HospitalInspections.org

Based on record review, staff interview and review of policy and procedures, the facility failed to ensure 5 of 14 (Patient 6, 9,10, 13, and 5) surgical patient records were timed when the physician and/or the anesthesiologist signed the consents. This failed practice had the potential to affect all surgical patients of the facility. The facility census was 280.

Findings are:

A. Review of the "Surgical Consents and Informed Consents" policy and procedure, last revised 6/2020 identified:
-All consent forms must be witnessed and dated by a staff member at least 18 years of age. A properly executed consent form must contain the following, Legible full signature (First and Last name) of patient or person legally authorized to consent on behalf of the patient; and a date and time consent is obtained.

B. Review of Patient 6's surgical medical record, identified that the patient was admitted on 8/23/23 for weight reduction surgery (robotic assisted laparoscopic sleeve gastrectomy). Review of Patient 6's "Consent for Surgery, Diagnostics or Therapeutic Procedure" dated 8/23/23 showed the patient and registered nurse (RN K) signed the form at 6:10 AM on 8/23/23. Physician W (MD W) signed and dated the form, the form lacked the time MD W signed the form.

-Review of Patient 9's surgical medical record, identified that the patient was admitted on 8/23/23 for a hysterectomy and bladder repair surgery (laparoscopic vaginal hysterectomy, bilateral salpingoophorectomy, posterior colporrhaphy with allograft and bilateral sacrospinous ligament suspension, anterior colporrhaphy, sling and cystoscopy). Review of Patient 9's "Consent for Surgery, Diagnostics or Therapeutic Procedure" dated 8/23/23 showed the patient and registered nurse (RN L) signed the form at 12:30 PM on 8/23/23. Physician C (MD C) signed and dated the form on 8/23/23, the form lacked the time MD C signed the form. The "Consent for Anesthesia Service" form showed the patient and RN L signed on 8/23/23 at 1:00 PM. Anesthesiologist M (Dr M) signed and dated the form 8/23/23, the form lacked the time Dr M signed the form.

-Review of Patient 10's surgical medical record, identified that the patient was admitted on 8/25/23 for a heart valve replacement (Aortic Valve Replacement). Review of Patient 10's "Consent for Surgery, Diagnostics or Therapeutic Procedure" dated 8/25/23 showed the patient and registered nurse (RN Z) signed the form at 5:45 AM. Physician B (MD B) signed and dated the form on 8/25/23, the form lacked the time MD B signed the form. The "Consent for Anesthesia Service" form showed the patient and RN Z signed on 8/25/23 and the Anesthesiologist A (Dr A) signed and dated the form 8/25/23, but lacked a time Dr A signed the form.

-Review of Patient 13's surgical medical record, identified that the patient was admitted on 8/24/23 for a repeat cesarean section. Review of Patient 13's "Consent for Surgery, Diagnostics or Therapeutic Procedure" dated 8/24/23 showed the patient and registered nurse (RN H) signed the form at 9:00 AM on 8/24/23. Physician K (MD K) signed and dated the form on 8/24/23, the form lacked the time MD K signed the form.

-Review of Patient 5's surgical medical record, identified that the patient was admitted on 8/23/23 for prostate surgery (Radical Prostatectomy). Review of Patient 5's "Consent for Anesthesia Service" form showed the patient and RN H signed on 8/23/23 at 11:26 AM and the Anesthesiologist D (Dr D) signed and dated the form 8/23/23 but lacked a time Dr D signed the form.

C. An interview with Surgical Registered Nurse (RN S) on 8/29/23 at 1333 stated, "Checking the consents for signatures is part of our review before the patients go into surgery. The consents are supposed to be signed and dated when completed."