HospitalInspections.org

Based on document review and interview, it was determined for 4 of 5 (Pt #1, Pt #2, Pt #4, Pt #11) patients records reviewed, the Hospital failed to ensure the patient or the patient's representative was provided the required information to make an informed decision and obtained a signed informed consent. this has the potential to affect all patients who receive care by the Hospital, with a current inpatient census of 93 patients.

Findings include:

1. The policy titled "Securing Signatures on Registration Forms" (dated 06/2017) was reviewed on 4/16/2021. The policy noted "Consent form includes: First signature: Consent for Treatment, release of information to insurance, doctor and financial responsibility. Second signature: Patient Rights & Responsibilities. Notice of Privacy Practice, Nondiscrimination Notice and Advanced Directives. Third signature: Plain Language Summary for Financial Assistance... 10. If the patient is mentally unstable to understand the consent at the time of admission, and is unable to sign; legal representative will be contacted for signature... C. Verbal/Phone Consent 1... is able to verbalize his/her consent, "Verbal Consent" should be entered in the signature box along with recording your initials and date. 2 If permission must be obtained by telephone, record at the bottom of the form "Permission by ______, relationship to patient and date/time."

2. Pt #1 Start of Care (SOC): 1/27/2021
Diagnosis: Delirium due to other medical problems. The record was reviewed on 4/14/2021 at approximately 1:00 PM. The Informed Consent lacked the patient or the patient's representative signature. The link on the documents screen to the Informed Consent noted "Verbal Consent Obtained". It was unable to be determined who gave the verbal consent and when and how the verbal consent was obtained.

3. Pt #2 SOC: 2/28/2021
Diagnosis: Confusion and Acute Respiratory Failure. The record was reviewed on 4/15/2021 at approximately 10:30 AM. The Informed Consent noted an electronic statement in the signature box that stated "Signature captured by (Pt #2) 2/28/2021 12:36 PM" and "verbal" was handwritten illegibly in the signature box. It was unable to be determined who wrote "verbal".

4. Pt #4 SOC: 4/7/2021
Diagnosis: NeuroCognitive Disorder with Alzheimers. The record was reviewed on 4/14/2021 at approximately 11:00 AM. The Informed Consent lacked the patient or the patient's representative signature.

5. Pt #11 SOC: 4/12/2021
Diagnosis: Altered Mental Status. The record was reviewed on 4/15/2021 at approximately 1:10 PM. The Informed Consent lacked the patient or the patient's representatives signature. The link on the documents screen to the Informed Consent noted "Verbal Consent Obtained". It was unable to be determined who gave the verbal consent and when and how the verbal consent was obtained.

6. During an interview on 4/15/2021 at approximately 2:45 PM, E#2 (Clinical Nurse Educator) reviewed Pt #1, Pt #2, Pt #4 and Pt #11's records and verbally agreed the Informed Consents were not completed per policy and should have been. E#2 stated "The patients were all confused, so they obviously can't give consent. It's not in the Registrars scope to determine if a patient is capable of making an informed decision or understand their rights or billing... I agree, the patient's caregiver should have been called or signed the consent at some point."