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Based on interview and record review, the facility failed to fully uphold the patients' right to informed decision making regarding their care and treatment. Five (5) of five sampled patient records failed to contain current anesthesia consents as required by 25 Texas Administrative Code (TAC) 601.9 (1), effective 9/01/2023 [ Patient IDs # 1, 4, 5, 6, 7].

Findings included:

Record review of facility policy titled " Consent: General Informed Consent," dated 01/01/2022, read: the patient, in collaboration with his/her physician is able to make decisions involving his/her heath care. The patient receives the necessary information to enable him / her to make treatment decisions that reflect his or her own wishes including decision making. Legal citations/ references listed included : TAC Chapter 601.

Review of 25 TAC 601. 9 showed "Disclosure and Consent:Anesthesia and /or Perioperative Pain Management (Analgesia) " was revised to include a listing of the names of all anesthesia providers [ Physician Anesthesiologist; Dentist Anesthesiologist; and Non-Anesthesiologist Physicians or Dentists]. In addition, the revision requires a listing of all anesthesia providers that are supervised by the former to include Certified Anesthesiologist Assistant;Certified Registered Nurse Anesthesiologist;and Physician in Training.

Record review of five (5) sampled patient record who underwent surgery in May and June 2024 ( Patient IDs # 1, 4, 5, 6, 7 ) failed to show the anesthesia consent required by 25 Texas Administrative Code (TAC) 601.9 (1), effective 9/01/2023 was being utilized.

The above findings were verified by Staff -A, RN on 6/26/2024 at the time of review.