HospitalInspections.org

Based on medical record review and interview, the facility failed to maintain patient records that include properly executed informed consent for 1 out of 10 patients in a surgical survey sample of 10 and 2 of 23 patients in an inpatient survey. The facility failed to document giving the Patients Bill of Rights to 11 out of 11 off site patients. (Patient identifiers are #2, #11, and #13.)

Findings include:

Patient #11
Review of the medical record on 7/20/16 revealed a current consent for Patient #11 that had entered though the emergency room. The current consent was not signed by the patient but was signed by a witness; however, it was not indicated on the consent form who this witness was in relationship to Patient #11.

Interview with Staff A, (RN Unit Manager), on 7/20/16 at 11:30 p.m. confirmed the informed consent for Patient #11 did not indicate the relationship to Patient #11.

Patient #13
Review of the medical record on 7/20/16, revealed a consent for Patient #13 that was not signed by the patient. The "Authorization for Treatment, Assignment of Benefits and Financial Agreement" Form was blank.

Interview with Staff A, (RN Unit Manager), on 7/20/16 at 11:30 p.m. confirmed the informed consent for Patient #13 was a blank form.



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Patient #2
Review on 7/20/16 of an off-site family practice's medical record for Patient # 2 revealed that there was a consent form for treatment signed and dated for March 2013 but not a current consent form signed and dated for a March 15, 2016 office visit.

Interview on 7/20/16 at 1:30 p.m. with Staff B confirmed that there was not a current signed consent form for treatment.

Review of 11 off-site medical records revealed that none of the records contained any documented evidence that the patients were given a copy or had the opportunity to review the State of New Hampshire Patients Bill of Rights.

Interview on 7/20/16 with Staff B (Practice Manager) confirmed the above findings.

Based on observation and interview, it was determined that the facility failed to ensure that all areas where medical records are stored are secured from unauthorized access.

Findings include:

Observation on 7/20/16 of the medical records department revealed a secure area where medical records were being processed.

Interview on 7/21/16 with medical records staff revealed that the hours of operation ended at 5 P.M., at which time the environmental services staff would enter the area to clean. Medical records staff confirmed that there was no process in place to secure the medical records from potential unauthorized access during the off hours.