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Based on record reviews and interviews, the hospital failed to ensure patients' rights were maintained by failing to properly execute informed consents and by failing to follow the hospital's policy on consents for 5 (#2, #3, #4, #5, #9) out of 8 patient medical records reviewed for consents.
Findings:
Review of Policy No. RI-020, Section: Ethics, Rights and Responsibilities, Subject: Consent and Disclosure revealed, in part, the following:
A.a.4. "It is the responsibility of the physician or healthcare provider actually performing the procedure to obtain the patient's 'informed consent.' "
A.a.4.a. "In order for the physician or healthcare provider to obtain a written informed consent he/she must answer the patient's questions and explain, in layman's language, the nature and purpose of the procedure, possible risks or side effects, alternative method of treatment and associated risks if any and why he has chosen the indicated procedure.
D. "A properly executed informed consent contains at least the following: 1. Name of Patient, and when appropriate, patient's legal guardian. 2. Name of Procedure. 3. Name of Practitioner(s) performing the procedure(s) as well as name(s) and specific significant surgical tasks that will be conducted by the practitioners other than the primary surgeon/practitioner. Significant surgical tasks include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues). 4. Risks. 5. Alternative procedures and treatments. 6. Signature of patient or legal guardian. 7. Date and time consent is obtained. 8. Statement that procedure was explained to patient or guardian. 9. Signature of professional person witnessing the consent. 10. Name/Signature of person who explained the procedure to the patient or guardian.
Patient #2
Patient #2 was an 80-year-old male admitted to the hospital on 2/25/13 with a diagnosis of cervical stenosis and brachial neuritis and was to receive a cervical epidural steroid injection at cervical 6 and 7 for pain relief.
Review of Patient #2's "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgment of Receipt of Medical Information" revealed the following sections of the consent form were left blank by S16Physician:
Section 2.a. Description, nature of the treatment/procedure and 2.b. Purpose; Section 3. Patient Condition; and Section 6.c. Authorized Physician.
In a face-to-face interview on 4/16/13 at 3:45 p.m., S1RN, Vice President (VP) of Quality Services, confirmed that the above mentioned sections of the consent form were left blank and the sections should have been completed according to regulations and hospital policy.
Patient #3
The patient was admitted to the hospital on 03/01/13 for a cervical rhizotomy procedure as an outpatient. Due to a post-operative complication the patient was intubated and admitted as an inpatient to SICU (Surgical Intensive Care Unit). Patient #3 was also a dialysis patient and was scheduled for dialysis the next day. Patient #3 was transferred to another acute care hospital where dialysis services were available. Review of the patient's medical record revealed that a transfer consent was not signed by the patient or the patient's family.

An interview on 04/16/13 at 4:10 p.m. was conducted with S5RN SICU. She was asked about the transfer consent form. S5RN SICU indicated Patient #3 was intubated and the wife was aware the patient was being transferred to another hospital. S5RN SICU indicated she forgot to get a transfer consent form signed as was required by hospital policy.

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 04/16/13 for a Carotid Endarterectomy. The patient's surgical procedure was done on 04/16/13 and the patient was then admitted to ICU (Intensive Care Unit).

Review of the "Patient consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" for Patient #4 revealed the following sections of the consent were left blank: Patient Condition, Material Risks of the Treatment Procedure, Risks Identified by the Louisiana Medical Disclosure Panel, Risks Determined by your Doctor, Additional Risks (if any) Particular to this patient because of a complicating medical condition, and Reasonable Therapeutic Alternatives and the Risks Associated with such Alternatives. Review of the consent revealed the only information documented on the consent was, "Right Carotid Endarterectomy", the patient and the pre-operative nurse's signatures and the date and time of their signatures. The section for the physician's signature and date and time of signature was also left blank.

In an interview on 04/17/13 at 9:34 a.m., S2RN CNO (Chief Nursing Officer) stated the nurses go over the consent with the patient's here (hospital). S2RN CNO verified the physician had not signed the surgical consent form. S2RN CNO verified the surgical consent did not include material risks, risks identified by the Louisiana Medical Disclosure Panel, or specific risk determined by the physician. She verified the consent did not contain any alternatives or the associated risks. S2RN CNO verified the only risks on the consent form were the general risks for any surgery. S2RN CNO stated the Operating Room (OR) RN was responsible to ensure the physician had signed the consent form and verified the OR RN had documented the consent was signed/dated/timed & witnessed.


Patient #5
Patient #5 was an 83-year-old male admitted on 1/24/13 with a diagnosis of peripheral vascular disease and was scheduled for a left femoral popliteal bypass surgical procedure.
Review of Patient #5's "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information, Transfusion of Blood and Blood Components" revealed the following sections of the consent form were left blank by S18Physician:
Section 2.a. Description, nature of the treatment/procedure; Section 3. Patient Condition; Section 6.e. Authorized Physician; and Physician/Provider Certification, signature, date, and time.
Further review of Patient #5's "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgment of Receipt of Medical Information" revealed the following sections of the consent form were left blank by S18Physician.
Section 3. Patient Condition; Section 4. Material Risks of Treatment Procedure; Section 5. Reasonable Therapeutic Alternatives and the Risks Associated with such Alternatives.
In a face-to-face interview on 4/17/13 at 3:00 p.m., S1RN, VP of Quality Assurance, confirmed that the above mentioned sections were left blank and the sections should have been completed according to regulations and hospital policy.


17091


Patient #9
Review of the medical record for Patient #9 revealed the patient was admitted to the hospital on 04/16/13 for a Forehead Pedicle Flap, Ear Cartilage Graft with Septoplasty, and possible skin graft to defect. The patient's surgical procedure was done on 04/16/13 and the patient was then admitted overnight.

Review of the "Patient consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" for Patient #9 revealed the following sections of the consent were left blank: Patient Condition, Material Risks of the Treatment Procedure, Risks Identified by the Louisiana Medical Disclosure Panel, Risks Determined by your Doctor, Additional Risks (if any) Particular to this patient because of a complicating medical condition, and Reasonable Therapeutic Alternatives and the Risks Associated with such Alternatives.

In an interview on 04/18/13 at 10:50 a.m., S2RN CNO (Chief Nursing Officer) reviewed the consent for Patient #9 and verified the surgical consent did not include material risks, risks identified by the Louisiana Medical Disclosure Panel, or specific risk determined by the physician. She verified the consent did not contain any alternatives or the associated risks. S2RN CNO verified the only risks on the consent form were the general risks for any surgery.


30172

Based on review of the Medical Staff Rules & Regulations, clinical record review, and staff interview, the hospital failed to ensure the medical staff enforced its rules & regulations as evidence by failing to ensure physician progress notes were sufficient to permit continuity of care and included documentation of the patient's condition and the need for transfer to another hospital for 1 (#3) of 3 sampled patients reviewed for transfers out of a total sample of 10.

Findings:

Review of the Medical Staff Rules & Regulations approved by the Governing Body on 04/11/13, revealed in part the following: D. Medical Records 1. Responsibilities of Attending Physician: The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient under his/her care. All medical records shall contain the following:....(i) conclusions at discharge or evaluation/treatment.....2. Inpatient Medical Records: Inpatient medical records shall also include the following:....(n) conclusions at termination of hospitalization, (o) clinical resumes and discharge summaries....7. Progress Notes: Pertinent progress notes sufficient to permit continuity of care and transferability shall be authored or countersigned daily by the attending physician....Each patient's clinical problems responsible for this admission should be clearly identified in the progress notes and correlated with specific orders....Pertinent progress notes shall be written at least daily on all patients, more frequently as dictated by clinical course and should include subjective complaints, objective findings, clinical assessment and therapeutic plans....


30172

Patient #3

The patient was admitted to the hospital on 03/01/13 for a cervical rhizotomy procedure as an outpatient. Due to a post-operative complication the patient was intubated and admitted as an inpatient to SICU (Surgical Intensive Care Unit). Patient #3 was also a dialysis patient and was scheduled for dialysis the next day. Patient #3 was transferred to another acute care hospital where dialysis services were available. Review of the patient's progress notes in the medical record revealed no documentation on Patient #3's present clinical problems and the continuity of care needed for the patient and why the transfer to another acute care hospital was necessary. Further review of Patient #3's progress notes revealed no clinical assessments or therapeutic plans documented by the patient's attending physician, S7Physician, pertaining to the patients' present medical condition.

An interview on 04/18/13 at 10:50 a.m. was conducted with S2RN CNO. She reviewed Patient #3's medical record and indicated there were no progress notes from Patient #3's attending physician, S7Physician, documenting the continuity of care needed for the patient and why the transfer to another acute care hospital was necessary. S2RN CNO further confirmed that the progress notes dated 03/01/13 by S17Physician only documented the post-operative complication and the anesthesia interventions. S2RN CNO indicated she was unable to find any progress notes dated 03/01/13 by the attending physician, S7Physician in Patient #3's medical record.

Based on record reviews and interviews the hospital failed to ensure all medical record entries were authenticated, dated, and timed, consistent with hospital policy for 6 (#1,#2, #3, #4, #6 #9) out of 10 sampled medical records reviewed.
Findings:
Hospital Policy Number IM-030, "Adequate Documentation of Medical Records," revealed in part: "all entries in the medical record must be timed, dated, and authenticated, and a method established to identify the author.
Patient #1
Review of the medical record for Patient #1 revealed the patient was a 70 year old female admitted on 12/20/12 for long term intravenous antibiotics for Discitis. Review of the record revealed on 12/26/12 the patient sustained ventricular arrhythmias, requiring defibrillation and resuscitation. The patient was then moved to ICU (Intensive Care Unit) on 12/26/12 and was transferred to another hospital on 12/27/13.

Review of the physician's orders revealed the following orders were not timed by the physician when the order was written:
"27 Dec (December)-Apresoline 10 mg. IVP (Intravenous push) Q 6 H prn B/P > 180 systolic/110 diastolic (every 6 hours as needed for Blood Pressure greater than 180 systolic and 110 diastolic).
CBC, BMP in am (Laboratory tests)
CM (Case Management) to work on transfer to ICU-(Hospital A)
Consult Dr. (S22Physician-Cardiologist)"

Review of the physician's orders revealed the following verbal orders were not signed by the physician:
"12/20/12 at 1400-Admit to Hospital ( hospital's name).
Dx: (Diagnosis) Osteomyelitis/Discitis
Code Status: Full code
VS (Vital Signs): every 4 hours
I & Os (Intake & Output) every shift
PICC (Peripherally Inserted Central Catheter) line change dressing per hospital policy
2000 calorie ADA Carb (American Diabetic Association Carbohydrate) control diet
Activity OOB (Out of Bed) to chair, ambulate with assist
PT and OT (Physical and Occupational Therapy) evaluation and treat.
Continue meds as per discharge medical record."

"12/20/12 at 1500 - Order Clarification: Rocephin 2 gm. IVPB Q 24 hours X 4 weeks (Intravenous piggy back every 24 hours for 4 weeks)."

"12/27/12 at 0215 - Stat EKG (Electrocardiogram) for rhythm change"

"12/27/12 at 0300 - Amiodarone 150 mg. bolus over 10 minutes. Increase Amiodarone 1 mg./minute."

Review of the physician's orders revealed the following verbal orders were signed by the physician, but failed to include the date and time of the authentication of the orders:
"12/23/12 - Nystatin cream to (B) groins tid (both groins three times a day)."

"12/26/12 at 0820 - Start Amiodarone gtt (drip) per protocol, DC (Discontinue) Lidocaine. Consult Dr. (S22Physician-Cardiologist). Transfer to ICU. Stat EKG, ABG (Arterial Blood Gas), pCXR (portable chest x-ray), cardiac enzymes, CMP, Mg (Complete Metabolic Profile, Magnesium level)."

"12/26/12 at 1100 - Mg rider (Magnesium infusion) 1 gram IV now."

"12/27/12 at 1550 - Apresoline 10 mg. IV X 1 now."

In an interview on 04/16/13 at 4:00 p.m., S1RN VP of Quality Services verified the record for Patient #1 was delinquent and provided copies of letters sent to the patient's physician. S1RN VP of Quality Services stated they were hopeful their electronic record would ensure compliance with dating/timing/authenticating issues.

Patient #2
Patient #2 is an 80-year-old male admitted to the hospital with a diagnosis of cervical stenosis and brachial neuritis. Patient #2 was admitted for an outpatient procedure of epidural steroid injection at cervical disks 6 and 7 for relief of pain.
Review of Patient #2's medical record forms entitled "Surgical Admission Form, History & Physical," the "Immediate Post Op Note," and the "Discharge Note" forms revealed the medical record entries for the above mentioned documents were not timed by S16Physician.
Review of the Patient #2's medical record "Anesthesia Preoperative Evaluation Form" completed by S17Physician revealed the "PreOp Evaluation by" section was not timed and the date documented was incomplete only containing the month and day. Further review of the section entitled, "Post-Operative Evaluation" revealed an incomplete date documented by S17Physician with only the month and day documented.
In a face-to-face interview on 4/16/13 at 3:45 p.m., S1RN, Vice President (VP) of Quality Services, confirmed and agreed the dates and times were not documented as specified on the forms identified above, and should have been completed according to hospital policy and regulations.
Patient #3

The patient was admitted to the hospital on 03/01/13 for a cervical rhizotomy procedure as an outpatient. Due to a post-operative complication the patient was intubated and admitted as an inpatient to SICU (Surgical Intensive Care Unit). A review of Patient #3's Physician orders on 03/01/13 revealed 5 different verbal order entries were taken by S5RN SICU from S7Physician. The 5 verbal orders were signed by S7Physician, but were not dated or timed as to when the orders were authenticated. A further review of Patient #3's progress note from S17Physician dated 03/01/13 revealed no time as to when the progress note was authenticated.

An interview on 04/18/13 at 10:50 a.m. was conducted with S2RN CNO. She reviewed Patient #3's medical record and confirmed the 5 verbal orders on 03/01/13 from S7Physician were not dated and timed as required by hospital policy. S2RN CNO further confirmed the progress note on 03/01/13 from S17Physicain was not timed as required by hospital policy.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 67 year old male admitted to the hospital on 04/16/13 for a right Carotid Endarterectomy. Review of the record revealed the patient had the procedure on 04/16/13 and was admitted to ICU.

Review of the Anesthesia Pre-operative Evaluation form revealed the form was signed by S17Physician on 04/16/13, but the time was left blank.

Review of the Immediate Post-Operative Note revealed S18Physician had signed the note with a date of 04/16/13, but the time was left blank.

Review of the Physician's Orders dated 04/16/13 revealed post-operative orders for ICU were written by S18Physician, but there was no time documented by the physician.

Review of the Progress Notes revealed an entry dated 04/17/13, "Vascular Surgery-POD (post op day) #1....", but there was no documented evidence of the time of the entry.

In an interview on 04/17/13 at 9:34 a.m., S2RN CNO (Chief Nursing Officer) reviewed the medical record for Patient #4 and verified the above medical record entries were not timed by the physicians.

Patient #6
Patient #6 is a 51-year-old male admitted on 4/16/13 with a diagnosis of herniated disc for a minimally invasive decompression of the lumbar disks 4 and 5.
Review of Patient 6's medical record "Anesthesia Preoperative Evaluation Form" under the section "PreOp Evaluation by" revealed the medical record entry did not have a time documented by S17Physician. Further review revealed an incomplete date was documented by S17Physician with only the month and day documented.
In a face-to-face interview on 4/17/13 at 3:00 p.m., S1RN,VPof Quality Services, confirmed and agreed that the documentation was not done and should have been completed according to hospital policy and regulations


17091

Patient #9
Review of the medical record for Patient #9 revealed the patient was admitted to the hospital on 04/16/13 for a Forehead Pedicle Flap, Ear Cartilage Graft with Septoplasty, and possible skin graft to defect. The patient's surgical procedure was done on 04/16/13 and the patient was then admitted overnight.

Review of the physician's orders revealed the Physician's Order Form Adult Anesthesia for pre-operative orders was signed by S17Physician, but was not dated or timed when the order was signed.

Further review of the physician's orders revealed a verbal order written at 04/16/13 at 12:30 p.m. to pre-medicate the patient prior to platelets transfusion. Another verbal order was written as follows: "04/16/13 at 1400-Labetalol 10 mg. IV Q 2 hours prn (as needed) - hold for HR (heart rate) < 70. Increase HOB (Head of Bed) to 45 degrees. Place at bedside: bipolar with forceps available, 1% Lidocaine." Both verbal orders were signed by the physician, but failed to include the date or time of the authentication of the order.

In an interview on 04/18/13 at 10:50 a.m., S2RN CNO (Chief Nursing Officer) reviewed the physicians' orders Patient #9 and verified the pre-operative orders written by S17Physician were not dated or timed by the physician. S2RN CNO stated the verbal orders indicated above were signed by the physician, but the only date and time of the orders was the order written by the physician at 1900 (order to transfuse platelets).



30172

Based on record review and interviews the hospital failed to ensure a transfer form was completed according to hospital policy when a patient was transferred to another acute care hospital for specialized services for 1 of 3 patient ( #3) medical records reviewed for transfer.

A review of the Hospital Policy No. PC-540, "Provisions of Care" revealed in part: c. The transferring physician and the nurse will complete documentation of the medical record ....., including the patient transfer form would be copied and sent with the patient at the time of the transfer. ......

Patient #3

The patient was admitted to the hospital on 03/01/13 for a cervical rhizotomy procedure as an outpatient. Due to a post-operative complication the patient was intubated and admitted as an inpatient to SICU (Surgical Intensive Care Unit). Patient #3 was also a dialysis patient and was scheduled for dialysis the next day. Patient #3 was transferred to another acute care hospital where dialysis services were available. Review of the patient's medical record revealed no documented evidence of a transfer form.

An interview on 04/16/13 at 4:10 p.m was conducted with S5RN SICU. She indicated that she was Patient #3's nurse on 03/01/13. S5RN SICU was asked who was responsible for completing the transfer form for a patient's transfer to another hospital. S5RN SICU indicated that the patient's nurse would be responsible for completing the form. She indicated that she was not sure if she completed a transfer form for Patient #3's transfer. S5RN SICU indicated it would be in the computer if she had completed a transfer form. She further indicated a completed transfer form was required by hospital policy.

An interview on 04/17/13 at 9:10 a.m. was conducted with S1RN Vice President of Quality Services. She was asked if a transfer form was completed for Patient #3. S1RN Vice President of Quality Services confirmed a transfer form was not completed by the SICU nurse or the attending physician as required by hospital policy.