HospitalInspections.org

Based on interview and record review the hospital failed to follow the policy and procedure titled "Admitting Verbal HCOA (Hospital Consent On Admission) Consent Guidelines," for five of ten sampled patients (Patient 10, 12, 13, 17, and 19) when the informed consents did not include date, time and documentation of witnesses.

These failures had the potential to result in unauthorized treatment and inaccurate documentation for Patient 10, 12, 13, 17 and 19.

Findings:

During a concurrent record review on 11/2/22, at 9:56 a.m., with the Manager of Critical Care Unit (MCCU) and Manager of Medical/Surgical Unit (MMSU), Patient 12, 13, 17, and 19's "Electronic Health Record" (EHR) was reviewed. Patient 12 was admitted in the ED on 10/28/22 at 10:07 a.m. with a diagnosis (the identification of the nature of an illness by examination of the symptoms) of Acute Hypoxemic Respiratory Failure (sudden breathing difficulty), Influenza (a common viral infection), and Asthma (a respiratory condition marked by spasms in the bronchi of the lungs causing difficulty breathing). Patient 13 was admitted in the ED on 10/23/22 at 11:34 a.m. with a diagnosis of Status Epilepticus (a continuous state of seizure). Patient 17 was admitted in the ED on 10/31/22 at 5:22 p.m. with a diagnosis of Upper GI (Gastrointestinal) hemorrhage (bleeding). Patient 19 was admitted in the ED on 10/27/22 at 12:13 p.m. with a diagnosis of Diabetes Mellitus II (high blood sugar levels in the blood resistant to insulin) with Ketoacidosis (a serious diabetes complication where the body produces excess ketones when there is not enough insulin in the body). MCCU and MMSU validated, Patient 12, 13, and 19 received treatments in the ED.

During a concurrent record review on 11/3/22, at 8:37 a.m., with the MCCU and MMSU, Patient 10's EHR was reviewed. Patient 10 was admitted in the ED on 10/24/22 at 2:30 a.m. with a diagnosis of Acute Pulmonary Embolism (a blood clot in the lungs). MCCU and MMSU validated, Patient 10 received treatment in the ED.

During a review of Patient 10's "Condition of Admission Assignment of Benefits & Notice of Financial Responsibility" consent form, dated 10/24/22, the consent form indicated, "Signature: Unable to sign. Date: 10/24/22." No indication of the time recorded. No indication of witnesses.

During a review of Patient 12's "Condition of Admission Assignment of Benefits & Notice of Financial Responsibility" consent form (written in Spanish), dated 10/28/22, the consent form indicated, "Patient or Representative Signature: Verbal by HU. Electronically signed at 10/28/22 11:48 a.m. Relationship name: blank (no indication). No indication of witnesses.

During a review of Patient 13's "Condition of Admission Assignment of Benefits & Notice of Financial Responsibility" consent form, dated 11/4/22, the consent form indicated, "Signature: blank." No indication of the time recorded. No indication of witnesses. Patient 13's "Conditions of Admission Consent to Treat" consent form, undated, indicated, "Signature of Patient/Parent/Conservator/Guardian/Agent: blank. Name/Relationship: Patient. Witness: [name of employee] pt (patient) unable to sign due to medical condition." No indication of the time recorded. No indication of a second witness.

During a review of Patient 17's "Condition of Admission Assignment of Benefits & Notice of Financial Responsibility" consent form, dated 11/4/22, the consent form indicated, "Signature: blank." No indication of the time recorded. No indication of witnesses. Patient 17's "Conditions of Admission Consent to Treat" consent form, undated, indicated, "Signature of Patient/Parent/Conservator/Guardian/Agent: blank. Name/Relationship: blank. Witness: blank. No indication of the time recorded.

During a review of Patient 19's "Condition of Admission Assignment of Benefits & Notice of Financial Responsibility" consent form, dated 11/4/22, the consent form indicated, "Signature: blank." No indication of the time recorded. No indication of witnesses. Patient 19's "Conditions of Admission Consent to Treat" consent form was not provided.

During an interview on 11/4/22, at 11:00 a.m., with the ED Manager Administrator (EDMA), EDMA stated patients were required to sign consents for treatment and financial responsibility when admitted in the ED. EDMA stated, if patients were unable to sign two staff signatures as witnesses were required. EDMA stated, the date and time were also required to be recorded. EDMA, stated there was a "glitch"(failure) in the hospital's electronic system where the date and time were not stamped during registration while staff obtained the consents. EDMA stated, the date and time was required on the consent forms to account for accurate record keeping.

During a review of the hospital's admitting guideline titled "Admitting Verbal HCOA (Hospital Consent On Admission) Consent Guidelines", dated 11/3/22, the guideline indicated, "Target Population: " ...patients unable to sign, and associated family members/partners who have had direct contact with the patient ... Instructions: ...if a signature cannot be obtained, two hospital employees are to witness the verbal consent and document the event in the patient's record ... The date, time and nature of the consent should be carefully documented ..."