HospitalInspections.org

Based on record review and interview, it was determined that the hospital failed to obtain patient signed consents for treatment in the Catheter Laboratory for 3 procedures of 5 total procedures reviewed. (Patient identifiers are #1 and #2)

Findings include:

Patient #1
Review on 12/11/18 at approximately 12:30 p.m. it was determined through patient record review of the electronic health record that Patient #1 had a medical procedure performed in the hospital's catheter laboratory on 11/7/18. There was no documentation of a signed consent for treatment for this patient.

Interview on 12/11/18 at approximately 1:45 p.m. with Staff A (Registered Nurse/Risk Management), revealed that neither she/he nor the medical records department could locate a signed consent form for Patient #1 for the above referenced procedure.

Patient #2
Review on 12/11/18 at approximately 12:32 p.m. it was determined through patient record review of the electronic health record that Patient #2 had a medical procedure performed in the hospital's catheter laboratory on 11/28/18 and a second procedure done in the hospital's catheter laboratory done on 12/1/18. There was no documentation of a signed consent for either treatment for this patient.

Interview on 12/11/18 at approximately 1:46 p.m. with Staff A, revealed that neither she/he nor the medical records department could locate a signed consent form for Patient #2 for either of the above referenced procedures.