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Tag No.: A0131
Based on clinical record review and interview, it was determined the Facility failed to obtain consent for treatment for 11 (#1, #3, #4, #6-#10, and #12-#14) of 15 (#1-#15) patients. Failure to obtain consent for treatment did not allow the Patients or their Caregivers to make knowledgeable, informed and clear decisions regarding their care. The failed practice affected Patients #1, #3, #4, #6-#10, and #12-#14. Findings follow:
A. Review of the clinical record for Patient #1 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #1 at 1400 on 04/25/17.
B. Review of the clinical records from 0830 to 1230 on 04/26/17 for Patient #3, #4, #6 and #7 revealed no signed consent for treatment. The findings were verified during an interview with Market Director #1 at 1230 on 04/26/17.
C. Review of the clinical record for Patient #8 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #1 at 1345 on 04/26/17.
D. Review of the clinical record for Patient #9 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #1 at 1348 on 04/26/17.
E. Review of the clinical record for Patient #10 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #1 at 1350 on 04/27/17.
F. Review of the clinical record for Patient #12 revealed no signed consent for treatment. The findings were verified during an interview with the 3 West Nurse Manager at 1400 on 04/26/17.
G. Review of the clinical record for Patient #13 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #2 at 1420 on 04/26/17.
H. Review of the clinical record for Patient #14 revealed no signed consent for treatment. The findings were verified during an interview with Market Director of Nursing #1 at 1421 on 04/26/17.