HospitalInspections.org

Based on clinical record review, staff interview, and facility policy/procedure review, the facility staff failed to ensure informed consent was obtained from the patient as per facility policy for three (3) of seven (7) patient medical records reviewed.

The findings include:

On 4/19/2021, the surveyors reviewed the medical records for seven (7) patients.

A review of the "General Consent for Treatment/Guaranty of Payment" for Patient #4 contained evidence of no patient label or patient name, date of birth (DOB) or medical record number (MRN) documented on the form. The consent form contained the documentation "Verbal consent" and the date. The form contained no evidence of a time or name of the person who received the verbal consent from the patient, as per facility policy.

A review of the "General Consent for Treatment/Guaranty of Payment" for Patient #5 contained evidence of documentation of "Verbal consent," and initials, but the form did not contain the name of the person who received the verbal consent from the patient, as per facility policy.

A review of the "General Consent for Treatment/Guaranty of Payment" for Patient #7 contained evidence of no patient label or patient name, DOB or MRN documented on the form. The consent form contained the documentation "Verbal consent" and the date. The form contained no evidence of a time or name of the person who received the verbal consent from the patient, as per facility policy.

During an interview on 4/20/2021 at 10:00 a.m., Staff Member (SM) #8 stated that verbal consent is obtained in the emergency department from patients who are medically unable to sign, depending on their medical condition, and registration staff is not required to go in to a patient's room's for written consent for patients with COVID. SM #8 stated that usually staff will document the reason for obtaining verbal consent instead of written consent, but not all staff will document the reason. SM #8 stated if the staff are unable to get consent from the patient, the staff will call the patient's family for verbal consent. SM #8 stated that for verbal consent the staff is supposed to document the time and date and staff's initials on the consent form. Then SM #8 stated "sometimes I forget or don't do that." SM #8 stated that the staff is supposed to put a patient label on the consent form or write the patient's name on the form, but "some [staff] don't label them at all." SM #8 stated that sometimes if a patient is brought in by rescue then it may be an hour before registration can get in to obtain consent from the patient.

A review of the facility policy titled, "Consents (Informed, General, Informed Refusal)," states in part:
...General Consent...3. The completed form is a permanent part of the medical record and will be labeled with patient identification...
...Procedures
Documentation
General Consent...If the patient is physically unable to sign but gives verbal consent, document this on the patient signature space with the name of the person who received the verbal consent from the patient.
d. The date and time of the patient's or representative's signature on the General Consent will be documented on the form by the Associate presenting the form for signature...