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 not getting signature on Consent for Treatment form for 3 (P3 (Patient), P13, P26) of 30 patient records reviewed. This deficient practice increases the likelihood of patients being unaware of the treatment they are consenting to.

A. Record review for P3 discharge date 11/09/21, consent to treatment not present in chart, no signature of consent obtained.

B. Record review for P13 discharge date 11/05/21, consent to treatment not present in chart, no signature of consent obtained.

C. Record review for P26 discharge date 10/30/21, consent to treatment not present in chart, no signature of consent obtained.

D. On 01/13/22 at 2:00 pm during interview with S(Staff) #16, Manager of Case Coordination and S17, Executive Director of Case Management "In our discharge policy, undated, care coordination is called in to find next of kin as a part of the care team. It is written in the policy. We use as many means as we can to get the information. We can call pharmacy, doctor's office and such to find next of kin." If there is a referral for case coordination to find next of kin for consent for treatment we work as a part of the team but getting the consent signed is not a part of a case coordinators role, but we do coordinate with the treatment team. In terms of consent there is do process that we follow at this time. For say insurance purposes we communicate with the financial office. We are a team and it is not a usual task we do but it can happen and we work as a part of the team."