HospitalInspections.org

Based on record review and interview, the facility staff in the ED (Emergency Department) failed to obtain written consent for procedures requiring consent on 2 occurrences for 1 of 3 patients (Patient #1) with procedures requiring consent in a sample of 12 records reviewed.

Findings:
Record review of the facility's policy titled "Informed Consent/General Consent Policy" #MR-003 undated, under "Procedures Requiring Informed Consent" revealed "A properly-executed written Informed Consent form is required for the following: a. Major or minor surgery involving entry into the body through incision or natural body opening."

Review of Patient #1's medical record revealed that Patient #1 had cystoscopies (a procedure that allows the doctor to examine the lining of the bladder and the tube that carries urine out of the body (urethra)) performed in the Emergency Department on 1/2/2021 and 1/3/2021. There was a provider note documenting a discussion of risks, benefits, alternatives and patient understanding and agreement to the procedures however no signed consent for the procedures was in the medical record.

On 3/9/2021 at 11:40 AM during interview with ED Manager A she confirmed that performance of a cystoscopy requires a written consent. ED Manager A confirmed that there were no written signed consents in Patient #1's medical record for the cystoscopies performed on 1/2/2021 and 1/3/2021.

On 3/9/2021 at 1:25 PM during interview with Director of Risk J, Director J stated, "We know we have a problem with consents going missing and we are currently working on a process to have them signed electronically."