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CHRISTUS ST VINCENT REGIONAL MEDICAL CENTER
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on interview and record reviews the facility failed to obtain a consent for treatment for 1 (P [patient] 10) of 10 (P1-P10) patients being reviewed for Patient Rights. This failed practice to obtain consent is likely to result in a violation of patients' rights to consent or refuse treatment.
The findings are:
A. Record review of the facility's policy titled "Patient Rights and Responsibilities" Dated 05/30/23, stated "Informed Consent: You have the right to reasonable, informed participation in decisions involving your health care. You have the right to give informed consent prior to the start of any procedure or treatment."
B. Record review of P10's Medical Record revealed P10 was admitted to the facility on 03/11/24, and discharged on 03/17/24, home with a family member. During this time the patent received treatment including medications, laboratory blood samples, diagnostic imaging (the use of electromagnetic radiation and certain other technologies to produce images of internal structures of the body for the purpose of accurate diagnosis) and assessments. The patient was noted to be alert and oriented and also had family members at the bedside.
C. Record review of the P10's Medical Record section "Registration History for the Patient Encounter" stated on 03/13/2,4 at 10:34 AM "[name of facility] REG [registration] PT [patient] MISSING CONSENT FOR TREATMENT" and on the day of discharge 03/17/24 ,at 12:50 PM "[name of facility] REG PT MISSING CONSENT FOR TREATMENT DOCUMENT," indicated that consent for treatment had not been obtained.
D. During an interview with Staff (S)12, Patient Access Service Director, on 03/27/24, at 11:38 AM, S12 confirmed that there was no consent for treatment obtained for P10. When asked who should sign a consent for treatment form. S12 stated "The patient, if the patient is not able to give consent, then we would ask a family member or someone that can give consent for the patient." When asked what patients should give consent for treatment. S12 stated "all patients."