HospitalInspections.org

Based on record review and interview the facility failed to provide the patient or his/her representative the right to make informed decisions regarding his or her care by documenting "verbal consent" only on Consent for Treatment form with no explanation of who gave consent or what was discussed for 10 (P1 (Patient) through P10) of 10 patient records reviewed. This deficient practice increases the likelihood of patients being unaware of the treatment they are consenting to.

The findings are:

A. Record review for P1 through P10 reveals:

1. Record review for P1 discharge date 09/14/21, consent to treatment not present in chart. Hard copy of the consent provided has "verbal consent" written in signature box with no mention of who gave verbal consent or what was discussed.

2. Record review for P2 discharge date 09/14/21, consent to treatment present in chart with "verbal consent" typed in the signature box with no mention of who gave verbal consent or what was discussed.

3. Record review for P3 date of discharge 09/15/21 consent states "verbal consent" only with no mention of who gave verbal consent or what was discussed.

4. Record review for P4 discharge date 09/15/21 consent to treatment present in chart with "verbal consent" written in the signature box with no mention of who gave verbal consent or what was discussed.

5. Record review for P5 discharge date 09/15/21, consent to treatment not present in chart but hard copy stating "verbal consent" provided with no mention of who gave verbal consent or what was discussed.

6. Record review for P6 discharge date 09/15/21 consent to treatment present in chart with "verbal consent" written in the signature box with no mention of who gave verbal consent or what was discussed.

7. Record review for P7 discharge date 09/16/21, no consent to treatment present in chart but provided hard copy that states, "verbal consent" with no mention of who gave verbal consent or what was discussed.

8. Record review for P8 discharge date 09/16/21, consent to treatment present in chart with "verbal consent" written in the signature box with no mention of who gave verbal consent or what was discussed.

9. Record review for P9 discharge date 09/16/21 consent to treatment present in chart but hard copy with "verbal consent" written in the signature box with no mention of who gave verbal consent or what was discussed.

10. Record review for P10 discharge date 09/16/21, consent to treatment not present in chart but hard copy with "verbal consent" written in the signature box with no mention of who gave verbal consent or what was discussed.

11. Record review of Policy titled Informed Consent dated 08/1980 and revised 11/2018 shows all consents need to be explained, signed and dated. Email chain documented 08/12/21 from educator from corporate office forwarded to the facility and the Patient Access Manager from Parent facility gives the "OK" for verbal consent but does not define to procedure or process needed and there is no change to the policy noted.

B. On 11/09/21 at 10:00 am during interview with Chief Nursing Officer and Quality Specialist (S(Staff)1 and S2) who confirmed, "the facility has been using verbal consent since August 2021 as per the main office. The facility did not make changes to the policy. To my knowledge (CNO) this has not been addressed in the Governing Body."

C. On 11/09/21 at 1:34 pm during interview with Patient Access Manager (S4) who confirmed, "It came about because of percentages of covid-19 (an illness caused by a coronavirus called SARSCov2 that can be transmitted through contact with another person who has the virus) positive patients that were 30-40 percent in this area. Hospitalizations were increased and patients were overflowing in the Emergency Room and staff was also having high covid numbers. The facility went to the process of adopting a "verbal consent" process. The patient or family member is asked to provide verbal consent. The decision was made by corporate legal offices and risk management that was discussed with regional and corporate office. The decision was adopted in late August and it was implemented. I am not aware of how long it took to implemented. I was not provided an actual policy but there were discussions about making sure patients are aware of the "verbal consent". It is done with the patient in front of them and they provide the form if it is requested. I reached out to the corporate office to ask if there has been a policy written but have not received a response. We will make changes within 24 hours"

Based upon record review and interview the facility failed to ensure that the Quality Assessment Process Improvement (QAPI) committee reported to the governing body about waiver for the verbal consent of a patient. This failed practice is likely to result in inconsistent care of patients .

The findings are:

A. Record review of the Quality Assessment Process Improvement (QAPI) committee meeting minutes revealed no
documentation of a verbal consent waiver presented in the quality committee meeting in September or October 2021.

B. On 11/09/2021 at 11:43 am during interview with S(Staff)3 (Director of Operations) confirmed that the verbal consent waiver was not addressed in the QAPI or Governing Body Committee Meeting.

Based on record review and interview the facility failed to ensure that discharge plans are responsive to the patients post-discharge needs when discharged home for 1 (P(Patient)#3 out of 10 patient records reviewed. This failed practice is likely to cause patients to be discharged without the proper instructions to care for the patient at home.

Findings are:

A. Record review of P(Patient)#3 medical chart revealed, on 9/15/2021 at time of discharge the patient did not receive instructions on what to do in case of an emergency or who to contact if the patient had complications while at home.

B. On 11/09/2021 at 3:00 pm during interview with S(Staff)#1, confirmed that the facility uses five different computer systems and programs that causes inconsistencies in the discharge process.