HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that medical records were accurately written for five of 19 medical records (MR11, MR13, MR21, MR37, and MR40) and information was accessible for one of 19 medical records (MR29).

Findings include:

Review of Interdepartmental Policy A#122 effective August 2013 "Patient Rights and Responsibilities" revealed, "Each inpatient and outpatient will receive a copy of the Patient Rights and Responsibilities brochure, as delineated below: Inpatients ... The patient Rights and Responsibilities brochure and the information sheet specific to each unit will be given to the patient and/or family/significant other at the time of admission to a unit. Receipt or refusal of Patient Rights and Responsibilities is documented on the Patient Safety-Admission Agreement form..."

Review of the Rules and Regulations of the Saint Vincent Health Center Medical Staff Manual approved October 8, 2013, revealed, "Article III General Conduct of Care Section 3.01 Informed Consent Medical Staff members will provide patients all reasonable information regarding the nature, benefits and risks of proposed procedures or treatments, and the nature, benefits and risks of alternatives to the treatment or diagnostic procedure that a reasonable person would consider material to the decision whether or not to undergo treatment or the diagnostic procedure according to Health Center policy..."

1. Review of MR11, MR13, MR21, MR37, and MR40 revealed all medical records contained a Patient Safety-Admission Agreement form. There was no documentation on the form to indicate whether or not the patient received or refused a copy of the Patient Rights and Responsibilities.

2. During an interview with the patient of MR21 on December 4, 2013, at approximately 1:25 PM, the patient confirmed (he/she) had received a copy of the Patient Rights and Responsibilities on admission.

Interview on December 4, 2013, at 1:55 PM with EMP40 confirmed the lack of documentation of the patient's receipt or refusal on the form.

3. Review of MR29 revealed the patient had a lumbar puncture performed on November 30, 2013. Further review of the medical record revealed a statement that informed consent had been obtained, however there was no documentation of an informed consent on the medical record.

During an interview with EMP3 on December 4, 2013, at approximately 2:45 PM, EMP3 stated the informed consent for MR29 was obtained but confirmed that the documented informed consent was not contained in the medical record.











E

The Condition for Physical Environment was found to be out of compliance during a Life Safety Survey completed on December 11, 2013. Further details are outlined in that Division of Life Safety Survey Report.