HospitalInspections.org

Based on record reviews and interviews, the facility failed to obtain written consent for treatment for 1 patient (P[patient] 2) of 10 patients (P1-P10) being reviewed for appropriate consent. This failed practice can lead to a violation of patient rights due to the lack of informed consent for treatment from the patient or the patient's legal guardian.

These findings are:

A. Record review of the facility's policy titled "Patient Rights and Responsibilities" dated 02/02/2023 section I-A titled "RIGHTS OF ALL PATIENTS" stated "Patients, or their legally authorized representatives, must be informed of the patient's right to:. . . . give informed consent prior to receiving treatment and after a clear explanation of the risks, benefits, medical consequences, including potential problems that might occur during recuperation, and alternative treatments."

B. Record review of P2's electronic medical record revealed that P2 was treated in the Emergency department and admitted to the inpatient unit to receive treatment on 01/27/24 at 11:23 PM. Record review of the Emergency Department Providers note revealed that the patient was alert and oriented and able to provide her own history. The record did not contain a consent for treatment in the patient's medical record.

C. During an interview on 03/20/24 at 1:12 PM, Staff ( S)7, Clinical Accreditation and Regulatory director, S7 stated "There is no consent for treatment for [P2]".

D. During an interview on 03/20/24 at 1:45 PM, with S13, Director of Risk Management, S13 confirmed consent for treatment should be obtained for 100% of patients.