Patients and Visitors

Patient Rights and Responsibilities

Mercy Iowa City heals and comforts the sick and works to improve the health of the community in the spirit of Jesus Christ and the Catholic tradition of the Sisters of Mercy. The values of respect, excellence, compassion, stewardship, and collaboration guide the care, treatment, and services we provide in the acute inpatient, ambulatory, home, and community settings.

Mercy recognizes the autonomy of the people we serve by respecting their right to make decisions about care, treatment, and services.

Mercy respects, protects, and promotes patient rights.

  • Informs the patient of his or her rights in all settings (including inpatient, outpatient, skilled nursing, hospice, and home health care) or when appropriate, the patient’s representative as allowed by law, of his or her rights, in advance of furnishing or discontinuing patient care whenever possible
  • Treats the patient in a dignified and respectful manner that supports his or dignity
  • The patients has the right to receive care in a safe setting
  • Supports the patient’s right to be free from all forms of abuse or harassment
  • Respects the patient’s right to and need for effective communication
  • Respects the patient’s cultural and personal values, beliefs, and preferences
  • Respects the patient’s right to personal privacy, including confidentiality of his or her clinical records
  • Respects the patient’s right to access information contained in his or her clinical records within a reasonable time frame
  • Respects the patient’s right to pain management
  • Accommodates the patient’s right to religious and other spiritual services
  • Allows the patient to access, request amendment to, and obtain information on disclosures of his or her health information, in accordance with law and regulation
  • Provides a standardized notice, "An Important Message from Medicare" (IM), within two (2) days of admission and a copy of the IM within two (2) days of discharge to each Medicare beneficiary who is an inpatient  

Mercy respects the patient’s right to receive information in a language or manner he or she (or the patient’s representative) understands.

  • Provides information in a manner tailored to the patient’s age, language, and ability to understand

  • Provides language interpretation and translation services, as necessary

  • Communicates with the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs  

Mercy respects the patient’s right to participate in decisions about his or her care, treatment, and services.

  • Involves the patient in the development, implementation, and revision of his or her inpatient plan of care, outpatient treatment/care plan, discharge plan, and pain management plan
  • Involves the patient in making decisions about his or her care, treatment, and services, including the right to have his or her family member or support person of his or her choice and his or her own physician notified promptly of his or her admission to the hospital
  • Provides the patient with written information about the right to refuse care, treatment, and services
  • Respects the patient’s right to refuse care, treatment, and services, in accordance with law and regulation
  • Respects the patient’s right to formulate advance directives and complies with these directives
  • Involves a surrogate decision-maker when a patient is unable to make decisions about his or her care, treatment, and services
  • Respects the surrogate decision-maker’s right to refuse care, treatment, and services on the patient’s behalf, in accordance with law and regulation
  • Involves the patient’s family in care treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation
  • Provides patient or surrogate decision-maker with the information about the outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions
  • Informs the patient or surrogate decision-maker about unanticipated outcomes of care, treatment, and services (hospital or licensed independent practitioner responsible for patient’s care, treatment, and services)

Mercy honors the patient’s right to give or withhold informed consent. 

  • Includes discussion about the patient’s proposed care, treatment, and services

  • Includes discussion about potential benefits, risks, and side effects of the patient’s proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation
  • Includes discussion about reasonable alternatives to the patient’s proposed care, treatment, and services; discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services
  • Includes a discussion about any circumstances under which information about the patient must be disclosed or reported; such circumstances may include requirements for disclosure of information regarding cases of HIV, tuberculosis, viral meningitis, and other diseases that are reported to organizations such as health departments or the Centers for Disease Control and Prevention. Obtains consent in accordance with hospital’s informed consent policy and processes and, except in emergencies, prior to surgery

Mercy honors the patient’s right to 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.

  • Obtains consent prior to producing recordings, films, or other images

  • Includes information of how recordings, films, or other images will be used when made for external purposes
  • Includes ethical mechanism with community input when patient is unable to give informed consent
  • Remains in hospital’s possession and is not used for any purpose until and unless informed consent is obtained
  • Destroys product or removes patient from the product when patient is unable to provide consent at the time of producing recordings, films, or other images and subsequently
  • Informs patient of his or her right to request cessation of the production of the recordings, films, or other image
  • Protects patient’s identity and confidential information by having anyone who is not already bound by the hospital’s confidentiality policy sign a confidentiality statement prior to producing recordings, films, or other images
  • Accommodates patient’s right to rescind consent before using recording, film, or image  

Mercy protects the patient and respects his or her rights during research, investigation, and clinical trials.

  • Reviews all research protocols and weighs the risks and benefits to the patient participating in the research

  • Helps the patient determine whether or not to participate in research, investigation, or clinical trials by providing an explanation of the purpose, expected duration of patient’s participation, clear description of procedures to be followed, a statement of the potential benefits, risks, discomforts, and side effects, and alternative care, treatment, and services available to the patient that might prove advantageous to the patient
  • Informs patient that refusing to participate in research, investigation, or clinical trials, or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and services unrelated to the research
  • Documents in the research consent form that the patient received information to help determine whether or not to participate in the research, investigation, or clinical trials; that the patient was informed that refusing to participate in research, investigation, or clinical trials, or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and services unrelated to the research; the name of the person who provided the information and the date the form was signed; and, describes patient’s right to privacy, confidentiality, and safety
  • Keeps all information given to subjects in the medical record or research file along with the consent forms

Mercy respects the patient’s right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services.

  • Informs the patient of the name of the physician who has primary responsibility for his or her care, treatment or services

  • Informs the patient of the name of the physician(s), clinical psychologist(s) or other practitioner(s) who will provide his or her care, treatment, and services

Mercy addresses patient decisions about care, treatment, and services received at the end of life.

  • Provides patients with written information about advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services
  • Provides patient with information upon admission about the extent to which the hospital is able, or unable, or unwilling to honor advance directives
  • Documents whether or not the patient has an advance directive in order to inform staff and licensed independent practitioners who are involved in the patient’s care, treatment, and services
  • Refers the patient to resources for assistance in formulating advance directives
  • Honors the patient’s right to formulate or review and revise his or her advance directives
  • Honors the patients advance directives, in accordance with law and regulation and the hospital’s capabilities
  • Documents the patient’s wishes concerning organ donation when he or she makes such wishes known to the hospital or when required by the hospital’s policy, in accordance with law and regulation
  • Honors the patient’s wishes concerning organ donation within the limits of the hospital’s capability and in accordance with law and regulation
  • Honors patient’s right to access care, treatment, and services regardless of the existence or lack of an advance directive

Mercy respects the patient’s right to be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse.

  • Determines how it will protect the patient from neglect, exploitation, and abuse that could occur while the patient is receiving care, treatment, and services

  • Evaluates all allegations, observations, and suspected cases of neglect, exploitation, and abuse that occur within the hospital
  • Reports allegations, observations, and suspected cases of neglect, exploitation, and abuse to appropriate authorities based on its evaluation of the suspected events, or as required by law

Mercy addresses the patient’s right to an environment that preserves dignity and contributes to a positive self-image.

  • Allows the patient to keep and use personal clothing and possessions, unless this infringes on others’ rights or is medically or therapeutically contraindicated, based on the setting or service

  • Offers patients telephone and mail service, based on the setting and population
  • Provides access to telephones for patients who desire private telephone conversations in a private space, based on the setting and population   

Mercy addresses the patient’s and his or her family’s right to have grievances reviewed by the hospital.

  • Establishes a grievance resolution process

  • Informs patient and his or her family about the grievance resolution process: Patient Advocate Specialist at (319) 339-3653 or (800) 637-2942 ext. 3653. Reviews and, when possible, resolves grievances from the patient and his or her family
  • Acknowledges receipt of a grievance that the hospital cannot resolve immediately and notifies the patient of follow-up to the grievance
  • Allows the patient to voice grievances and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care
  • Provides the individual with a written notice of its decision and includes the name of the hospital contact person, steps taken on behalf of the individual to investigate the grievance, results of the process, and date of completion of the grievance process
  • Resolves grievances and provides a written response within seven (7) days; when this is not possible, the patient is informed that Mercy is still working on the grievance and will respond within sixty (60) days
  • Includes a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the quality improvement organization (QIO).
  • Provides the patient with the telephone number and address needed to file or appeal a grievance with the relevant state authority: Division of Health Facilities, Iowa Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa, 50319, telephone (515) 281-4115.
  • Provides the patient with the telephone number and address needed to voice concerns regarding patient care or safety by contacting the Office of Quality Monitoring of The Joint Commission at (800) 994-6610 or by e-mail at complaint@jointcommission.org 

Mercy addresses the patient’s right to access protective and advocacy services.

  • Provides resources to assist the family and courts to determine the patient’s needs for protective services, when applicable

  • Maintains a list of names, addresses, and telephone numbers of patient advocacy groups, such as a state authority or a protection and advocacy network
  • Gives the list of patient advocacy groups to the patient when requested

Mercy respects the patient’s right to visitation privileges.

  • Informs each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section.
  • Informs each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
  • Does not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability; and
  • Ensures that all visitors enjoy full and equal visitation privileges consistent with patient preferences
  • Notifies patient that Mercy reserves the right to limit visitors including, but not limited to the following:
  • Any court order limiting or restraining contact
    • Behavior presenting a direct risk or threat to the patient, hospital staff, or others in the immediate environment
    • Behavior disruptive of the functioning of the patient care unit
    • Reasonable limitations on the number of visitors at any one time
    • Patient’s risk of infection by the visitor
    • Visitor’s risk of infection by the patient
    • Extraordinary protections because of a pandemic or infectious disease outbreak
    • Patient’s need for privacy or rest
    • Need for privacy or rest by another individual in the patient’s shared room
    • Determination by a health care professional using his or her best clinical judgment that visitation is not appropriate
    • Environment not conducive for visitation, such as the Operating Suite, Cardiovascular Lab, and other procedural areas 

Mercy informs the patient about his or her responsibilities related to his or her care, treatment, and services.

  • Defines the patient’s responsibilities, including but not limited to:

    • Providing information

    • Asking questions

    • Following instructions

    • Accepting consequences

    • Following rules and regulations

    • Showing respect and consideration

    • Acknowledging when he or she does not understand the treatment course or care decision

    • Meeting financial commitments

  •  Informs the patient about his or her responsibilities in accordance with its policy

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