HospitalInspections.org

Based on a review of facility documents and staff interview (EMP) it was determined that the facility failed to obtain a properly execute an informed consent for one of one medical record reviewed(MR1)

Findings:

A review of facility policy revealed;

"... Informed consent Policy, Date 9/18... II ...
3. General Rule: Incompetent Patient - Except in cases of emergency, if the adult patient is incompetent to provide informed consent, substitute consent must be obtained from, in descending order, the following: (1) the legal guardian or the holder of a power of attorney which specifically authorizes the holder to make medical treatment decisions or a surrogate specified by the patient in an advance directive, (2) a spouse, unless an action in divorce is pending AND there are adult children of the patient who are not children of the spouse, (3) an adult child, (4) a parent, (5) an adult sibling, (6) an adult grandchild or (6) an adult who has knowledge of the patient ' s preferences and values, including but not limited to religious and moral beliefs, to assess how the patient would make health care decisions ..."

"... Policy Number HPA011 ... Date Created 11/20/2017 ... Obtaining Consent and Contact Phone Number in the ED...Procedure: ... III. UNABLE TO SIGN
a. This indication can only be used if the patient is transferred out of the facility, discharged from the facility, or deceased with no family available.
b. If the patient is unable to sign and there is no legal representative available, the registrar will document this in Hospital Account Notes and will choose to mark the consent as "UNABLE TO OBTAIN" from the menu in Epic Documents
c. If the patient is unable to sign the reason must be documented
i. Patients physical condition
ii. Mental status
d. Use of this status must be witnessed on the consent document by a non-registration staff member

The review of MR1 revealed that the "Wellspan Health Consent for Treatment" was signed by 2 witnesses and indicating "... Patient is unable to sign because ______ ..." The form had "condition" hand written into the blank space.

Interview on October 8, 2019, with EMP1 revealed that the RN signed consent for treatment (RN does not remember who asked her to sign or why she signed the consent for treatment) just that the patient was unable to sign and at that time. Further interview revealed that nursing staff on the Behavioral Health Unit were aware of the Guardianship but only by looking at the old medical records would other staff throughout the hospital become aware of the guardianship.