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Based on interview and record review, the facility failed to ensure Patient 1 consented for hemodialysis (procedure for cleaning the blood of waste products) treatment prior to receiving hemodialysis treatment. This failure resulted in a violation of Patient 1's right to make an informed decision regarding his or her care.

Findings:

During a review of Patient 1's History and Physical, dated 10/9/23, indicated Patient 1 was admitted to the facility on 10/8/23, with diagnoses that included End Stage Renal Disease (ESRD, loss of kidney function, wherein the kidneys no longer work as they should to meet a person's needs).

During a review of Patient 1's medical record indicated a Physician Order for hemodialysis, dated 10/10/23 at 8:13 AM.

During a review of Patient 1's Hemodialysis Record, dated 10/10/23 at 10:12 AM, indicated Patient 1 received hemodialysis treatment.

During a concurrent interview and record review with Informatics Registered Nurse (RN 1) on 11/14/23 at 4:14 PM, RN 1 stated she was unable to locate documented evidence to show Patient 1 consented for hemodialysis treatment on 10/10/23.

During an interview with the Chief Nursing Officer (CNO) on 11/15/23 at 9:27 AM, the CNO stated the physician should have discussed with Patient 1 or patient's representative the risks and benefits of procedures/treatments, including hemodialysis treatments prior to the start of the treatment. The CNO reviewed Patient 1's medical record and was unable to locate and provide documented evidence to show Patient 1's verbal or written consent was obtained for the hemodialysis treatment completed on 10/10/23.

During a review of the facility's policy and procedure (P&P) titled, "Consents," dated 3/22, the P&P indicated, "2.3.1 The hospital cannot permit any treatment, without the risk of liability, unless the patient, or a person, or a person legally authorized to act on his behalf, has consented thereto ... 2.7 Who May Give Consent ... 2.7.1 A competent adult patient."