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Based on record review and interview the facility failed to obtain informed consent for a SANE (Sexual Assault Nurse Exam) exam for 2 Patients (Pt. #1) and (Pt. #2) out of 6 medical records reviewed where SANE exams were performed.

Findings Include:

Review of Facility Policy titled, "Consent to Treatment" #SJH.ADM.012, dated 01/25/2023 revealed, "Purpose: This policy provides guidelines and defines the procedures that should be followed when informed consent is obtained...5. If possible, the patient's consent should be obtained sufficiently in advance of the proposed treatment or procedure to provide the patient with adequate time to consider all choices and make an intelligent, informed decision."

Review of Facility Policy titled "Advance Directives" #AJH.CLN.001, dated 03/03/2022 revealed, "...B. Power Of Attorney for Health Care: A Power of Attorney for Health Care is a designation by an individual of a health care agent to make health care decisions on the individual's behalf if the individual becomes incapacitated....G. Incapacity: Incapacity is an individual's inability to receive and evaluate information effectively to communicate decisions...the Power of Attorney takes effect upon a finding of incapacity by two physicians or one physician and one psychologist who have personally examined the patient and who have signed a statement certifying the patient has incapacity..."

On 5/16/2023 record review of Pt. (patient) #1's medical record revealed Pt. #1 had an advanced directive. A copy of the document was in his/her medical record. The record revealed a Progress Note dated 9/2/2022 that revealed a diagnosis of dementia, "patient is confused and may need activate (sic) POA (Power of Attorney)" The record revealed a "Consent for Sexual Assault Examination by a Sexual Assault Nurse Examiner" dated 9/5/2022 at 5:15 PM and signed with a verbal consent by Pt. #1's "POA". The medical record revealed an "Activation of Power of Attorney for Healthcare Statement of Incapacity" dated 9/8/22, 3 days after the POA signed the consent.

This finding was confirmed during record review on 5/16/2023 by Director G.

On 05/16/2023 record review of Pt. #2's medical record revealed Pt. #2 had an advanced directive that was not activated. A copy of the document was in his/her medical record. The record revealed a "Consent for Sexual Assault Examination by a Sexual Assault Nurse Examiner" dated 08/12/22 at 3:36 PM with telephone consent given by Pt. #2's "POA".

On 05/16/2023 at 3:40 PM in an interview with Director of Quality and Safety Staff C, when asked if POA activation forms were in Pt. #2's medical record, Staff C stated, "There is no evidence of activation of the POA."