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Based on interview and record review, the facility failed to afford patients the right to be informed, ask questions, and give written consent for treatment resulting in the potention for loss of rights for all patients served in the emergency department. Findings include:

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A-131 Failure to afford patients the right to give written consent for treatment.

Based on interview and record review, it was determined that the facility failed to afford 7 of 13 sampled patients the right to be informed, ask questions, and give written consent for treatment resulting in the potential for a loss of rights for all patients. The findings include:

13 Emergency Department (ED) records were reviewed.
Patient #2's medical record revealed the patient was treated in the facility ED on 11/22/2021. Review of Patient #2's Face sheet revealed an admitting diagnosis of abdominal swelling after procedure. Patient #2's consent for treatment revealed that on the line for patient signature the words "verbal consent from pt" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19 precautions".

Patient #3's medical record revealed the patient was treated in the facility ED on 02/08/2022. Review of Patient #3's Face sheet revealed an admitting diagnosis of nausea/fatigue. Patient #3's consent for treatment revealed that on the line for patient signature the words "verbal consent per pt " written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "C-19 precautions".

Patient #4's medical record revealed the patient was treated in the facility ED on 02/07/2022. Review of Patient #4's Face sheet revealed an admitting diagnosis of difficulty breathing. Patient #4's consent for treatment revealed that on the line for patient signature the words "verbal from pt" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19 precautions". Patient #4 was chosen by facility staff as a patient for the surveyor to interview, and was not observed to be in isolation at the time of the interview. Patient #4 stated she had not signed consent for treatment.

Patient #5's medical record revealed the patient was treated in the facility ED on 02/08/2022. Review of Patient #5's Face sheet revealed an admitting diagnosis of Right knee and Left elbow pain. Patient #5's consent for treatment revealed that on the line for patient signature the word "verbal consent" written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19". Patient #4 was chosen by facility staff as a patient for the surveyor to interview, and was not observed to be in isolation at the time of the interview. Patient #5 stated she had not signed consent for treatment.

Patient #6's medical record revealed the patient was treated in the facility ED on 01/17/2022. Review of Patient #6's Face sheet revealed an admitting diagnosis of abdominal pain and rectal bleeding. Patient #6's consent for treatment revealed that on the line for patient signature the words "verbal from pt " written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19 precautions".

Patient #12's medical record revealed the patient was treated in the facility ED on 01/25/2022. Review of Patient #12's Face sheet revealed an admitting diagnosis of Left shoulder pain. Patient #12's consent for treatment revealed that on the line for patient signature the words "verbal obtained by pt " written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19".

Patient #13's medical record revealed the patient was treated in the facility ED on 02/02/2022. Review of Patient #13's Face sheet revealed an admitting diagnosis of vaginal bleeding/5 weeks pregnant. Patient #13's consent for treatment revealed that on the line for patient signature the words "verbal consent from pt " written. On the line for witness, two staff signatures were present. No other signatures were present on the consent for treatment form. On the line for reason acknowledgement could not be obtained, "Covid 19 protocol".

In an interview on 02/08/2022 at 1450, Staff M, Registration Manager, stated registration staff are obtaining verbal consents from all patients, not just Covid symptomatic or Covid positive patients. They do not give the consent form to the patient. Staff M stated even if a patient comes in with complaints other than Covid symptoms, "anyone can test positive for Covid later". Registration staff do not go into the patient room and do not offer the patient the opportunity to sign consent.

In an interview on 2/9/2022 at 1110, Staff B, Chief Nursing Officer, stated it was her expectation that staff should follow the proper process and obtain consent appropriately. Staff B was queried as to what her expectation was for obtaining patient consent appropriately, she stated every patient should have the opportunity to be informed, ask questions and give written consent.

In a interview on 2/8/2021 at 1430, Staff A, Director of Accreditation and Compliance was queried about the facility's policy regarding general consent for treatment. Staff A stated the facility did not have a policy for General Consent for Treatment. Staff A provided a policy titled "Informed Consent for Diagnostic or Therapeutic Procedures and Treatments". Staff A stated this was the only policy the facility had pertaining to consent for treatment.

Per "Informed Consent for Diagnostic or Therapeutic Consent for Treatment" policy dated 10/12/2021, under "MHC Staff Responsibility" B. The patent will be allowed time to read the form, or it will be read to him/her in its entirety, by an MHC staff member, family member, or interpreter.