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WELLSTAR MCG HEALTH, AFFILIATED WITH MED COL
CONTENT OF RECORD: INFORMED CONSENT
Tag No.: A0466
Based on a review of medical record, policies and procedures, and staff interview, it was determined that the facility failed to ensure that patient's rights were promoted and protected when one patient (P) (P#1) of four (P#1, P#2, P#3, P#4) patients reviewed failed to have a consent for medical treatment documented in the electronic medical record.
Findings Included:
A review of the medical record for P#1 revealed that no consent for treatment was on file.
A review of the facility's policy titled, "General Consent Policy," policy #387, last reviewed 10/6/24, revealed that the purpose of the policy was to detail that the facility will ensure that consent for treatment is obtained on every patient and documented appropriately in the medical record.
During an interview on 7/17/2024 at 10:15 a.m. in a conference suite, Manager of Regulatory Affairs (MRA) AA revealed that every patient should have a consent form for treatment signed and in each patient's chart upon admission, as appropriate. MRA AA said that she and other members of the team could not locate a consent for treatment on file for P#1.