HospitalInspections.org

Based on review of documentation and interview it was determined that the facility did not ensure that informed consent documents were properly executed.

Findings were:

A facility policy entitled " Informed Consent " stated in part,
" A. Documentation
(1) In an adult patient in a hospital is comatose, incapacitated or otherwise mentally or physically incapable of communication and, according to reasonable medical judgment, is in need of medical treatment, the attending physician shall describe the:
(i) Patient ' s comatose state, incapacity, or other mental or physical inability to communicate in the patient ' s medical record; and ...
(d)obtain a signed disclosure and consent form, evidencing such informed consent, from the patient or surrogate decision-maker, as appropriate."

A review of medical records revealed 3 of 3 patients with consents signed by another individual that did not include an explanation why the patient was unable to sign the form.
? Patient # 1 had a Patient Authorization Record which included the " Authorization for Care " which signed by another individual (daughter), the area indicating " Reason Patient Unable to Sign " was blank. Patient #1 signed consents in other portion of the medical record and the triage note indicated the patient was alert and oriented upon admission. Patient #1 also had Advanced Directives listing her two sons, not a daughter as her Power of Attorney.
? Patient # 5 had a Patient Authorization Record which included the " Authorization for Care " which signed by another individual (wife), the area indicating " Reason Patient Unable to Sign " was blank. Patient #1 signed consents in other portion of the medical record and the triage note indicated the patient was alert and oriented upon admission.
? Patient # 8 had a Patient Authorization Record which included the " Authorization for Care " which signed by another individual (mother), the area indicating " Reason Patient Unable to Sign " was blank. Patient #1 signed consents in other portion of the medical record and the triage note indicated the patient was alert and oriented upon admission.

This lack of properly executed consent forms was confirmed in an interview with staff member #1 on 01/15/13.