HospitalInspections.org

Based on review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure consent for treatment was obtained for five of 25 medical records reviewed (MR1, MR2, MR3, MR4 and MR5.)

Findings include:

Review on August 6, 2014, of the facility policy "Patient's Bill of Rights / Responsibilities," dated reviewed January 2013, revealed "... 9. The patient has the right to full information in layman's terms, concerning his diagnosis, treatment and prognosis including information about alternative treatments, and possible complications. When it is not medically advisable to give such information to the patient , the information shall be given on his behalf to the patient's next of kin or any other appropriate persons. Except for emergencies, the physician must obtain the necessary informed consent prior to the start of any, procedure, treatment or both. ..."

Review on August 6, 2014 of the facility policy and procedure "Consents," dated last revised January 1, 2014, revealed "Policy: It is the policy of Lehigh Valley Hospital - Hazleton to obtain a consent on behalf of all patients regardless of sex or marital status prior to the performance of a medical procedure or admission to the hospital. ... Criteria: The following criteria will be used to define medical procedure or treatment: 1. Major or minor surgery which involves an entry into the body, either through an incision or through one of the natural body openings. 2. All procedures in which anesthesia will be used. 3. Non-surgical procedures. Such procedures would include: but not be limited to diagnostic procedures. 4. All procedures which the Medical Staff determine require a specific explanation to the patient. 5. For the use of a drug when it is investigational. Exceptions: In the event is it not possible to obtain a signature authorizing emergency treatment of a patient, adult or minor and in the sole opinion of the treating physician emergency treatment is necessary for the patient's health and such treatment is given, then the physician should write and sign a statement explaining why treatment was given without an authorized signature consent."

Review of MR1 revealed presentation to the emergency room on April 9, 2014, after a syncopal episode at home. There was documentation the patient's family was present, including the patient's spouse, who was identified as the Power of Attorney (POA). There was no documentation the consent for treatment was obtained. There was no consent for treatment form in MR1.

Review of MR2 revealed two separate presentations to the emergency room for treatment, on June 9, 2014, and July 2, 2014. The consent form for each presentation to the emergency room documented unable to sign. There was no documentation in MR2 attempts were made to contact the patient's next of kin or POA for consent to treat. There was documentation that the next of kin (POA) was identified.

Review of MR3 revealed an emergency room presentation on June 4, 2014. MR3 was transferred to a higher level of care. The transfer sheet was signed by the patient's next of kin. The general consent form in MR3 documented unable to sign. There was no documentation the patient's next of kin was notified to request consent to treat.

Review of MR4 revealed an emergency room presentation for treatment on June 18, 2014. The consent form documented unable to sign. There was no documentation in MR4 an attempt was made to contact the patient's next of kin or POA for consent to treat. There was documentation the patient was discharged home, and the patient signed the discharge instructions.

Review of MR5 revealed a emergency room presentation for treatment on June 1, 2014. The consent documented "patient incapable of signing." Documentation in MR5 revealed the patient was discharged to home a few hours later. The discharge instructions were signed by MR5.

Interview on August 6, 2014, with EMP1 confirmed there were no signed consents for treatment in MR1, MR2, MR3, MR4 and MR5. EMP1 confirmed the established policy for obtaining consent was not followed.

Interview on August 6, 2014, with EMP3 confirmed they do not always call next of kin to obtain the consent to treat. EMP3 confirmed that for patients discharged from the emergency room there is no attempt by registration to get the consent for treatment signed after the initial presentation, even if the patient is capable of signing prior to discharge or if the patient's family presents to the emergency room.