HospitalInspections.org

Based on record review and interview, the facility failed to ensure that there was a signed "Consent for Admission and Treatment" in the medical record for 2 of 20 (#17 and #18) records reviewed.

Findings:

Record review for patient #17, admitted on 12/15/10, did not reveal any signed admission paperwork including consent for admission and treatment.

Record review for patient #18, admitted on 1216/10 at 8 PM, did not reveal any signed admission paperwork including consent for admission and treatment.

Interview with the Admissions Coordinator on 12/17/10 at 4:00 PM, revealed that they do not have a process in place when the patient is admitted after hours.

Interview with the Chief Nursing Office on 12/17/10 at 4 PM, revealed that she concurred with the statement made by the Admissions Coordinator.

Facility policy calls for the admission paperwork to do on admission by the patient or the significant other.