HospitalInspections.org

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure the consent to treat form was completed according to the facility's policy for two (2) of four (4) records reviewed.

The findings were:

On 5/31/2022, the surveyors reviewed four (4) clinical records. Two (2) of the clinical records contained documentation that a verbal consent was obtained; in lieu of the patient's or authorized representative's signature.

A review of the facility's policy titled, Consents (Informed, General, Informed Refusal), reads in part: " ...6. Verbal Consent: If the patient is physically unable to sign but gives verbal consent, document "Unable to Sign/Verbal Consent" on the Patient Signature space. This entry must be authenticated by the author (Associate who received the verbal consent from the patient) with their name, date, and time. "Unable to Sign/Verbal Consent - Name of Associate who received verbal consent from the patient/DATE/TIME...".

During the clinical record review, the surveyors discussed the findings with Staff Members #1 & #2.

The findings were reviewed again during the exit conference on 6/1/2022.

Based on interview and facility document review, it was determined that the facility's COVID-19 staff vaccination policy failed to meet the standard of the regulation.

The findings included:

The facility's policy for staff COVID-19 vaccinations, was reviewed in conjunction with staff COVID-19 vaccination documentation on 6/1/2022. The facility's policy failed to contain the following required items:

1.) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (g)(1) of the regulation;

2.) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by CDC;

3.) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the hospital has granted, an exemption from the staff COVID-19 requirements;

4.) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and

The surveyor and Staff Member (SM) #2 discussed the facility's policy and SM #2 acknowledged that it did not contain all of the required items.

The findings were reviewed again during the exit conference on 6/1/2022.