HospitalInspections.org

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on July 20, 2016, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 20, 2016 for Life Safety Code.

Based on record review and interview, the facility to document evidence of informed consent for treatment was obtained for 1 (#10) of 24 sampled patients whose medical records were reviewed for consent, out of a total of 24 sampled patients resulting in the potential for patients and/or patient representatives not being informed of the risks and benefits of treatments. Findings include:

On 7/20/16 at approximately 1520, a review of the electronic closed medical record was conducted with Medical Records Staff I.

According to the admission records patient #10 was a 74 year old male who presented to the Emergency Department (ED) on 5/8/16 at 1914. There was no consent for treatment documented in the clinical record. When queried Staff I stated, "I don't see one (consent for treatment)." Staff I further stated, "It's possible since the patient came after 7 PM the nursing staff would have had the patient sign a paper form for consent for treatment. It's possible the consent was obtained and scanned but I don't see it now." Staff I further stated, "We don't keep a hard chart. All documents are scanned and shredded."

When asked to explain whose responsibility it was to make sure a consent for treatment was documented in the clinical record Staff I stated, "It's my responsibility."

On 7/20/16 at 1550 further review of the medical record documented the following:

A review of physician orders dated 5/8/16 at 1931 included:
1. Xopenex 1.25 milligrams (mg) inhalation one time only.
2. Intravenous (IV) bolus of 0.9 percent (%) Sodium Chloride (NaCl) 250 milliliters (ml) over 30 minutes.

A review of the Medication Administration Record (MAR) dated 5/8/16 documented the patient received:
Xopenex 1.25 mg via nebulizer at 1938 and 250 ml of NaCl at 1935.

A review of physician orders dated 5/8/16 at 2015 documented:
1. Observation per Attending Medical Doctor.
2. Diagnosis: COPD (Chronic Obstructive Pulmonary Disease) exacerbation, Dyspnea acute, CHF (Congestive Heart Failure), End Stage Renal Disease.
3. Condition guarded.
4. DNR status (Do not resuscitate).
5. Vitals every 6 hours/Accuchecks twice per day.
6. Diet: Healthy heart diabetic renal diet 2000 calories.
7. Labs daily Complete Blood count and BMP (basic metabolic panel)
8. Med's- Solumedrol 62.5 mg IV every 8 hours. Zithromax 500 mg IV every 24 hours. Xopenex 1.25 milligrams (mg) inhalation every 8 hours. Albuterol 2.5 mg inhalation every 8 hours.
9. Resume home medication per signed list.

A review of the (MARS) dated 5/9/16 documented the patient received:
Xopenex 1.25 mg at 0140 inhalation. Albuterol 2.5 mg inhalation at 0601. Solumedrol 62.5 mg IV at 0454.

On 7/21/16 at approximately 1050 a review of the facility's "Medical Record Content" policy
(dated 4/2016) documented:
"Admitting/Registration is responsible for collecting information to identify the patient, completing all areas within the demographic section of the electronic health record (EHR)...Registration staff will also assure a signature for the Consent to Admission and Treatment is obtained."