HospitalInspections.org

Based on review of hospital policy, and three of 40 records reviewed ( patients #10, #11, and #12), it was determined that 1) for patient #10, the hospital failed to document the identity of the telephone consenter for two consents; 2) for patient #11, the hospital generalized an anesthesia consent to all future procedures during the patient admission; 3) for patient #12, the hospital specified the surgical procedures, and also stated, "Surgery as indicated" which failed to specify other procedures for patient #12's consent.

Review of the hospital policy, "Informed Consent Requirements" (revised 04/15), revealed under section "V. Documentation," a telephone consent needs to have documented the name and relationship of the consenter.

Patient #10 was an elderly patient admitted to the hospital for treatment of sepsis. A consent, "ICU Consent for Diagnostic and Therapeutic Procedures," dated (2/15/17) was found to be missing the telephone consenters name and relationship to patient. Another consent labeled, "Consent and Authorization for Blood and or Blood Product Transfusions," was also found to be missing the name and relationship of the telephone consenter. While this consent did have the name of the patient's spouse and phone number on the front of the consent it cannot be determined who the telephone consenter was since it was not filled out in the appropriate area of the consent.

Patient #11 was a young adult who was admitted to the hospital for septic shock. A consent for anesthesia dated (12/1/16) was found in his record. The area for the type of surgery or procedure to be performed had written "All necessary procedures this admission." This statement failed to name the specific procedure for which the patient or patient representative was consenting.

Patient #12 had a consent for surgery dated (2/19/16), and titled, "Consent for Surgery and Other Procedures," on record. The specific procedure was entered on the form. However, the area under the statement, "The following procedures may be done by a member of the treatment team" had written "as above and surgery as indicated." While the specific procedure were detailed in the first part of the consent, the "surgery as indicated" statement did not meet the standard for informed consent.

Based on all documentation, the hospital failed to meet standards for informed consent for patients #10, #11 and #12.