As a natural outgrowth of our basic beliefs, our statement of mission and
our core values, and as a healthcare facility concerned with meeting your needs,
we affirm your rights and responsibilities as a patient.
1. You have the right to be informed of the patient rights in advance of
furnishing or discontinuing patient care whenever possible (see “Advance
Directives-Five Wishes” on page 14).
2. You have the right to file a grievance and to be informed of the
process to review and resolve the grievance (see “Speak Up: How to File a
Compliment or Complaint” on page 15).
3. You have the right to participate in the development and
implementation of your plan of care.
4. You or your representative have the right to make informed decisions
regarding your care, including being informed of your health status, involved in
care planning and treatment and being able to request or refuse treatment. This
right must not be construed as a mechanism to demand the provision of treatment
or services deemed medically unnecessary or inappropriate.
5. You have the right to formulate advance directives and to have
hospital staff and practitioners who provide care in the hospital comply with
these directives (see “Advance Directives-Five Wishes” on page 14).
6. You have the right to have a family member or representative of your
choice and your physician notified promptly of your admission to the
7. You have the right to personal privacy.
8. You have the right to receive care in a safe setting (see “Staying
Safe in the Hospital” on page 6).
9. You have the right to be free from all forms of abuse or
10. You have the right to the confidentiality of your protected health
information, and may obtain, in writing, a copy of the hospital’s Notice of
Privacy Practices (see “Private Information and Medical Records” on page
11. You have the right to access, request amendment to, and receive an
accounting of disclosures regarding information contained in your clinical
records within a reasonable time (see “Private Information and Medical Records”
on page 12).
12. You have the right to be free from restraints and seclusion of any
form that are not medically necessary or are used as a means of coercion,
discipline, convenience or retaliation by staff.
1.You have the responsibility to provide accurate and complete
information concerning your present complaints, past illnesses,
hospitalizations, medications, and other matters relating to your
2. You have the responsibility to speak up if you feel your safety or the
quality of your care is at risk.
3. You are responsible for asking questions if you do not understand the
course of your medical treatment or what is expected of you.
4. You are responsible for following the treatment plan established by
your physician, including the instructions of nurses and other health
professionals as they carry out the physician’s orders.
5. You are responsible for expressing any concerns about your ability to
follow the proposed treatment plan.
6. You are responsible for your actions, and the outcome of your care,
should you refuse treatment or do not follow your physician’s orders.
7. You are responsible for assuring that your financial obligations of
your hospital care are fulfilled as promptly as possible.
8. You are responsible for following the hospital’s rules and
9. You are responsible for being considerate of the rights of other
patients and hospital personnel.
10. You are responsible for being respectful of your personal property
and that of other persons in the hospital.
Private Patient Information–Medical
Our core values ensure that we maintain the confidentiality of your
personal and medical information in accordance with Health Insurance Portability
and Accountability Act (HIPAA). If you would like a copy of our Notice of
Privacy Practices or feel that your privacy has been compromised, please contact
our patient advocate by dialing 7959 from a hospital phone or “0” and asking to
speak to the patient advocate. If you would like a copy of your medical record,
please contact our Health Information Management department by dialing
Do Not Resuscitate (DNR)
In the event your breathing or heart stops, you can specify that extra
measures not be taken to revive you. This Do Not Resuscitate (DNR) order is
written by your physician and followed by all your hospital healthcare
providers. You will still receive the highest quality of care and attention to
ensure your comfort. A DNR order may be canceled at any time by telling your
doctor. This information is also addressed in the Five Wishes Advance
At Good Samaritan Hospital, pain management is one of
our top priorities. During your hospital stay we will do everything we can to
manage your pain. Please let your nurse know immediately if your pain is not under control.
As a patient at Good Samaritan Hospital, you can
• information about pain and pain relief measures
• your pain to be managed
• your reports of pain to be accepted and alternatives to be
• to be treated with respect at all times
As a patient, it would help us if you:
• asked what to expect regarding pain and its
• discussed pain relief options
• helped to develop a pain management plan
• asked for pain relief when pain first begins and inform your healthcare
if your pain is not
Advance Directive–Five Wishes
Many things in life are out of our hands, but by using the Good Samaritan
endorsed Five Wishes advance directive, you can control how you wish to be
treated if you become seriously ill. Five Wishes is an easy-to-complete form
that makes your personal, emotional and spiritual needs as well as your medical
wishes known by checking a box, circling a direction or writing a few sentences.
It lets you appoint the person you choose to make your healthcare decisions if
you are unable (power of attorney for healthcare) and once signed, is valid
under the law in Nebraska.
You are not required to have an advance directive, but Five Wishes or
other types of advance directives containing a living will and power of attorney
for healthcare, are helpful if questions arise about the kind of medical
treatment that you do or do not want and who you want to make those decisions if
you are unable. As long as you can make personal decisions on your own behalf,
your healthcare providers will rely on you, not your advance directive. You can
cancel your advance directive at any time by destroying your original copy and
contacting those with copies.
If you choose to complete an advance directive, make sure that someone,
such as a family member, knows where it is located.
You might also consider the following:
• If you have a power of attorney for healthcare, give a copy or the
original to your “agent” or “representative.”
• Tell your healthcare provider that you have an advance directive and
ask the provider to make it part of your medical record.
• Keep a second copy of your advance directive in a safe place where it
can be found easily, if it is
• In your purse or wallet, keep a small card that states you have an
advance directive, where it is located and who your “agent” or
“representative” is, if you have named one.
• If you move, make sure your advance directive is valid in that
Good Samaritan Hospital offers an informational video about our Five
Wishes advance directive on TV channel 77 in all patient rooms. You can receive
a Five Wishes booklet or the Nebraska Department of Social Services written
description of Nebraska’s law concerning advance directives by contacting Good
Samaritan Care Management by dialing 7408 on any hospital phone. If you have
additional questions about your legal rights, you should seek the professional
advice of an attorney.
Good Samaritan Hospital reserves the right not to comply with directives
given by a patient or their named decision maker if those directives conflict
with the moral position of the Catholic Church or hospital policy. If Good
Samaritan Hospital is unable to comply with your directives, we will make every
effort to assist with your transfer to a different facility. Five Wishes does
comply with the moral position of the Catholic Church and hospital policy.
Speak-Up: How to File a
Compliment or Complaint
At Good Samaritan Hospital, we strive to provide a safe and caring
environment making your stay the best experience possible. We want you to be
completely satisfied with your visit and would like to know if we have surpassed
your expectations or if there are areas in which we can improve.
You may provide feedback, that will get our timely and focused
attention, in a variety
of ways: (We treat all comments in a professional and private
· talk directly with your immediate caregiver
· ask to speak to a supervisor
· call the patient advocate by dialing 7959 from a hospital phone or by
dialing “0” and asking to speak to the patient
· complete a “Speak Up” form found throughout the
· if phoned after your discharge, participate in our contracted national
If you feel that any of your rights as a patient (refer to the “Patient
Rights” on page 9) have been violated, you have the right to initiate a formal
grievance by notifying our patient advocate advocate in writing at:
Kearney, Nebraska 68848-1990
Or you may call (308) 865-7959 and speak directly with
the patient advocate.
You will be contacted upon receipt of your grievance to investigate the
issue. Our grievance committee, comprised of Good Samaritan staff, will then
contact you in writing within 35 days to detail the steps taken on your behalf.
At that time you will be informed of the results of this process. That letter
will also contain a contact for further correspondence.
Regardless of whether you choose to use the hospital’s grievance
procedure, you also have the right to file a complaint with:
Office of Civil Rights US
Department of HHS
601 E. 12th St. · Rm 248 · Kansas City, MO
The Joint Commission Office of
One Renaissance Blvd. · Oakbrook Terrace, IL
994-6610 · (630) 792-5636 (fax)