HospitalInspections.org

Based on review of medical records, policies and procedures, and staff interview, it was determined that the facility failed to ensure that informed consents were completely filled out for six (6) myelogram procedures, medical record numbers (#s 2, 3, 4, 6, 7, and 8) of ten (10) sampled medical records.

Findings were:

Review of ten (10) medical records, specifically the informed consents for myelograms (special x-ray using dye to view the bones between the spine) revealed the following:

#2 indicated that the procedure diagnosis was M48.061 an ICD code (International Classification of Diseases of the World Health Organization). This ICD code indicated spinal stenosis (narrowing of the spinal canal). This consent was missing the name of the person who explained the procedure, the patient's printed name, witness signature, date and time the consent was signed. Patient #2 had signed the consent.

#3 this consent was missing the procedure diagnosis, name of the person who explained the procedure, date and time the consent was signed. Patient #3 printed and signed his/her name and a witness co-signed the form.
#4 this consent was missing the procedure diagnosis,the name of the person who explained the procedure,the date and time the consent was signed. The patient printed and signed his/her name and a witness co-signed the form.
#6 indicated that the procedure diagnosis was M54.16 an ICD code (indicating pain, numbness, tingling, or weakness along the course of the nerves in the lower
back region). This consent was missing the name of the person explaining procedure. Patient #6 printed, signed, dated, and timed the consent, and a witness co-signed the form.
#7 this consent was missing the procedure diagnosis, name of the person who explained the procedure, a witness signature, the date and time the consent was signed. Patient #7 signed the consent.
#8 this consent was missing the name of the person who explained the procedure. The form had the procedure diagnosis, the patient had printed his/her name, signed, dated, and timed the form, and there was a witness signature.

Facility policy entitled Informed Consent, Policy #142, last Revision Date 07/18/16, Effective Date 07/27/16, revealed the purpose was to assure that all patients and/or authorized representatives were to be given informed consent for the provision of medical and/or surgical care at the facility. The policy noted that the informed consent was the responsibility of the physician providing the medical/surgical intervention.

During an interview (#11) on 02/05/17 at 9:14 a.m. to 9:50 a.m. in the Quality Conference Room, the Accreditation Manager confirmed that six (6) of the 10 myelogram consents (#s 2, 3, 4, 6, 7, and 8) were not fully completed.