HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the facility staff failed to ensure medical records contained informed consent forms for procedures performed on 1 (one) of 4 sampled patients that received procedures requiring informed consent (Patient #2).

The findings include:

A review on 08/29/2025 of the hospital policy titled "Consent," with a current effective date of 05/24/2022, revealed, "...VIII. Documentation: ... F. The nurse is responsible for assessing that the consent form is completed and that the patient or person authorized to sign for the patient communicates an understanding of the procedure/treatment. G. A copy of the executed consent form is placed in the patient's medical record..."

A closed medical record review, on 08/26/2025, of Patient #2 revealed the patient was transferred from an outside facility for worsening diffuse abdominal pain associated with poor appetite. The review indicated the patient had a vascular catheter (a temporary dialysis catheter) placed on 06/19/2024 at 1914 and initiated SHIFT therapy (continuous dialysis for slower ammonia removal) on 06/20/2024 at 0133. The record review showed that the providers obtained informed consents, but the medical record did not include the consent forms.

An interview with Administrative Staff # 1 on 08/29/2025 at 1254 revealed that the consent forms for the vascular catheter and the shift therapy could not be located.

A follow-up interview with Administrative Staff # 1 on 08/29/2025 at 1325 revealed that consent should have been obtained and documented on a consent form.

Based on policy review, medical record review, video review and interview, the Emergency Department staff failed to document a patient reassessment per policy for 1 of 11 sampled Emergency Department medical records (Patient #1).

The findings include:

Review on 08/28/2025 of the hospital policy titled "Adult Patient Reassessment" effective date October 18, 2024, revealed "... Procedural Guidelines: ... Patient Reassessment (Waiting Room) The frequency of reassessment is based on the patient's acuity, condition, history, and complaint. ESI (Emergency Severity Index - triage system) level two (2) patients will be reassessed every two (2) hours. ... Reassessment includes vital signs and pain level. Physical assessments will be completed as needed. RN (Registered Nurse) or EMT-P (Emergency Medical Technician - Paramedic) may complete reassessments. ..."

Review of the Emergency Department record for Patient #1 on 08/26/2025 revealed a 29-year-old female presented to the Emergency Department on 08/04/2025 at 1226 via ambulance, with a chief complaint of sickle cell crisis and weakness. Patient #1 was triaged by RN #2 at 1236 and reported chest pain level of 1 out of 10 (0 being no pain, 10 being worst pain). Patient #1 was assigned an ESI level (acuity level) of "2" during triage assessment. Vital signs at 1239 were Temperature (T) 98.7, Heart Rate (HR) 78, Respiratory Rate (RR) 18, Blood Pressure (BP) 101/73 and Oxygen Saturation (SpO2) was 97% on Room Air (RA). Review of record revealed documentation at 1240 by RN #2 that Patient #1 reported intermittent, squeezing chest pain rated at "4". A medical screening exam (MSE) was completed by MD #3 at 1244. Review of the Emergency Department timeline revealed that Paramedic #4 documented the vital signs timer was reset/restarted at 1420 with no documentation of reassessment of vital signs or pain. Medical record review revealed that Patient #1 was reassessed by MD #3 after altercation with security at 1600. Nursing staff documented at 1602 that the Patient refused vital signs. Patient #1 was discharged to local police custody at 1627.

Review on 08/29/2025 of video footage in the waiting room revealed that Patient #1 left the waiting room to go to X-ray department at 1335 and returned at 1340 to the same waiting room area behind the half-wall. Video review from 1340 to 1430 failed to reveal Paramedic #4 completing a reassessment of vital signs for Patient#1.

Interview on 08/28/2025 at 1255 with Paramedic #4 revealed the paramedic role included reassessment of vital signs and pain based on ESI acuity level. Interview revealed that for an ESI level "2" acuity, the paramedic should have reassessed vital signs and pain level every two (2) hours. Paramedic #4 stated that a reassessment was not completed due to Patient #1 was not in the waiting room at the time the reassessment should have been completed.

Interview on 08/29/2025 at 1015 with Director #5 revealed that Paramedic #4 failed to reassess Patient #1's vital signs and pain while in the waiting room per hospital policy. Interview revealed the paramedic or nurse assigned in the waiting area were expected to reassess ESI level 2 patients every two (2) hours.

NC00231099; NC00233242; NC00232476; NC00232752; NC00232052; NC00231956; and NC00233969