HospitalInspections.org

Based on interviews and medical record review, the facility failed to honor the patient's representative the right to refuse treatment for 1 (Sample Patient #10) out of 10 sampled patient medical records. This resulted in the patient (Patient #10) receiving a surgical intervention that was not consented for by the mother of Patient #10.


The findings include:


1. An interview with the mother of Patient #10 was conducted on August 09, 2016 at 5:15 PM. She stated, "My daughter was taken to the facility; my mother, who is her caregiver, has taken her to the hospital for a bowel obstruction. Basically, surgery was done without my consent; The doctor felt that it was an emergency situation. If they had spoken with me, they would have known. I told them that if they spoke with me, they would have seen that the Power of Attorney was not valid...I told everyone that I did not want her to have surgery."


2. A review of the medical record for Patient #10 (Subject of complaint) documented that the patient was admitted on July 7, 2016 and discharged from the facility on July 22, 2016. The patient's Grandmother consented for the admission to the hospital.


a.) The medical record also documented, in the History of Present Illness (HPI) that the patient has a history of cerebral palsy, seizures, colostomy, and signs of shortness of breath (s/o SOB), who presents with complaint of abdominal distension, described as increasing in severity over the past few months.

3. A review of the medical record for Patient #10, who was admitted to the facility on multiple occasions, including the following dates and had the Consent for Treatment at the facility signed by the Grandmother on the following dates:

a.) Admitted for Laparotomy performed in the main operating room at the facility on 1/20/2016 (Consent signed by Grandmother).

b.) Admitted for a Colonoscopy performed in the main operating room at the facility on 1/20/2016 (Consent signed by Grandmother).


4.) A review of the Patient Face Sheet, which documented emergency contact information for this patient, lists the mother of Patient #10 as an emergency contact, and includes her phone number; in the second spot for emergency contact information, the Grandmother is documented, also with a phone number.


5.) A review conducted of the scanned Power of Attorney requested, and it is dated as entered into the patient's medical record on the day of the procedure, July 7, 2016. The Power of Attorney was stated by (Employee E) to have been discovered by the hospital to represent the Grandmother as a Power of Attorney over the daughter's estate and/or business affairs legally, and this was not a representation for the Grandmother to make medical decisions for the patient.


6.) An interview was conducted with Employee A on August 11, 2016 at 9:57 AM. She stated, "If the patient does have an Advanced Directive, we notate that on the form. If they don't have one, we inform the medical staff, who would direct them to Case Management. Every patient receives a Patient Rights book."


7.) An interview was conducted with Employee B on August 11, 2016 at 12:15 PM with (Employee C) present and she stated that by the time she was introduced to the case by (Employee D), the facility had reviewed the Power of Attorney, because the mother contacted the facility and told them that she did not want Patient #10 to have the procedure (The procedure had already been performed). A review of the Advanced Directive was conducted by the Legal Department at this time, revealing that the Grandmother did not have the authority to make medical decisions for Patient #10. Employee B also stated during this interview, that the facility would follow Florida Statutes as consenting authority on medical procedures.