HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the hospital staff failed to obtain informed consent for 1 of 9 patients (patient #8).

The findings included:

Review of hospital policy, "CONSENT FOR TREATMENT", revised on 03/11 revealed, "...PROCEDURE...B. The physician is responsible for informing the patient or the patient's representative of the risks, benefits, alternatives, and possible complications of the treatment, operation or procedure. These conservations and the patient's consent's should be documented in the medical record prior to the treatment and prior to any pre-treatment medications or treatment that could affect his/her decisional capacity. C. Documentation of consent should be verified in the medical record before beginning treatment..."

Medical record review conducted on 02/21/2013 revealed a 65-year-old patient admitted on 02/12/2013. Continued medical record review revealed upon admission, the patient did not sign an authorize consent for treatment form.

Interview with hospital staff #2 conducted on 02/21/2013 at 1205 confirmed the patient did not sign an authorize consent for treatment form upon admission. Continuing in the interview revealed, the consent for treatment should have been obtained before beginning any treatment.

Based on observation, the hospital staff failed to discard Accu-Chek control solution when expired for 2 of 4 Accu-Chek Machines.

The findings include:

Observation conducted on 02/21/2013 at 1100 revealed Accu-Chek (blood glucose) case(#1) with an Accu-Chek monitor, one strip container, one Low control solution, and one High control solution. Further observation revealed the Low control solution had a discard date of 01/25/2013 (27 days after expiration) and the High control solution had a discard date of 02/07/2013 (14 days after expiration).

Interview with hospital staff #2 conducted on 02/21/2013 at 1110 revealed the Low and High control solution were out of date and the hospital staff did not follow policy and procedure related to discarding expired control solutions.

Observation conducted on 02/21/2013 at 1100 revealed Accu-Chek case (#2) with an Accu-Chek monitor, one strip container, one Low control solution, and one High control solution. Further observation revealed the Low control solution had a discard date of 01/25/2013 (27 days after expiration) and the High control solution had a discard date of 02/07/2013 (14 days after expiration).

Interview with hospital staff #2 conducted on 02/21/2013 at 1110 revealed the Low and High control solution were out of date and the hospital staff did not follow policy and procedure related to discarding expired control solutions.