HospitalInspections.org

Based on interview and record review, it was determined that the facility failed to afford 9 of 10 sampled patients the right to give written consent for treatment resulting in the potential for a loss of rights for all patients. The findings include:

10 Emergency Department (ED) records were reviewed.
Patient #1's medical record revealed the patient was treated in the facility ED on 5/31/2021. Review of Patient #1's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #2's medical record revealed the patient was treated in the facility ED on 7/29/2021. Review of Patient #2's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #3's medical record revealed the patient was treated in the facility ED on 08/01/2021. Review of Patient #3's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #5's medical record revealed the patient was treated in the facility ED on 07/23/2021. Review of Patient #5's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #6's medical record revealed the patient was treated in the facility ED on 06/19/2021. Review of Patient #6's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #7's medical record revealed the patient was treated in the facility ED on 07/04/2021. Review of Patient #7's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #8's medical record revealed the patient was treated in the facility ED on 07/08/2021. Review of Patient #8's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #9's medical record revealed the patient was treated in the facility ED on 05/20/2021. Review of Patient #9's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

Patient #10's medical record revealed the patient was treated in the facility ED on 05/21/2021. Review of Patient #10's consent for treatment revealed that on the line for patient signature the word "verbal" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form.

In an interview on 8/3/2021 at 1155, Staff D stated it was the general practice, since Covid, for registration staff to obtain verbal consent from all patients, without regard to mental status or capacity. Staff D stated they would need to have the Infection Control team do an education with the registration staff on how to approach patients so written consent could be obtained. When the surveyor requested a copy of the consent policy and procedure, Staff D stated the facility did not have one for this situation or area.