HospitalInspections.org

Based on facility policy, medical record review, and interview, the facility failed to ensure one of two current patients (Patient #12), and five of eleven discharged patients (#26, 27, #29, #30, and #31) received informed consent by a physicians. The hospital census was 196.


Findings included:

1. Review of the facility policy titled, "Consent - General and Informed", reviewed 04/08, gave direction, in part, to include the following:
"All patients will receive adequate information to participate in care decisions and provide informed consent prior to treatment of any medical condition. The physician will provide information as to the nature of the proposed care, treatment, services, medications, interventions or procedures. The physician will also provide information concerning the risks, benefits, complications and alternatives to the proposed treatment prior to requesting consent and consequences of refusal of treatment, if applicable."
"II. Situations requiring informed consent
A. Any surgical intervention;
B. Administration of anesthesia".

Review of the facility's Medical Staff "Rules and Regulations", revised 07/20/09, gave direction, in part, to include the following:
"Consent must be obtained from the patient or other authorized individual prior to rendering treatment except in cases of extreme emergency ...".

Review of the facility policy titled "Documentation Guidelines for the Medical Staff" (undated) states in section E: "Informed consent must precede a surgical or invasive procedure. Prior to the procedure, the physician must document informed consent in the patient record or sign the consent form."

2. Review of current Patient #12's medical record on 03/29/10 at 2:45 p.m. showed that he/she had a Coronary Artery Bypass Graft (open heart surgery) on 03/27/10. A form titled, "Consent for Anesthesia Services", was not signed by the anesthesia provider.

During an interview on 03/29/10 at 2:45 p.m., Nursing Director, staff I, stated that the anesthesiologist was in the department so staff I would get the consent signed. After getting the anesthesiologist's signature, staff I stated that it was fixed. Surveyor stated that to get the anesthesiologist's signature after the patient had the surgery does not show that the patient received informed consent.

Further review of Patient #12's medical record showed a form titled, "Consent to Operation Coronary Artery Bypass". The physician's signature was not dated and signed.


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3. Review of discharged Patient #26's medical record on 03/30/10 at 3:50 p.m. showed the patient has a Cesarean Section (C-Section) on 02/03/10. Findings included:
- A form titled "Consent for Anesthesia Services" dated 02/03/10 was signed by the physician but not dated and timed. The form does not indicate the type of anesthesia being given.
- A form titled "Consent to Operation" for " Repeat Cesarean Section" dated 02/03/10 was signed by the physician but the signature was not dated and timed.

4. Review of discharged Patient #27's medical record on 03/30/10 at 3:55 p.m. showed the patient had a Cesarean Section (C-Section) on 02/03/10. Findings included:
- A form titled, "Consent for Anesthesia Services" was not signed by the anesthesia provider. The form does not indicate the type of anesthesia being given.
- A form titled "Consent to Operation" for " Primary Cesarean Section" dated 02/03/10 was signed by the physician but the signature was not dated and timed.

5. Review of discharged Patient #29's medical record on 03/30/10 at 4:20 p.m. showed the patient had a Cesarean Section (C-Section) on 02/04/10. Findings included:
- A form titled, "Consent for Anesthesia Services" dated 02/04/10 was not signed by the anesthesia provider. The form does not indicate the type of anesthesia being given.
- A form titled "Consent to Operation" for " Primary Cesarean Section" dated 02/04/10 was signed by the physician, but the signature was not dated and timed.

6. Review of discharged Patient #30's medical record on 03/30/10 at 4:25 p.m. showed the patient had epidural anesthesia during labor and delivery. Findings included:
- A form titled "Consent for Anesthesia Services" dated 02/04/10 was signed by the physician, but the signature was not dated and timed. The form does not indicate the type of anesthesia being given.

7. Review of discharged Patient #31's medical record on 03/30/10 at 4:30 p.m. showed the patient had epidural anesthesia during labor and delivery. Findinds included:
- A form titled "Consent for Anesthesia Services" dated 02/03/10 was signed by the physician, but the signature was not dated or timed. The form does not indicate the type of anesthesia being given.
- A form titled "Timeout Checklist for Operations and/or Invasive Procedures" dated 02/04/10 for " Epidural " was signed by a physician, but the signature was not dated and timed.

Based on observation, the facility failed to protect patient's rights to privacy by placing patient names in public view in one Intensive Care Unit, the Pediatric Unit, the Medical/Oncology Unit, and the Urology/General Medicine unit. The hospital census was 196.

Findings included:

1. Observation on 03/29/10 at 2:40 p.m. in the Cardiovascular, Neuro Surgical Intensive Care Unit (ICU) showed a cardiac monitor with patients' last names posted. The monitor was at the nurses' desk and visible from the public hallway. This affected all 11 patients in the ICU.

2. Observation on 03/30/10 at 2:05 p.m. in the pediatric unit showed charts containing the patient's medical records with the patient's first and last names written on the chart's binder. The charts were positioned so the names were visible from the public hallway. This affected three patients in the pediatric unit.


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3. Observation on 03/30/10 at 9:00 a.m. in the Medical/Oncology Unit showed charts containing the patient's medical records with the patient's first and last names written on the chart's binder. The charts were positioned so the names were visible from the public hallway. This affected all 21 patients on the unit.

4. Observation on 03/30/10 at 9:15 a.m. in the Urology/General Medicine Unit showed charts containing the patient's medical records with the patient's first and last names written on the chart's binder. The charts were positioned so the names were visible from the public hallway. This affected all 21 patients on the unit.

Based on medical record review and interview, the facility failed to ensure medications were administered within 30 minutes of the scheduled time for two (Patient #13 and #14) of six patients observed for medication pass. The hospital census was 196.

Findings included:

1. Review of the facility policy titled, "Protocol for Administration of Medications", revised 07/09, gave direction, in part, to include the following:
"All medication administrations are verified for the right drug, dose, time, and route prior to administration."

Review of the facility policy titled, "Protocol for Barcoded Administration", revised 07/07, gave direction, in part, to include the following:
"Dose time window for a scheduled medication will be 2 hours before and 2 hours after scheduled time."
On the attached "Standard Medication Times/Abbreviations", revised 04/08, the following was stated:
"The window for med pass will be two hour before and after the scheduled dose.

2. Review of current Patient #13's medical record on 03/30/10 at 10:10 a.m. showed the following medications were not given at the scheduled time:
On 03/29/10:
- Coreg (for heart failure) 3.125 mg (milligrams) 1 tab (tablet) oral. Scheduled for 9:00 a.m. Given at 8:19 a.m.
- Cardizem (for high blood pressure)240 mg 1 cap (capsule) oral. Scheduled for 9:00 a.m. Given at 8:19 a.m.
- Lasix (to help remove excess fluid) 40 mg slow (intravenous [administered through a catheter inserted into the patient's vein]) push. Scheduled for 9:00 a.m. Given at 8:19 a.m.
- Lopressor (for high blood pressure) 25 mg 1 tab oral. Scheduled for 9:00 p.m. Given at 10:10 p.m.
- Benicar (for high blood pressure) 40 mg tab oral. Scheduled for 9:00 a.m. Given at 8:22 a.m.
On 03/30/10:
- Lasix 40 mg slow IV push. Scheduled for 6:00 a.m. Given at 7:05 a.m.

3. Review of current Patient #14's medical record on 03/30/10 at 10:20 a.m. showed the following medications were not given at the scheduled time:
On 03/30/10:
- Norvasc (for high blood pressure or angina [chest pain])) 5 mg oral. Scheduled for 9:00 a.m. Given at 9:38 a.m.
- Lexapro (anti-depressant) 10 mg oral. Scheduled for 9:00 a.m. Given at 9:37 a.m.
- Amitiza (for irritable bowel syndrome with constipation) 24 mcg (micrograms) oral. Scheduled for 9:00 a.m. Given at 9:36 a.m.
- Sodium Polystyrene Sulfonate (to lower the potassium level in the blood) 60 ml (milliliters) oral. Scheduled for 9:00 a.m. Given at 9:38 a.m.
- Spiriva (to relax the bronchial muscles)18 mcg inhalation. Scheduled for 8:00 a.m. Given at 9:38 a.m.

4. During an interview on 03/30/10 at 10:15 a.m., Director of Pharmacy, staff U, stated that the policy is to give medications between one hour before and one hour after the scheduled time.

5. During an interview on 03/30/10 at 4:30 p.m., Nursing Director, staff I, stated that in regards to the policy that referenced a two hour before and two hour after window to give medications is that a prompt comes up electronically asking the nurse for an override or it would trigger a medication error if the medication is administered outside of this four-hour window.

Based on record review, the medical staff failed to document the date and time of signatures for for seven (Patient #25, #26, #27, #28, #29, #30 and #31) of eleven discharged patient records reviewed. The facility census was 196.

Findings included:

Review of the facility policy titled "Documentation Guidelines for the Medical Staff" (undated) states in section B: "All entries in the patient record should be dated, signed, and, when appropriate, timed."

1. Review of the medical record for discharged Patient #25 showed:
- A form titled "History and Physicial Examination" was signed by the physician but the signature was not dated and timed.
- A form titled "Obstetric Discharge Summary" was signed by the physician, but the signature was not dated and timed.

2. Review of the medical record for discharged Patient #26 showed:
- A form titled "Timeout Checklist for Operations and/or Invasive Procedures" for a procedure that appears to read "C S Spinal" dated 02/03/10 was signed by a Registered Nurse (RN) but not dated and timed.
- A second form titled "Timeout Checklist for Operations and/or Invasive Procedures" dated 02/03/10 for " Repeat Cesarean Section " was signed by an RN, but the signature was not dated and timed.
- A form titled "Consent for Anesthesia Services" dated 02/03/10 was witnessed by an RN, but the signature was not dated and timed. The form does not indicate the type of anesthesia being given.
- A form titled "Consent to Operation" for " Repeat Cesarean Section" dated 02/03/10 was witnessed by an RN, but the signature was not dated and timed.
- A form titled "Information and Consent for Patients with Prior Cesarean Section" dated 02/03/10 was witnessed by an RN, but the signature was not dated and timed.
- A form titled "Lactation Consultation" dated 02/04/10 was signed by an RN, but the notation is not timed.
- A form titled "Obstetric Discharge Summary" was signed by the physician, but the signature was not dated and timed.

3. Review of the medical record for discharged Patient #27 showed:
- A form titled "Timeout Checklist for Operations and/or Invasive Procedures" for "Epidural" anesthesia dated 02/03/10 was completed by a staff member whose "signature" was initials only and the "signature" was not dated or timed.
- A second form titled "Timeout Checklist for Operations and/or Invasive Procedures" for "Primary Cesarean Section" dated 02/03/10 was completed and signed by a person without identified credentials, but the signature was not dated and timed. The form was also completed incorrectly (nothing was checked off).
- A form titled "Consent to Operation" for " Primary Cesarean Section" dated 02/03/10 was witnessed by an RN, but the signature was not dated and timed.
- A form titled "Consent for Anesthesia Services" dated 02/02/10 was witnessed by an RN, but the signature was not dated or timed. The form does not indicate the type of anesthesia being given.

4. Review of the medical record for discharged Patient #28 showed a form titled "Obstetric Discharge Summary" was signed by the physician, but the signature was not dated and timed.

5. Review of the medical record for discharged Patient #29 showed:
- A form titled "Information and Consent for Patients with Prior Cesarean Section" dated 02/04/10 was witnessed by an RN but not dated and timed.
- A form titled "Consent to Operation" for " Primary Cesarean Section" dated 02/04/10 was witnessed by an RN, but the signature was not dated and timed.
- A form titled "Consent for Anesthesia Services" dated 02/04/10 was witnessed by an RN, but the signature was not dated or timed. The form does not indicate the type of anesthesia being given.

6. Review of the medical record for discharged Patient #30 showed:
- A form titled "Timeout Checklist for Operations and/or Invasive Procedures" dated 02/05/10 for " Epidural " was signed by a physician but not dated and timed.
- A form titled "Consent for Anesthesia Services" dated 02/04/10 was witnessed by an RN, but the signature was not dated and timed. The form does not indicate the type of anesthesia being given.
- A form titled "Obstetrical Anesthesia Record" dated 02/05/10 was signed three times in each of three boxes titled "Surgeon," "Anesthesiologist," and "CRNA." None of the signatures were dated or timed. Additionally, there are several notations on the form and it is evident the same person did not make all notations. None of the notations are authenticated with signature to verify who wrote the note.

7. Review of the medical record for discharged Patient #31 showed:
- A form titled "Timeout Checklist for Operations and/or Invasive Procedures" dated 02/04/10 for " Epidural " was signed by a physician but not dated and timed.
- A form titled "Consent for Anesthesia Services" dated 02/03/10 was witnessed by an RN, but the signature was not dated or timed. The form does not indicate the type of anesthesia being given.
- A form titled "Obstetrical Anesthesia Record" dated 02/04/10 was signed three times in each of three boxes titled "Surgeon," "Anesthesiologist," and "CRNA." None of the signatures were dated or timed. Additionally, there are several notations on the form and it is evident the same person did not make all notations. None of the notations are authenticated with signature to verify who wrote the note.

8. During an interview 0n 03/31/10 at 10:00 a.m., staff B, the Head Nurse of the Obstetric and Gynecology unit said the discharge date and time on the form titled "Obstetric Discharge Summary" are to be completed by nursing staff when the patient actually goes home and the forms reviewed within the above listed charts were completed incorrectly.