HospitalInspections.org

Based on medical record review, staff interview and policy review, the facility failed to ensure the patient or his or her representative has the right to make informed decisions regarding his or her care for two of ten patients reviewed (Patient #1 and #6). This could affect all patients receiving services from this facility. The facility census was 82.

Findings include:

Review of the facility's policy titled, General Consent Standard Operating Procedures, last approved or reviewed 03/10/21, revealed the purpose of this standard operating procedure was to provide action steps for Patient Services Specialists (PSS) or other appripriate caregivers, to utilize best efforts to obtain signature of a patient or authorized representative on the Patient Acknowledgement and Consent Form appropriately and timely. The Patient Acknowledgement and Consent Form is the form patients are asked to sign that indicates, generally, they provide consent for one or more of the following, they acknowledge receipt of Notice Of Privacy Practices, and consent to its terms, they agree to comply with financial expectations, they consent for routine care, they acknowledge some of their caregivers may be trainees; they acknowledge an understanding about patient valuables, etc. The PSS are required to use best efforts to obtain signatures on the Patient Acknowledgement and Consent Form during the registration/check in process.

1. Review of the medical record for Patient #1 revealed an admission date of 01/14/22. Review of the "Patient Acknowledgement and Consent Form" revealed Patient Services Specialist (PSS) had made handwritten entries on the consent as follows: 01/15/22 at 11:39 AM patient isolated, unable to sign, first attempt and initialed the entry. Another entry by PSS staff documented on 01/15/22 at 4:32 PM patient isolated, unable to sign and again initialed the entry. A third entry by PSS staff was dated 01/15/22 at 8:35 PM patient iolated unable to sign, third attempt. The medical record lacked documentation of any further attempts to obtain general consent for treatment. In addition, the medical record contained documentation facility staff were in contact with the family and there was a Durable Power of Attorny (DPOA) advanced directive in the medical chart designating a family member as the responsible party.

Interview with a Patient Services Specialist on 02/09/22 at 1:30 PM confirmed the facility made three attemtps but was unable to provide documentation that attempts to reach the duly appointed surrogates were made.


21893

2. Review of the medical record for Patient #6 revealed an admission date of 01/27/22. Review of the "Patient Acknowledgement and Consent Form" revealed documentation on 01/27/22 at 2:02 PM, 2:20 PM, and 2:35 PM that staff made three attempts to interview the patient but were unable to do so due to the patient's condition. The medical record lacked documentation of any further attempts to obtain general consent for treatment. The medical record documented that the patient was unresponsive on arrival to the emergency department on 01/27/22 at 1:54 PM. The patient was intubated emergently and placed on a ventilator on 01/27/22 at 2:53 PM. The medical record contained documentation procedural consents were obtained on 02/01/22 and 02/03/22 from the patient's representative. In addition, the medical record contained documentation facility staff were in contact with the family.

Based on policy review, medical record review, and staff interview, the facility failed to ensure a physician order was obtained for non-violent restraints according to policy and procedure for one of one medical record reviewed with restraints (Patient #6). A total of ten medical records were reviewed. The census was 85.

Findings include:

Review of the policy titled, "Restraint Use Procedure for Nonviolent/Non-Self Destructive Behavior," effective 12/18/19, revealed a renewal restraint order must be obtained every calendar day.

Review of the medical record for Patient #6 revealed an admission date of 01/27/22. Nursing flowsheets noted monitoring and documentation of the non-violent restraints from 01/27/22 at 11:00 PM through 01/30/22 at 3:29 PM, when the restraints were discontinued. The medical record lacked evidence of a physician order for bilateral soft wrist restraints for 01/30/22.

Staff A and B confirmed these findings during an interview on 02/10/22 at 8:00 AM.