HospitalInspections.org

Based on document review, record review and staff interview it was determined the facility failed to ensure the execution of informed consent forms for anesthesia, per policy, for eight (8) of (10) ten outpatient surgery patients reviewed for consent (patients # 1, 2, 3, 5, 6, 7, 9 and 10). This failure creates the potential for incomplete records and/or patient rights to be violated.

Findings include:

1. The policy "Consent for Anesthesia Form," approved 4/16, was provided for review. The policy states, in part: "All proper procedures will be followed in the attainment of consent as outlined in the Patient Consent Policy."

2. The policy "Patient Consent," last revised 1/2016, was provided for review. The policy states, in part: "Informed consent is required for the following procedures: ...I. Anesthesia Services...Assure that the consent has been signed by the patient, the surgeon, and a witness. The 'witness' is simply verifying that the signature is indeed that of the patient or other person legally designated to sign."

3. Review of the 12/27/16 consent for anesthesia services for patient #1 revealed the witness signature line was blank.

4. Review of the 12/27/16 consent for anesthesia services for patient #2 revealed the witness signature line was blank.

5. Review of the 12/29/16 consent for anesthesia services for patient #3 revealed the witness signature line was blank.

6. The above findings were reviewed and discussed with Clinical Infomatics Specialist #1 between 1:00 p.m. and 3:00 p.m. on 2/27/17 and she agreed with the findings.

7. Review of the 12/30/16 consent for anesthesia services for patient #5 revealed the witness signature line was blank.

8. Review of the 12/16/16 consent for anesthesia services, reviewed again on 12/30/16, for patient #6 revealed the signature line was blank.

9. Review of the 12/16/16 consent for anesthesia services, reviewed again on 12/30/16, for patient #7 revealed the witness signature line was blank.

10. Review of the 02/27/17 consent for anesthesia services for patient #9 revealed the witness signature line was blank.

11. Review of the 02/27/17 consent for anesthesia services for patient #10 revealed the witness signature line was blank.

12. The records for patients #5, 6, 7, 9, and 10 were reviewed and discussed with Clinical Infomatics Specialist #1 between 12:30 p.m. and 1:00 p.m. on 02/28/17 and she agreed with the above findings.