HospitalInspections.org

Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure patients were afforded the right to make informed decisions regarding care for one (1) of ten (10) patients (patient #1). Review of the facility's polices revealed the patient's or the patient's representative had the right to participate in the development of their plan of care, including providing consent to, or refusal of, medical or surgical interventions. The patient or the patient's representative should receive adequate information, provided in a manner that the patient or the patient's representative could understand, to assure that the patient or the patient's representative could effectively exercise the right to make informed decisions. The facility failed to ensure the policies were followed as evidenced by Patient #1 not having a signed consent for treatment.

The findings include:

Review of the facility's policy, "General Authorizations and Consent", review date of 07/12/07, revealed a general consent for treatment must be signed for every patient. If the patient was present and able to sign, the patient must sign for consent, if the patient was unable to sign due to an emergency or urgent medical condition, the consent form should be noted that the patient was unable to sign due to his/her medical condition and the form should be witnessed by two (2) employees.

Review of the facility's policy, "Patient Registration", review date of 08/17/07, revealed all registrars will be responsible for getting the required documents signed which includes Consent/Authorization for Treatment (includes assignment of benefits) and Check List indicating the patient received the information packet [which includes Patients Rights and Responsibilities]. It further states any patient who is unable to complete the process, must be documented on the consent form, with two witness signatures on the consent for treatment form. A follow-up with the patient will be required to be completed during admission and/or before discharge.

Review of the facility's policy, "Admission of Patients", revised date of 11/10, revealed prior to leaving Admissions to go to the Nursing Unit, the following tasks shall have been accomplished by Admissions: including patients' rights information given to patients.

Review of the medical record, revealed the facility admitted Patient #1 on 05/28/11 at approximately 11:00 AM. Further review of the medical record revealed the patient had diagnoses which included Chest Pain, Implantable Cardioverter-defibrillator, Brain Stem Injury, Diabetes, Smoker, Anxiety and Depression.

Observation and interview of Patient #1, on 05/31/12 at 11:30 AM and 2:00 PM revealed the patient to be in bed in a hospital gown with his/her eyes closed. Repeated attempts of verbal stimulus resulted in acknowledgement of surveyors presence in room but were unsuccessful to arouse the patient to a level of dialogue.

Interview conducted at Patient #1's bedside with a facility contracted sitter, on 05/31/12 at 11:30 AM and 2:00 PM, confirmed Patient #1's response/actions during those times was consistent with behavior she had witnessed since 8 AM on 05/31/12.

Record review of Patient #1's scanned medical record, 05/28/12 admission date, revealed no evidence of the "AUTHORIZATIONS AND CONSENTS" form. Further review of the patient's active medical record 05/30/12 and 05/31/12 also revealed no evidence of the signed or unsigned form.

Review of the "Star Notes Processor", last edit date 05/28/12 at 11:12 AM, revealed "PT UNABLE TO SIGN/VERIFY" was printed on the Consent/Authorization for Treatment Form.

Interview with the Director of Nursing (DON), on 05/31/12 at 4:10 PM, revealed the consent to treat should have been in Patient #1's medical record. She stated the Admissions Department was responsible for obtaining the general medical consent/authorization to treat and dissemination of "Patient & Visitor Information Guide" which included patient's rights and responsibilities as part of the admission process. She further stated the consent was usually signed prior to the patient going to the nursing unit but if the situation required the patient to bypass the initial registration the Admissions Department/Registrars were still responsible for completing the admission process to include the Consent/Authorization for Treatment Form.