HospitalInspections.org

Based on record review, four of 13 patient records lacked documentation that patients had given consent for treatment.

Findings:

1. Patient 3 was admitted to the hospital on 9/10/11 with cerebral edema (excessive fluid in the substance of the brain). Patient 3's medical record was reviewed on 9/14/11 at 8:45 a.m. The record indicated on 9/10/11 she had a central venous line inserted (a procedure to insert a catheter into a large vein in the neck or chest). There was no evidence in the chart that Patient 3 had consented to this procedure.

2. Patient 6 was admitted to the hospital on 9/10/11 with a subdural hematoma (collection of blood on the surface of the brain). Patient 6's medical record was reviewed on 9/14/11 at 9:30 a.m. The record indicated she received blood and blood products (plasma) without consent for this treatment.

3. The primary function of a hospital's "Conditions of Admission" form is to document the patient's consent to hospitalization and routine services provided [see California Hospital Association, Consent Manual, Chapter 8].

Patient 6 was admitted to the hospital on 9/10/11 for a subdural hematoma (collection of blood on the surface of the brain). A review of the patient's medical record was done on 9/14/11 at 9:30 a.m. There was no evidence the patient/representative had signed a hospital Conditions of Admission.

Patient 10 was admitted to the hospital on 9/5/11 for alcohol withdrawal. Review of Patient 10's emergency department record on 9/14/11 at 11 a.m. revealed he was confused during admission, and remained confused during his stay in the emergency department. Despite this assessment of confusion, the patient signed his Conditions of Admission. There was no evidence that Patient 10's mental capacity was clear enough to understand this consent.

Based on record review, the hospital failed to provide written evidence a patient has the right to formulate an advance directive for one of 13 sampled patients (6).

Findings:

Patient 6 was admitted to the hospital on 9/10/11 with a subdural hematoma (collection of blood on the surface of the brain). A review of the patient's medical record on 9/14/11 at 9:30 a.m. had no indication the hospital inquired, or provided, the patient or the patient's representative with information regarding advance directives.

Based on observation and interview, sterile supplies were not stored in a manner that ensured safety for patient use.

Findings:

On 9/14/11, an environmental tour was conducted on the medical intensive care unit (MICU). During the visit, an unidentified non-patient room was noted to be locked. When asked, staff did not know what was in the room nor did they have a key to open it. A master key was eventually located and the door was opened.

In this room there was a bronchoscopy (device/procedure to see inside the lungs) cart that included three containers of the medication Lidocaine (a local anesthetic). In addition to the cart, there were three sterile packs labeled Bronchoscopy stored on a footstool, one stored on top of a video monitor, and another on a makeshift shelf.

Storing sterile packs on a footstool and on top of a video monitor does not ensure the integrity and cleanliness of the sterile packs. In addition, because staff did not know who had access to the room or what was in the room, safety of the equipment and surrounding areas could not be ensured.