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Based on a review of hospital policy "Informed Consent" (Effective Date 02/17/2015), and patient #2's record it was determined that the hospital failed to consult patient #2 or certify an incapacity prior to obtaining consent for a procedure from patient #2's son.

Review of hospital policy Informed Consent, revealed in part, "Surrogate Decision Making 1. After a patient has been certified as being incapable of making an informed decision, decisions concerning health care shall be made by a health care agent ..." The policy goes on in part, to describe the certification process.

Patient #2 was a female in her 90's who presented to the hospital in late January 2017 with complaints of blood in her urine. Patient #2 was admitted. Patient #2 was noted to be oriented to person, place and time, but was difficult to understand. She spoke Russian and was documented as having poor English communication. Further documentation revealed her refusal of a translator, stating that she understood English well. On the day of admission, patient #2 required a transfusion. Instead of obtaining a consent from patient #2, a telephone consent was obtained from patient #2's son.

There was no documentation indicating that patient #2 lacked capacity to make her own decisions. Therefore, the hospital failed to honor patient #2's right to participate in her own care when the hospital sought consent from patient #2's surrogate.