HospitalInspections.org

Based on document review and interview the facility failed to ensure 4 (Patient #3, #12, #15, and #18) of 10 patient records reviewed executed a properly signed consent for treatment. Also, the facility failed to follow the facility policy when obtaining a signed consent for treatment and have two witnessed signatures.

Findings include:


Patient #3

A review of Patient #3's medical record was conducted on 5/17/2022 with Staff #9 at after 12:30 PM. The medical record revealed there were two dates of service for treatment in the Emergency Room.

2/08/2022 Visit

A review of Patient #3's medical record dated 2/08/2022 was conducted with Staff #9. The medical record revealed she was transported to the Emergency Department (ED) by EMS (Emergency Medical Services). No consent for treatment was signed by Patient #3 or a legally authorized individual.

A review of the document titled, "ER TRIAGE SIGN-IN" revealed Patient #3's name and date of birth was documented, and EMS was documented as the reason for today's visit.

The bottom of the document was as follows:

" ...CONSENT FOR TREATMENT, I consent to hospital services, treatment and diagnostic procedures by the hospital as ordered by my physician and consultants selected by my physician, and I accept financial responsibility..."

No signature by Patient #3 or legally authorized representative was found within the medical record.


A review of the notes made by Staff #9 on 2/8/2022 at 9:02 AM was as follows:

"VERBAL OVER PHONE".

Staff #9 confirmed no name of an individual giving verbal consent for treatment was documented in the medical record.



2/10/2022 Visit

A review of Patient #3's medical record dated 2/10/2022 was conducted with Staff #9 on 5/17/2022. The medical record revealed Patient #3 was transported to the ED by EMS. No consent for treatment was signed by Patient #3 or legally authorized representative.

A review of the document titled, "ER TRIAGE SIGN-IN" revealed Patient #3's name and date of birth was documented, and EMS was documented as the reason for today's visit. The bottom of the document was as follows:

" ...CONSENT FOR TREATMENT, I consent to hospital services, treatment and diagnostic procedures by the hospital as ordered by my physician and consultants selected by my physician, and I accept financial responsibility..."

No signature by Patient #3 or legally authorized representative was found within the medical record.

A review of the notes made by Staff #18 on 2/10/2022 at 5:49 PM was as follows:

"PT DISCHARGED BEFORE GETTING CONSENTS".

Staff #9 confirmed no consent for treatment was in the medical record.



Patient #12

A review of Patient #12's medical record dated 2/10/2022 was conducted with Staff #6 on 5/18/2022. The medical record revealed Patient #12 was transported to the ED by EMS. No consent for treatment was signed by Patient #12 or legally authorized representative.

A review of the document titled, "ER TRIAGE SIGN-IN" revealed Patient #12's name and date of birth was documented, and EMS was documented as the reason for today's visit. The bottom of the document was as follows:

" ...CONSENT FOR TREATMENT, I consent to hospital services, treatment and diagnostic procedures by the hospital as ordered by my physician and consultants selected by my physician, and I accept financial responsibility..."

No signature by Patient #12 or legally authorized representative was found within the medical record.


A review of the notes made by Staff #18 on 2/10/2022 at 11:59 PM was as follows:

" ...2/10/2022 11:59 PM, Spoke with niece who updated contact info and gave verbal consent ..." No name of the individual giving was listed.

A review of the document titled, "FACILITY CARE CONSENT" revealed on the line for Signature of Patient/Legally Authorized Representative Staff #18 documented "VERBAL". The consent was witnessed by Staff #18 on 2/10/2022 at 9:00 AM. No second witness signed the consent.


Patient #15

A review of Patient #15's medical record dated 2/10/2022 was conducted with Staff #6 on 5/18/2022. The medical record revealed Patient #15 was transported to the ED by EMS. No consent for treatment was signed by Patient #15 or legally authorized representative.

A review of the document titled, "ER TRIAGE SIGN-IN" revealed Patient #15's name and date of birth was documented, and EMS was documented as the reason for today's visit. The bottom of the document was as follows:

" ...CONSENT FOR TREATMENT, I consent to hospital services, treatment and diagnostic procedures by the hospital as ordered by my physician and consultants selected by my physician, and I accept financial responsibility..."

No signature by Patient #15 or legally authorized representative was found within the record.


A review of the notes made by Staff #18 on 2/10/2022 at 5:04 PM was as follows:

" ...2/10/2022 5:04 PM, Pt vrfyd (sic) demo and gave verbal consent ..."

A review of the document titled, "FACILITY CARE CONSENT" revealed on the Signature of Patient/Legally Authorized Representative Line Staff #18 documented "VERBAL". The consent was witnessed by Staff #18 on 2/10/2022 at 2:51 PM. No second witness signed the consent.

Patient #18

A review of Patient #18's medical record dated 3/02/2022 was conducted with Staff #6 on 5/18/2022. The medical record revealed Patient #18 was transported to the ED by Arkansas EMS. No consent for treatment was signed by Patient #18 or legally authorized representative.



A review of the notes made by Staff #19 on 3/02/2022 at 2:13 AM was as follows:

" ...03/02/2022 2:13 AM, Pt here via EMS from Arkansas Nursing & Rehab. Pt here alone. Unable to verify or sign due to altered mental status..."

A review of the document titled, "FACILITY CARE CONSENT" revealed on the Signature of Patient/Legally Authorized Representative Line Staff #19 documented "VERBAL". The consent was witnessed by Staff #19 on 3/02/2022 at 1:09 AM. No second witness signed the consent. No name was documented on who gave verbal consent.

No signature by Patient #18 or legally authorized representative was found in the medical record.




An interview was conducted with Staff #9 on 5/17/2022 at 1:20 PM.
Staff #9 was asked to explain how the consent process was completed for patients that came by EMS or those that came through the Emergency entrance by private vehicle. Staff #9 stated, "When a patient comes through the ambulance entrance, we get the name, date of birth, and presenting symptoms. We will then register them, and the consent is printed and then we take the consents back there to the patient to get them signed. If we have to get a verbal consent, we do that and then sign it as a witness. We try and call a family member and get a verbal consent and then we put it in the notes. Sometimes when we are swamped with walk-ins it's hard to get back there." Staff #9 was then asked if a second witness signed the verbal consent, and she replied the nurse is usually in the room, but she doesn't sign the consent as a witness. Then we have to scan the consent into the record. Staff #9 was then asked if she was aware what the facility policy required to witnesses for verbal consents. Staff #9 replied, "No I was not aware of that."

An interview was conducted with Staff #8 on 5/17/2022 at 1:50 PM. Staff #8 was asked if the nurses ensured that a treatment consent was signed and witnessed by the nursing staff before any treatment was given to the patients. Staff #8 stated, "The only time we do consents is if there is a procedure that needs to be done. We just assume the consents are done by the registration clerk before they come back. If it's a lifesaving emergency they will not usually be signed anyway, but the clerks call family or have family sign when they get there."





A review of the facility policy titled, "Consent, Informed, Policy # AD-PP-35" with an approval date of 9/2020 was as follows:

" ...PURPOSE:

To assist the physician in communicating information concerning the diagnosis, treatment, surgery or procedure, benefits/risks/alternatives, and likely prognosis in terms that the patient can reasonably be expected to understand.

POLICY:

To safeguard the rights of the patients, it is the Hospital policy that the patient has the opportunity to discuss treatment, surgery, and procedures with the patient's physician before they are begun. The patient has the right to consent or refuse the treatment, surgery, or procedures. Except in emergencies or unusual circumstances, the hospital facilities cannot be used without this discussion and patient's consent.

The legal signing of consent is in accordance with the laws of the State of Texas.

Adults-who may consent

Those persons eighteen years of age or older and who are not incompetent may give consent.

Surrogate decision makers may consent for an adult when an adult patient in a hospital is comatose, incapacitated, or otherwise mentally or physically incapable of communication or decision-making.
...
A surrogate decision-maker's consent to medical treatment that is not made in person shall be reduced to writing in the patient's medical record, signed by the hospital staff member receiving the consent, and countersign in the patient's medical record or on an informed consent form by the surrogate decision-maker as soon as possible ..."



Staff #1, #2, #6, #8, #10, and #12 confirmed all verbal consents require 2 signatures from hospital personnel.

Staff #1, #2, #6, #8, #10, and #12 confirmed the findings.