HospitalInspections.org

Based on medical record review, staff interview and facility policy review, the facility failed to provide one patient, Patient #8, of 20 patients reviewed, an informed consent.

Findings include:

A medical record review on the morning of 2/25/16 found Patient #8 did not have an informed consent. Patient #8 was seen on 12/1/15 in the Emergency Department for abdominal pain.

An interview with the Director of Nursing, DON, on the afternoon of 2/25/16 revealed that all patients were required to receive an informed consent.

A review of the facility policy titled, "Informed Consent" with revision date of 3/2/09 revealed, "The patient will be informed of procedures, potential adverse reactions and potential outomces."

Based on medical record review, staff interview and facility policy review, the facility failed to ensure the physician(s) signed the verbal orders for 5 patients (#11, #15, #17, #18, #19) of 20 patients reviewed.

Findings include:

On the morning of 2/25/16, a review of 20 medical records found 5 patients had unsigned verbal physicians' orders.

An interview with the Director of Nursing, DON, on the afternoon of 2/25/16 revealed that verbal physician's orders needed to be signed within 24 hours.

A review of the facility policy titled, "Medication Verbal Orders Required Elements" with revision date of 4/13 revealed, "III. Procedure: D. The attending physician must sign the written record of the verbal/telephone order within 24 hours of giving the order."