HospitalInspections.org

Based on record review and staff interviews, the facility failed to ensure that medications were administered in accordance with physician orders for 1 of 6 sampled patients (#2). The findings are:

A. Record review of Patient #2's medical record revealed the following:
1. Record review of the Patient Disposition Page dated 10/31/10 indicated that the patient presented to the emergency room (ER) at 12:44 pm on 10/31/10, he was triaged at 12:45 pm, and had a medical screening examination at 13:33 (1:33 pm).
a. Record review of the Nurse documentation from the ER dated 10/31/10 indicated that at 2:53 pm, patient was seen by a Gastroenterologist who performed a GI (gastrointestinal) consultation.
b. Record review of the Physician Orders dated 10/31/10 indicated that the Gastroenterologist ordered the following at 3:30 pm: "Go-lytely [a bowel preparation] 1 gallon by mouth over 4 hours, starting at 5 pm today, NPO [nothing by mouth] past midnight tonight. Schedule patient for a colonoscopy with conscious sedation to be done tomorrow am."
The orders indicated that they were faxed to the pharmacy at 1830 (6:30 pm); this was one hour and a half after the Go-lytely was to be administered.
c. Review of the Patient Medications Dispensed Report indicated that at 6:39 pm, the Go-lytely container was dispensed to the ER from the pharmacy.
d. On 03/03/11 at 12:45 pm, during interview, the emergency charge nurse who was on duty the evening of 10/31/10 stated that if the physician had ordered the Go-lytely at 5:00 pm, the administration of the Go-lytely to the patient should have started in the emergency room. She confirmed by reviewing the patient's chart that the Go-lytely had not been administered in the ER.
e. Record review of the Patient Disposition Page dated 10/31/10 indicated that the patient was transferred to the floor at 19:23 (7:23 pm).
f. On 03/03/11 at 8:05 am, during interview, the admitting night nurse taking care of the patient on the floor stated that as soon as they got the patient settled in the room she started the Go-lytely preparation.
g. Review of the Patient #2's Medication Administration Record dated 10/31/10 indicated that the Go-lytely was started at 9:50 pm; this was four hours and fifty minutes after the Go-lytely should have been started.

Based on record review and interview, the hospital failed to obtain a properly executed informed consent form and place it in the patient's chart for 1 of 6 sampled patients (#2) before a colonoscopy and an anoscopy were performed on the patient on 11/01/10. The findings are:

A. Review of Patient #2's Physician Orders dated 10/31/10 at 3:30 pm revealed an order for a colonoscopy to be done on 11/01/10 in the morning and the hospital needed to "obtain consent for it."

B. Review of Patient #2's Operative Report dated 11/02/10 revealed the doctor wrote, "I was unable to perform anoscopy at the bedside,..."

C. Review of Patient #2's clinical record revealed no informed consent for either procedure.

D. Review of the hospital's Informed Consent Policy and Procedure, effective 12/08, read as follows:
"A. Physician's Role in Obtaining Informed Consent. The physician ... must obtain the patient's consent for surgical procedures or other specific invasive procedures to be performed by a physician ..."
"E. Responsibility to Obtain Consent. Generally, the health care practitioner who is directing the provision of the treatment or care or who is performing a procedure has the duty to obtain informed consent for such treatment or care from the patient.
"F. Procedures/Treatments Requiring Consent Be Obtained by Physicians. The following procedures, but not limited to those listed, shall be performed only after the ordering physician obtains an informed consent....Other invasive procedures including: ... Endoscopic procedures; ..."

E. On 03/03/11 at 1:05 pm, the Risk Manager confirmed there was no signed informed consent for the colonoscopy in the clinical record. When asked, she stated that it should have been obtained and included in the clinical record.

F. On 03/03/11 at 11:30 am, Surgeon #1 stated in interview that he did not obtain an informed consent for the anoscopy done on Patient #2 on 11/01/10 and he felt that he did not need to obtain one before performing this procedure. He further stated that if this procedure had been done in his office, he would have obtained an informed consent prior to the procedure.