulations concerning the privacy and confidentiality of protected health information. A covered entity is any healthcare provider (doctors, dentists, hospitals, etc.), healthcare clearinghouses, and health plans. As a covered entity, Wise Regional Health System is committed to obeying the law and respecting your privacy.
Compliance with HIPAA was required by April 14, 2003. As of that date, all patients should receive a copy of the hospital’s Notice of Privacy Practices on their first admission. This document explains how your protected health information may be used by the hospital in conjunction with the law as well as your rights with regards to your private health information.
If you have any questions concerning our privacy practices, please contact your nurse or the hospital’s Privacy Officer at (940) 627-5921 extension 1248.
If you feel that Wise Regional Health System has violated your privacy, you may make a complaint to our Privacy Officer at (940) 627-5921 extension 1248 or you may file a complaint with the Secretary of Health and Human Services if you believe the law has been violated.
Compliance
Wise Regional Health System must follow many laws, regulations, policies, and procedures that affect our conduct. To obtain guidance on a compliance issue or report a possible violation, you may report your concerns to your nurse, the Compliance Officer or any other member of the Compliance Committee, or you can always contact the COMPLIANCE HOTLINE at 1-877-668-4394.
Patient Safety – Fall Precautions
At Wise Regional Health System, fall precautions are an extremely important part of the patient’s safety. Protocols are in place to maintain safety for all patients and visitors.
When a patient is admitted, we recommend keeping two top bed rails elevated while in bed. For patient’s that are identified as a “high risk for falls”, an attempt will be made to place them near the nurses’ station or they may be placed on a “bed check.” The bed check system sounds an alarm and alerts nursing staff when a patient gets out of bed. There may be times when staff may request a friend or family member to remain with the patient to enhance patient safety.
