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Based on medical record review, policy review, and staff interview the facility failed to ensure all patient consent forms were completed by the appropriate person in a timely fashion. This affected one of ten medical records reviewed (Patient 9).

Findings include:

The medical record for Patient 9 was reviewed on 05/06/10. The patient was admitted to the facility at 3:37 PM on 01/28/10. The consent form was not completed until 01/28/10 at 8:10 PM, over four hours later. Verbal consent was given at that from the patient's guardian and witnessed by two nurses. The medical record contained a clinical note dated 01/28/10 at 8:10 PM that stated the guardian called the hospital, stated consent for treatment had not been given and demanded to know what was happening to the patient. The clinical note also stated the guardian's questions were answered and verbal consent obtained at that time.

Staff B was interviewed on 05/06/10 at 1:45 PM. Staff B stated consents usually are obtained immediately upon arrival at the facility. If the patient cannot sign, the power of attorney or guardian would be contacted and verbal consent obtained. If the power of attorney or guardian could not be reached, a note would be entered into the registration system. The registration system note for Patient 9 dated 01/28/10 at 3:54 PM was then reviewed. This note stated Patient 9 could not sign the consent forms and the advanced directive forms were printed and sent to the nursing floor. The note lacked documentation of contact or attempted contact of the patient's guardian. Staff B could not speak to whether or not the guardian was contacted for consent.

The policy for Consent - General and Minors was reviewed on 05/06/10. The policy stated that consent for a physician declared incompetent patient would be obtained by the person with legal authority, power of attorney or guardian, to consent on behalf of such person. The policy lacked documentation of a time frame to obtain the consent for treatment.

Staff A was present during review of Patient 9's medical record and Staff B's interview and discussed all findings at the time they were discovered.

This substantiates Complaint OH00053709.