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Centura Health

Patient Bill of Rights

Carta de Derechos del Paciente

At Centura Health, we believe that you are in control of your health and the decisions about your health. We are passionately committed to supporting your decisions. At each of our hospitals, facilities and services, we support a Patient Bill of Rights and Responsibilities. Knowing your rights and role as a patient will help you make better decisions about your health care.

If you feel your rights are being overlooked, all Centura Health facilities maintain formal concern, complaint and grievance procedures. These procedures are entailed within the following Patient Bill of Rights.

This Bill of Rights and Responsibilities also describes your responsibilities and role as a patient. Patients who choose to disregard their rights and responsibilities agree to accept the consequences which could jeopardize the goal of providing you a superior patient experience and the highest quality of care.

A copy of the patient bill of rights and responsibilities is provided upon registration. A copy of the facility Patient Rights and Responsibilities policy and procedure will also be provided to patients upon their request.

Patient Bill of Rights

Patient Rights:
Centura Health Hospitals support the rights of all patients across the lifespan including geriatric, adult, adolescent, pediatric, infant and neonatal populations. These rights may be exercised through the patient individually or through their surrogate decision maker (legal representative).

You have the right to. . .

  1. Be informed of your patient rights in advance of receiving or discontinuing care when possible.
    1. You, your family and/or surrogate decision-maker (legal representative) will receive a written copy of the Patient Rights upon admission or in advance of receiving or discontinuing care when possible.
    2. If you, your family and/or surrogate decision-maker (legal representative) do not understand the written word, you will receive your rights verbally in a manner you can understand.
    3. Patient Rights are visibly posted in points of entry to the organization as well as on the reverse side of your Hospital Admission Agreement.
  2. Have impartial access to care and visitation. No one is denied access to treatment or visitation because of disability, national origin, culture, age, color, race, religion, gender identity, sexual orientation. No one is denied examination or treatment of an emergency medical condition because of their source of payment.
    1. Care is provided in response to your requests and needs, so long as that care is medically indicated and is within the hospital’s capacity, its stated mission and philosophy, and relevant laws and regulations.
    2. For individuals who come to the Emergency Department, the hospital may request payment information and an insurance card, so long as doing so does not delay the medical screening examination.
  3. Give informed consent for all treatment and procedures with an explanation in layman terms of:
    1. Recommended treatment or procedure.
    2. Risks and benefits of the treatment or procedure.
    3. Likelihood of success, serious side effects, and risks including death.
    4. Alternatives and consequences if treatment is declined.
    5. Explanation of the recovery period.
    6. Whether physicians or qualified medical providers other than the responsible practitioner will be performing important parts of the surgery or administer the anesthesia.
      1. Facility staff and providers will follow facility Informed Consent policy and procedure.
      2. Facility staff and providers will follow the process required for recording or filming the identification, diagnosis or treatment of patients.
  4. Participate in all areas of your care plan, treatment, care decisions, and discharge plan.
    1. You, and/or surrogate decision-maker (legal representative) have the right to be involved in issues of:
      1. decisions regarding your own care and course of treatment,
      2. withholding resuscitative services,
      3. withdrawing life-sustaining treatment, and
      4. care at the end of life.
    2. You, your family and/or surrogate decision-maker (legal representative) have the right to include or exclude any or all family members in participating in your care decisions.
    3. You, your family and/or surrogate decision-maker (legal representative) have the right to be informed by the patient’s physician and healthcare team responsible for care of any continuing health care requirement following discharge from the facility.
    4. You, your family and/or surrogate decision-maker (legal representative) have the right to be involved in resolving dilemmas about care decisions.
    5. You have the right to have your medical needs and your psychological needs met, when possible.
    6. You have the right to receive information in a manner that you understand. As best possible, the facility will provide information that is appropriate to your age, understanding and language.
  5. Have appropriate assessment and management of your pain.
    1. You will be assessed for pain using tools that measure your pain intensity or other features.
    2. Reassessment of pain will occur after each pain intervention involving medication.
  6. Be informed of your health status/prognosis.
    1. Your physician and healthcare team shall communicate information regarding your health status/prognosis to the best of their knowledge.
    2. Your physician(s) and health care team will communicate unanticipated outcomes of care, treatment and services related to sentinel events.
  7. Be treated with respect and dignity.
    1. You will receive considerate, compassionate, and respectful care with recognition of your dignity, psychosocial needs, personal values and beliefs, and spiritual and cultural practices.
    2. You are allowed and encouraged to express your cultural practices and spiritual beliefs, as long as they do not harm or interfere with the well-being of others or your treatment and well- being.
    3. Concern for optimal comfort and dignity shall guide all aspects of care during the final stages of life. The framework for addressing issues related to care at the end of life includes:
      1. providing appropriate treatment for any primary and secondary symptoms, according to your wishes;
      2. managing pain aggressively and effectively;
      3. sensitively addressing issues such as autopsy and organ donation;
      4. respecting your values, religion, and philosophy;
      5. involving you and your surrogate decision-maker (legal representative) and, where appropriate, the family in every aspect of care; and
      6. responding to the psychological, social, emotional, spiritual, and cultural concerns of you and your loved ones.
  8. Personal privacy, comfort and security to the extent possible during your stay.
    1. Privacy and dignity will be protected during personal hygiene activity (e.g., toileting, bathing, and dressing).
    2. Anyone not involved in your care will not be allowed to examine or treat you without your consent.
    3. Reasonable visual and auditory privacy will be offered when interviewed, examined, and/or treated.
      1. In some circumstances, privacy cannot be fully guaranteed (e.g., open units, such as: the emergency departments, radiology, post anesthesia care, intensive care). These open units facilitate direct visualization of patients who are subject to rapid changes in condition. In these units during physical examination, your physical privacy will be maintained.
    4. Should the actions of another patient or a visitor be unreasonably disturbing, you will be transferred to another room equally suitable when one is available.
    5. Comfort needs will be met to the extent possible.
    6. Valuables will be secured in a locked area, per request.
  9. Be free from restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff.
  10. Confidentiality of all communication and clinical records related to your care.
    1. Discussion or consultation involving your case will be conducted discreetly, and individuals not directly involved in your care will not be present without permission.
    2. All communications (e.g., discussions about your condition, treatment, care, etc.) and records pertaining to your care, including source(s) of payment for treatment, will be treated as confidential and securely maintained.
    3. Clinical records will be read only by individuals directly involved in your treatment/care or in the monitoring of its quality or by individuals authorized by law or regulation.
      1. Other individuals will have access to only that portion of information that is necessary to provide effective responsive services.
    4. Clinical records will be maintained in a secure environment, and clinical information will be reasonably protected so that no unauthorized individuals might see it.
    5. Although your identity is not shared, some aspects of your care may be shared for staff or medical educational purposes.
  11. Have access to telephone calls, mail, etc. Any restrictions to access will be discussed with you, and you will be involved in the decision when possible.
  12. Have the right to choose a “visitor” who may visit you including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and your right to withdraw or deny such choice at any time. You also have the right to an identified “support person” who can make visitation decisions should you become incapacitated.
    1. Generally you have the right to expect unrestricted access to visitation and/or communication.
      1. Any restrictions or limitations on visitation will be fully explained in a language that is understood, and with your participation.
    2. All visitors chosen by you shall enjoy “full and equal” visitation privileges, consistent with your wishes. In order to promote rest, comfort, healing, privacy, safety, and a safe, secure and orderly environment, there are circumstances and departments where the number of visitors may be limited.
    3. If a “support person” has been identified by you to make decisions regarding visitors, it must be understood that this “support person” is not a legal representative and is only serving to make decisions regarding visitors if you are incapacitated. This does not supersede a Medical Durable Power of Attorney or other legal representative.
    4. If you are incapacitated and there is a clear dispute between two or more people over whether a particular person should be allowed to visit you, proof of relationship will be required. [The following forms of proof are suggested: an advance directive naming the individual support person, approved visitor or designated decision maker; shared residence; shared ownership of a property or business; financial interdependence; marital/relationship status; existence of a legal relationship recognized in any jurisdiction; and acknowledgment of a committed relationship (i.e. an affidavit). This list of proof and documentation is not intended to be exhaustive of all potential sources of information regarding proof of a relationship to allow patient visitation or support person preferences.]
  13. Have access to interpreter services at no cost to you or your companion when you do not speak or understand the language, as well as communication aides, at no cost to you or your companion, for the deaf, blind, speech impaired, etc., as appropriate.
    1. A Companion is a person who has a communication impairment (blind, deaf, hard of hearing, etc.), and is one of the following:
      1. a person whom you indicate should communicate with personnel about you, participate in any treatment decision, play a role in communicating your needs, condition, history or symptoms to personnel or help you act on the information, advice, or instructions provided by personnel; or
      2. a person legally authorized to make health care decisions on behalf of you; or
      3. such other person with whom personnel would ordinarily and regularly communicate your medical condition.
    2. The facility will take reasonable, usual and customary steps to assist in effective communications for those with Limited English Proficiency (LEP) and/or speak a language other than English. This includes vital documents including but not limited to hospital admission agreement, treatment consents, waivers of rights, financial and insurance benefits forms. All interpreters or translation aids and services will be provided without cost to the person being served.
      1. Interpreters will be provided, when necessary, for Limited English Proficient speaking individuals.
    3. Assistive devices will be made available for any other identified communication barrier. (hearing impaired, visually impaired, speech impaired or manually impaired)
  14. Have access to pastoral/spiritual care.
    1. You, your family, or surrogate decision-maker (legal representative) may request pastoral/spiritual care from clergy of your choice or from the facility’s chaplains.
    2. Access to chaplains may be arranged through the Spiritual Care Department at each facility or through the facility operator.
  15. Receive care in a safe setting.
    1. Staff will follow current standards of practice for your environmental safety, infection control and security.
    2. The healthcare team will consider your emotional health as part of a safe setting.
    3. The facility will comply with all regulatory life safety standards.
    4. Protective privacy shall be provided should you and/or your physician believe it is necessary for your personal safety.
  16. Be free from all forms of abuse or harassment.
    1. This right includes all patients, visitors and associates.
    2. Staff will not willfully inflict injury, unreasonable confinement, intimidation or punishment upon you.
    3. Staff will not willfully cause physical harm, pain, or mental anguish; this includes:
      1. staff neglect,
      2. indifference to infliction of injury, or
      3. intimidation of you by another. (Definition of neglect for the purpose of this statement is “the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness”).
  17. Have access to protective services (e.g., guardianship, advocacy services, and child/adult protective services).
    1. If you are in need of protective services (e.g., guardianship and advocacy services, conservatorship, and child or adult protective services), you have the right to assistance by a designated healthcare team member or independent individual in accessing the appropriate services. You, and when appropriate, your family, surrogate decision-maker (legal representative) will be provided in writing:
      1. A list of names, addresses, and telephone numbers of pertinent local, regional and state client advocacy groups maintained by the facility.
      2. State survey and certification agency, the state licensure office, the state ombudsman program, the protections and advocacy network, and the Medicaid fraud control unit; and
      3. Information regarding your right to file a complaint with the state survey and certification agency if there is a concern about abuse, neglect, or about misappropriation of property in our facility.
  18. Request medically necessary and appropriate care and treatment.
    1. You have the right to:
      1. consult a specialist (at your expense),
      2. change physician(s) and/or any member of the healthcare team,
      3. transfer to another hospital
    2. You or your surrogate decision-maker’s (legal representative) right to make decisions about care is not equivalent to an ability to demand treatment or services that are deemed medically inappropriate or unnecessary.
  19. Refuse any drug, test, procedure, or treatment and be informed of the medical consequences of such a decision.
    1. Your refusal of any drug, test, procedure, or treatment will not compromise your access to care.
    2. Should you refuse care; consequences of such refusal will be explained and documented.
  20. Consent to or refusal to participate in teaching programs, research, experimental programs, and/or clinical trials.
    1. The facility will protect all patients and respect their rights during research, investigation, and clinical trials involving human subjects by:
      1. giving information to make a fully informed decision;
      2. describing expected benefits;
      3. describing alternatives that might also help you;
      4. explaining procedures to be followed;
      5. explaining your right to refuse to participate, and that your refusal will not compromise your access to the facility’s services.
  21. Receive information about Advance Directives. Set up or provide Advance Directives and have them followed. Designate a surrogate decision-maker (legal representative) as permitted by law and as needed.
    1. Absence of an advance directive will not compromise access to care.
    2. If you have an advance directive, the facility’s health care professionals and designated representatives shall inform appropriate staff of and enable staff to honor the directives within the limits of the law and the organization’s mission, philosophy, and capabilities.
    3. Designated staff shall provide assistance if you do not have an advance directive but wish to formulate one.
    4. Your surrogate decision-maker (legal representative, guardian, medical durable power of attorney agent, proxy decision-maker) has the right to exercise, to the extent permitted by law, the rights delineated on your behalf if you:
      1. have been adjudicated incapacitated in accordance with the law,
      2. have been determined by your physician to be medically incapable of understanding the proposed treatment or procedure,
      3. are unable to communicate your wishes regarding treatment, or
      4. are a non-emancipated minor unless receiving treatment which state or federal law provides that you may consent to.
    5. Complaints concerning advance directives will follow the patient grievance process.
  22. Participate in decision-making regarding ethical issues, personal values or beliefs.
    1. When issues arise, the facility will inform you, your family and/or surrogate decision-maker (legal representative) of the right to access the facility’s Ethics Committee and the process for ethical issues resolution, including an ethics consult. The facility will facilitate the process for resolution of ethical issues according to policy and procedure.
  23. Have a family member or representative of your choice and your physician promptly notified of your admission to the hospital.
    1. Notification will be made as soon as can be reasonably expected.
  24. Know the names, professional status and experience of your caregivers.
    1. Staff and volunteers will wear a name badge while on duty.
    2. Upon request, information regarding an individual’s experience shall be made available.
    3. Upon request, you and/or your surrogate decision-maker (legal representative) will be informed of:
      1. The name of the physician/other practitioner who has primary responsibility for your care.
      2. The identity and professional status of individuals responsible for authorizing and performing procedures or treatment.
      3. Professional relationship to another health care provider, vendor or institution that might suggest a conflict of interest.
      4. Any professional relationship to educational institutions involved in your care.
      5. Any business relationships between individuals treating you or between the organization and any other health care service, or educational institutions involved in your care.
  25. Have access to your clinical records within a reasonable timeframe.
    1. You may inspect your clinical record upon reasonable notice (in accordance with Colorado Law) and have a clinician explain any parts that are not understood.
    2. You may have your clinical records made available to you or your legally authorized representative (in accordance with the state law and regulations of the Colorado Department of Public Health and Environment) through the Health Information Management Department.
    3. You may have copies of your clinical record (at a reasonable expense to you).
    4. Other individuals can have access to your clinical record upon your written authorization or that of your legally authorized representative.
  26. Be examined, treated, and if necessary, transferred to another facility if you have an emergency medical condition or are in labor, regardless of your ability to pay.
    1. Facility staff will follow their Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure.
  27. Request and receive, prior to the initiation of non-emergent care or treatment, the charges (or estimate of charges) for routine, usual, and customary services and any co-payment, deductible, or non-covered charges, as well as the facility’s general billing procedures including receipt and explanation of an itemized bill. This right is honored regardless of the source(s) of payment.
    1. Based upon insurance information provided by you, your family or surrogate decision-maker (legal representative), the facility shall provide assistance estimating co-payment, co-insurance, deductible or other charges that must be paid.
    2. You have the right to question or appeal decisions made by payers (i.e., insurance, Medicare, Medicaid, HMOs, etc.) regarding limitations of the amount paid and/or types of treatment covered. The concerns/issues may be referred to the facility’s billing department, and if needed these staff members will make the appropriate referrals. Call the hospital operator “0” or the hospital’s main number and ask for the billing department.
  28. Be informed of the hospital’s complaint and grievance procedure and whom to contact to file a concern, complaint or grievance.
    1. The facility will provide a fair, fast and objective review of complaints
    2. The facility will follow the Complaint and Grievance Policy and Procedure.
      1. Note: If you have financial issues or questions, please contact Centura Consumer Operations at (303) 715-7000. Toll free: 888-269-7001
    3. To improve your patient experience, it is important for the facility to provide prompt responses to concerns. The facility encourages patients to speak with staff who are caring for them, or contact the hospital operator by dialing “0” and ask for the Patient Representative; the Department Manager of the department providing your care; or RN Administrative Manager.
    4. The facility will also inform you that you may contact The Health Facilities Division of the Colorado Department of Public Health and Environment and The Office for Civil Rights directly regardless of whether you first used the hospital’s complaint and grievance process.

      Colorado Department of Public Health and Environment
      Mail: Colorado Department of Public Health and Environment
      4300 Cherry Creek Drive South Denver, CO 80222-1530

      Telephone: (303) 692-2827

      The Office for Civil Rights
      Department of Health and Human Services
      999 18 th Street, South Terrace, Suite 417
      Denver , Colorado 80202
      Telephone: 303-844-2024 / TDD 303-844-3439
      Fax: 303-844-2025

      If after speaking with the hospital or system representative your patient complaint remains unresolved, the facility will inform you that you may also contact The Joint Commission:

      Division of Accreditation Operations, Office of Quality Monitoring
      The Joint Commission
      One Renaissance Boulevard
      Oakbrook Terrace, IL 60181
      Telephone: 1-800-994-6610 or (630) 792-5276
      Fax: Office of Quality Monitoring (630) 792-4276.

      The facility will also inform you that you have the right to file a complaint with the Colorado Board of Medical Examiners, the State Board of Dental Examiners and the Colorado Podiatry Board if you have concerns with your physician, dental or podiatric patient care services, excluding fee disputes.

  29. You have the right to receive a complete copy of the Hospital’s Notice of Privacy Practices.
    1. Facility Patient Access staff will provide a copy of this upon registration.

Neonatal, Infant, Pediatric and Adolescent Rights

  1. Neonates, child and adolescent patients possess the same rights and responsibilities of adult patients. It is, however, the responsibility of the parent/guardian to implement these rights and responsibilities on their behalf.
  2. To receive encouragement for the participation and involvement of the parent/family/guardian throughout treatment. It is the responsibility of all Centura Health facilities to communicate issues surrounding the care of the patient including, but not limited to: discussion of the perception of the patient’s needs; information concerning condition, treatment and progress; involvement in the treatment, as appropriate; and participation in discharge planning.
  3. To be provided a physical and social environment that is conducive to the care and treatment of neonates, children and adolescents. Age appropriate normalizing activities and resources are provided for and encouraged, such as play and recreation.
  4. To provide a physical and social environment that allows for normalizing experiences in self care and fulfillment of age appropriate responsibilities. Centura Health facilities coordinate these needed experiences through community resources such as tutors recommended by the patient’s school district.
    1. Additional therapy may be provided through the hospital’s Physical and/or Occupational Therapy departments as appropriate.
  5. To receive care in an environment with appropriate security and safety measures

Patient Responsibilities

You have the responsibility to . . .

  1. Ask questions and promptly voice concerns.
    1. You, your family and/or surrogate decision-maker (legal representative) are responsible for asking questions when you do not understand what has been told to you about your care or what is expected of you.
  2. Give full and accurate information as it relates to your health, including medication.
    1. You, your family and/or surrogate decision-maker (legal representative) have the responsibility to provide, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives and other matters relating to your health.
  3. Report changes in your condition or symptoms, including pain, and request assistance of a member of the health care team.
    1. The facility will encourage you and your visitors to seek assistance when your condition worsens.
  4. Participate in the planning of your care, including discharge planning.
  5. Follow your recommended treatment plan.
    1. You, your family and/or surrogate decision-maker (legal representative) should express concerns regarding ability and willingness to follow the proposed course of treatment. The healthcare providers will make every effort to adapt the treatment plan to your specific needs and limitations. If you refuse treatment or do not follow instructions, you must accept the consequences of your decision.
    2. You, your family and/or surrogate decision-maker (legal representative) are responsible for keeping appointments. If you are unable to keep an appointment, then it is also your responsibility to notify the appropriate practitioner and/or facility.
  6. Be considerate of other patients and staff.
    1. You, your family and/or surrogate decision-maker (legal representative) are responsible for being considerate of the rights of other patients and staff, including assisting in the control of noise, smoking, following visitation policies and visiting hours, following security procedures and/or aiding in the prevention of distractions.
    2. In providing care, healthcare facilities have the right to expect behavior on the part of patients, their relatives and friends, which is reasonable and responsible considering the nature of the patient’s illness.
  7. Secure your valuables.
    1. The facility is not responsible for any valuables or belongings kept in your possession.
    2. You are encouraged to send your valuables and/or belongings home with your family.
  8. Follow facility rules and regulations.
    1. In order to promote health, Centura facilities are non-smoking. Patients, Associates and Visitors will be asked to comply with the “Non-Smoking” policy of the organization. Several Centura campuses are entirely smoke free. For those that are not smoke free, facilities will provide patients, families and visitors with the location of the designated smoking areas upon request.
    2. Includes visitation hours and limitation of visitors
  9. Respect property that belongs to the facility or others.
    1. This includes being responsible to keep all areas of the facility free of paper, food, drinks, trash, etc.
    2. This includes prevention of theft.
  10. Understand and honor financial obligations related to your care, including understanding your own insurance coverage.
    1. For assistance, call the hospital operator (“0”) who will forward your call.

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