HospitalInspections.org

Based on interview and record review, the facility failed to fully uphold the patients' right to informed decision making regarding their care and treatment.

A sampled patient record failed to show a fully completed anesthesia consent as required by the Texas Administrative Code (TAC) Title 25, Part 7: Medical Disclosure Panel -rule 604.5 (1)- [ citing Patient ID # 1 ]

Findings included:

Record review of facility policy titled " Consent for Treatment (Adults and Minors)', last revised 12/2018, showed: an informed disclosure and consent form shall be obtained prior to all invasive diagnostic , surgical or medial procedures ( including blood administration, anesthesia administration , disposal off tissue. limbs, sterilization, photography, and observer. "

Review of Texas Administrative Code [TAC], Title 25, Part 7: Texas Medical Disclosure Panel 604.5 (1) showed "Disclosure and Consent: Anesthesia and /or Perioperative Pain Management (Analgesia) " required the consent 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 on 10/16/2024 with Staff ID-M, RN showed:

-Patient ID # 6 presented to the ER on 8/23/2024: was admitted as an inpatient.

-Review of a form titled " DISCLOSURE AND CONSENT-ANESTHESIA and/or PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA) .

The consent showed the Patient ID # 1 was to undergo a "left lower extremity angiogram and other indicated procedures." The type of anesthesia to be administered , as indicated by check mark was "MODERATE SEDATION."

There were no anesthesia provider names listed or the names of any staff supervised by provider to administer anesthesia.

Further review of the record showed Patient ID # 1 underwent an angiogram to the left lower leg on 8/27/2024. She received moderate sedation that included the administration of versed and fentanyl.

The above findings were verified by Staff -M, RN at the time of review.

Based on interview and record review, the hospital failed to fully implement its policy related to patient formulation of advance directives for 1 of 4 current patients (Patient ID # 6) ; and 1 discharged patient (Patient ID # 1) .

Findings included :

TX00515220

Record review of facility policy titled " Inpatient Do Not Resuscitate (DNR), Out of Hospital DNR, and Advance Directives Policy", last reviewed 09/2027, showed:

Procedure:

NURSING :

5. Upon admission to the nursing unit, the patient's nurse will check the Condition of Admission form and the admission assessment to determine if the patient has been asked about advanced directives.
a) this information will be documented on the admission assessment form.
b) if the information is not present, the nurse will request the information from the patient slash family and document on the admission assessment and request a copy be brought to the hospital to be placed in the chart.
In the interim, substance of the advanced directive or the intent will be documented by the RN on the admission assessment. See.
c.) Until a copy of the patient's advance directive is on the chart, the nurse should make reasonable attempts to obtain the copy and document the attempts in the electronic medical record. A reasonable attempt is defined by attempting at the time of admission and again within the first 48 hours in the hospital stay.
d) if the patient and /or family indicate these directives have been executed, the nurse will obtain copies or requests they be brought in and place them in the patient's medical record.
6. During the patient's hospitalization, any person who becomes aware that the patient has executed or revoked an advanced directive will notify the patient's nurse so that proper documentation can be placed in the chart. Additionally, the attending physician will be notified.
~~~~~~~~~~~~~~~~~

Patient ID # 6:

Record review on 10/16/2024 on 5 North Tower with Staff ID-F, RN, showed:

Patient ID # 6: was admitted on 10/14/2024

Review of Nursing Admission Assessment showed a section titled "ADVANCE DIRECTIVES" that contained several questions. These included:

- Question: Durable power of attorney ? answer was "YES"

-Question : Copy of durable power of attorney on chart? This was left blank.

Staff-ID-F said that the documents are scanned in registration, but there should be a copy in the patient's chart. There was no copy located in the patient's chart.

~~~~~~~~~~~~

Patient ID # 1:

Continued record review on 10/16/2024 with Staff ID-M, RN showed:

Patient ID # 6 presented to the ER on 8/23/2024: was admitted as an inpatient; and discharged on 08/28/2024.

Review of Patient ID-#1's ER nursing admission and her inpatient nursing admission showed inconsistencies related to documentation of a durable power of attorney/

ER Record:

Question: Durable power of attorney ? answer was "NO"

Inpatient record:

Question: Durable power of attorney ? answer was "YES

Question: Copy of durable power of attorney on chart? This was left blank.

There was information provided regarding "surrogate decision maker" that included son's name and telephone number."

There was no durable power of attorney located as a scanned documented for the 8/23/2024 admission. A fully dated and notarized power of attorney was located attached to a prior admission on 07/03/2024.

During an interview on 10/06/24 at 10:40 AM with Staff ID-K, RN, she said that all advance directive documents are requested at each admission. They do not "carry over" from one admission to the next.