HospitalInspections.org

Based on medical record reviews and staff interviews, the hospital failed to ensure that 1 of 10 sampled records (Pt. #1) contained pertinent information in regard to how an injury occurred, pertinent information of the treatment by Physician D, exact location of injury on face, and depth of the wound. This has the potential to affect all pts. who present to the ED. A 3 day average of pts. who presented to the ED on 8/16/13 through 8/18/13 is 21 pts. per day.

Findings include:

Per review of the ED medical record of Pt. #1 on the afternoon of 10/30/13, Pt. #1 entered the ED on 8/16/13 at 1:29 p.m. with a 1 cm laceration over mandible. Depth or if superficial, and which side of face not identified. There is no history documented as to how this injury occurred by either RN C or Physician D. Physician D did not document procedure performed. RN C documented that 2 sutures were placed. Type of sutures is not documented.

Per interview with ED Manager A at 2:31 p.m. on 10/30/13, when Surveyor asked A if felt documentation of Pt. #1's 8/16/13 ED visit was complete, A said, "No."

Per interview with Physician B at 3:10 p.m. when Surveyor mentioned that ED documentation of Pt. #1's 8/16/13 visit was vague, B stated, "I agree."

Based on policy review, medical record reviews, staff interviews, and individual interview, the facility failed to ensure that appropriate legal authorized individual signed or gave verbal consent to treat 1 of 10 pts. sampled (Pt. #1) and failed to obtain consent to treat 1 of 10 pts. sampled (Pt. #10). Failure to obtain appropriate consents to treat pts. who enter the ED has the potential to affect all pts. presenting to the ED, which is of a 3 day average from 8/16/13 through 8/18/13, 21 pts. per day.

Findings include:

A 10/30/13 afternoon review of policy entitled, "Informed Consent" , effective 3/1/12 and last updated 3/1/13, states the following under #8:

"Non-Abandoned Minors with Unavailable Parents-Legally, only the parent or legal guardian can give valid consent for treatment of a child, in the absence of an emergency.

1.) Per telephone interview with RN C, beginning at 12:38 p.m. on 10/30/13, C said individual E was on the phone in the ED where Pt. #1 was roomed on 8/16/13. When C asked E if was calling Pt. #1's mother F, E said was. Per RN C, said did not hear phone discussion of E.

Per telephone interview with Individual E beginning at 1:56 p.m. on 10/30/13, E stated that informed registration RN C and CNA G upon entrance that had no parental rights-only visitation rights for Pt. #1. Per E, E tried to telephone biological mother of Pt. #1 F and was unable to reach F by phone. Per E, Pt. #1 had a 1 cm laceration in right lower cheek right above jaw.


Per medical record review of Pt. #1 on the afternoon of 10/30/13, the following was noted:

Pt. #1 was brought into the ED by mother of child per RN C documentation. Review of the form entitled: "Consent to arrange payment and release Information was signed and under relationship to Pt. Individual E printed "mother".

Per face to face interview with CNA G at 3:00 p.m. on 10/30/13, when G was asked if Individual E had said that had no parental rights when brought Pt. #1 into the ED on 8/16/13, G replied, "She (E) did tell me right when she came into the room. She (E) said, ' I just want to let you know I don't have parental rights. I've been trying to get a hold of the Mom." '

During the exit interview with ED Director- Physician B and ED Manager A at approximately 3:10 p.m. on 10/30/13, when it was mentioned by Surveyor that there was no documentation in the 8/16/13 ED record of Pt. #1 that hospital staff tried to contact biological Mother F, A said, "No, there wasn't." B said, that Individual E should not have put relationship as mother on the consent form.


2.) Per medical record review of Pt. #10 beginning at 12:12 p.m. on 10/30/13, Pt. #10 presented to the ED at 3:16 p.m. on 8/17/13 with gastrointestinal bleeding, was examined by the ED physician, and tests were completed for treatment. No consent for treatment form was in the record. This was shared with ED Manager A at the time. At 2:17 p.m. on 10/30/13, A said that there was no consent form for Pt. #10's 8/17/13 visit.