HospitalInspections.org

Based on document review and interview, facility failed to notify patient representative of patient health decline, and failed to involve patient representative in patient treatment, services, and decisions for 1 of 10 patient medical records reviewed. (P2)

Findings include:

1. Facility policy titled Patient Rights and Responsibilities, PolicyStat ID 10309215, last revised 5/23/2022, indicated on Page 2, under Patients Rights and Responsibilities, Participation in Care, You have the right to have your family and surrogate decision makers involved in your care, treatments, services, and decisions.

2. Review of P2 MR indicated:
a. Facility lacked documentation of notifying FM1 (P2's Family Member) of P2's decline in condition on 3/30/24, and involve FM1 in treatment, services, and decisions when patient decline occurred.

3. In interview on 9/30/24 at approximately 1010 hours with A3 (Patient Safety Leader) and A4 (Accreditation), they confirmed FM1 was not notified of P2's decline in condition and treatment being administered to P2. FM1 phoned facility after two attempts to contact P2 the morning of 3/30/24 and was notified at that time of patient's decline and procedure. A4 confirmed there was a lapse in communication by the facility.

Based on document review and interview, facility failed to complete documentation of consent for treatment per facility policy for 3 of 10 MRs reviewed. ( P8, P9, P10)

Findings include:

1. Facility policy titled Consent to Medical Care for Adult Patients, PolicyStat ID: 10458941, last revised 2/22/22, Page 1, under policy statement, ERD #27. Free and informed consent requires that the person or the person's surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all. Page 2, under Informed Consent Form: Form used by hospital or practice to document the patient has agreed to the medical intervention. This policy will use the general term "Informed Consent Form" with the understanding that each hospital or practive may refer to their Informed Consent Form by a specific name or that there may be specific forms for specific procedures.

2. Review of P8 MR indicated:
a. Patient admitted to facility on 8/19/24 with diagnosis of Pneumothorax.
b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy.

3. Review of P9 MR indicated:
a. Patient admitted to facility on 9/15/24 with diagnosis of Respiratory Failure.
b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy

4. Review of P10 MR indicated:
a. Patient admitted to facility on 9/13/24 with diagnosis of Small Bowel Obstruction.
b. Lack of documentation of signed Consent and Conditions of Admission form per facility policy.

5. In interview on 9/30/24 at approximately 1000 hours with A3 (Patient Safety Leader), he/she confirmed P8, P9 and P10 MR lacked documentation of a signed Consent and Conditions of Admission form per facility policy.