HospitalInspections.org

Based on review of 6 closed medical records, policies and procedures, and other pertinent documents, it was determined that the hospital failed to uphold the patient right to make informed decisions regarding care and treatment for 1 of 6 patients reviewed.

The findings include:

Patient #8 (P8) presented to the hospital's Emergency Department (ED) due to shortness of breath and decreased activity at the group home where P8 resided. On admission, the provider documented that P8 was alert and oriented times 2-3 (to person, time, and place); however, the provider also noted that P8 could not provide credible medical history due to intellectual delays.

During the admission, P8 received two Computed Tomography scans (CT scans) with intravenous contrast. A CT scan is an imaging procedure during which a series of x-rays are taken and a computer is used to create more detailed images of the body. Intravenous (injected into a vein with a needle) contrast is often used during CT scans to help better visualize blood vessels and structure of various internal organs.

The hospital required completion of an informed consent form for the use of intravenous contrast during imaging procedures, when performed under non-emergent circumstances, as evident by the presence of two consent forms in P8's medical record. These forms explained why the contrast was used and outlined the risks and benefits involved with the administration of the contrast. The surveyor noted that the patient or their representative did not sign these consent forms. The first consent form had a blank "Patient/Responsible Party Signature" line. The second form had an illegible name signed on the "Patient/Responsible Party Signature" line, and the the word "PA-C" (which is an acceptable abbreviation for "Physician Assistant") documented on "Relationship to Patient" line.

There was no documented evidence in P8's medical record that the patient or their representative were informed of or consented to the CT-scans with IV contrast. Additional review of P8's record found no evidence that these procedures were performed under emergent circumstances.

The hospital failed to ensure that members of its medical staff provided P8 and/or their representative with the opportunity to participate in their care, discuss risk and benefits of proposed procedures and treatments, and provide informed consent to or refuse procedures and treatment.