HospitalInspections.org

Based on review of records and interview, the medical staff failed to execute the informed consent forms completely, in that on 2 of 2 consents for patient #23 were not properly executed.

Findings included:

On 7/17/2018, an informed consent for Patient #23 was executed for a Pleural drain placement. The risks and hazards were not completed on the consent. The physician did not date and time the consent with his signature.

On 7/24/2018, an informed consent for Patient #23 was executed for a Chemical Pleurodesis using doxycycline. The physician did not sign, date or time the consent.

Review of policy titled: Consent and Disclosure for Medical and Surgical Procedures on 10/18/18 documented:
It is the policy of Medical City Dallas Hospital that the patient and/or other surrogate decision maker has the right to be informed about and participate in decisions regarding his/her care...Prior to performance of certain medical, diagnostic (see procedures as listed in Section IV.D.3) and any surgical procedures, the medical staff (physician, oral surgeon, or podiatrist) must inform the patient and/or surrogate decision makes of the following:

C. Benefits, risk and undesired effects of the procedure, potential problems related to recuperation, the probability of improvement, the possible results/prognosis of non -treatment and significant alternative treatments...

An interview with Personnel #4 on 10/16/2018 at 1:25 PM confirmed that the risk and benefits were not listed on the informed consent for 7/17/2018. Furthermore, Personnel #4 also confirmed that the informed consent for 7/24/2018 was not signed by the physician and was not dated or timed.