HospitalInspections.org

Based on record review, interview, and facility policy review, the facility failed to ensure health care services were provided in accordance with the facility's established policies for two of ten patients (Patients #1 and #3). Patients #1 and #3 presented to the Emergency Room (ER)/Emergency Department (ED) seeking treatment, however, the facility failed to obtain consent for treatment from Patient #1 and Patient #3's Legal Guardians, in accordance with the facility's policies.

The findings include:

Review of the facility's "Registration of Emergency Room Patients" policy (revised 01/27/10) revealed, "The triage nurse examines the patient and determines the level of care and order of medical screening. At this time he/she will obtain consent for treatment."

Review of the facility's "Admission of Patients to the Emergency Department" policy (revised 09/17/09) revealed, "All Emergency Department patients must sign a 'Consent for Treatment in the Emergency Department' form. If the patient is unable to sign, the significant other may sign. If no one available is authorized to sign the consent, document the reason patient is unable to sign."

Review of the facility's "Consent to Treatment of Patients in the ER who have Legal Guardians or POA's" policy (dated June 2010) revealed, "to receive medical treatment, someone must consent to the provision of such treatment." The review revealed ER staff must make an attempt to contact the Legal Guardian/POA before the provision of treatment except in "true" emergency situations. The policy stated if staff was unable to reach the Legal Guardian, staff was to leave a message "with the call back number of 545-5546" and document the contact or attempted contact in the nursing documentation. The policy also stated when a patient was admitted to the nursing unit the ER staff would inform the receiving unit in the "hands off communication" that staff had spoken to the Legal Guardian or left a message. If ER staff had left a message for the Legal Guardian, the receiving nursing unit would be responsible to continue attempts to contact the patient's Legal Guardian.

1. A review of Patient #1's medical record revealed the patient presented to the ER from a nursing home on 10/21/11, and was admitted to the facility with an admission diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease with possible Aspiration Pneumonia. The review revealed the nursing home had sent Patient #1's "Admission and Discharge Summary" sheet or face sheet and "Resident Transfer" form, both of which indicated the patient was "State Guardianship" and listed the guardian's name and contact information. Further review of Patient #1's record revealed the "Authorizations and Consents" form was blank and did not contain dates or the guardian's signature. In addition, the medical record revealed no documented attempts to obtain consent to treat from Patient #1's Legal Guardian.

2. A review of Patient #3's medical record revealed the patient presented to the ER from a nursing home on 10/22/11, and was admitted to the facility with an admitting diagnosis of Large Bowel Obstruction. The review revealed the nursing home had sent an "Admission Information Sheet" which contained the patient's Responsible Party's name and contact information. Further review of Patient #1's record revealed no "Authorizations and Consents" form in the chart and there were no signatures or dates on the Patient's Rights form. In addition, the medical record revealed no documented attempts to obtain consent to treat from Patient #3's Legal Guardian.

Review of both patients' medical records revealed RN #1 provided treatment for the patients while they were in the ER. Interview conducted on 12/08/11, at 5:20 PM, with Registered Nurse (RN) #1 revealed the nurses were responsible to contact and obtain consent to treat patients with a Legal Guardian as per the facility policy. RN #1 stated nurses were to make several attempts to contact the patient's legal guardian, document the contact or attempted contacts in the nurse's notes, and report the attempted contacts to the nursing unit that would receive the patient for admission. The interview revealed RN #1 was unable to explain why she had not obtained consent to treat or documented the attempts to contact the Legal Guardians for Patients #1 and #3.

Interviews conducted on 12/08/11, at 4:55 PM and 5:10 PM, with Licensed Practical Nurses (LPNs) #1 and #2 revealed ER nurses were responsible to obtain the patients' consent for treatment while patients were in the ER, and prior to admission to the nursing unit. However, the interviews revealed the LPNs did not confirm/verify that consent to treat had been obtained prior to admission to the unit.

Interviews conducted on 12/08/11, at 4:20 PM and 4:35 PM, with the ER Director and the Director of Nursing (DON) revealed nurses in the ER had the responsibility to obtain consent for treatment from all patients that presented to the ER, and included consent to treat patients with Legal Guardians. The interviews confirmed nurses were required to document attempts to contact the Legal Guardian, as applicable, in the nurse's notes and to inform the nursing unit that admitted the patient of the unsuccessful attempts.