HospitalInspections.org

Based on interview and record review, the facility failed to follow their policy for informed consent for 3 of 10 (Patients #8, #9, and #10) sampled patients, resulting in the potential for uniformed decisions and a loss of patient rights for all patients served by the facility. Findings include:

Record review of patient #8's electronic medical record revealed the patient was an 86-year-old male who as admitted to the facility on 04/23/23 for shortness of breath. Further document review revealed "Verbal Consent" for treatment was checked. However, there was no evidence of the required signatures of two associates, date, or time with the verbal consent notation.

Patient #9's electronic medical record revealed the patient was a 27-year-old male who was admitted to the facility on 03/16/2023 after being found in the street in his wheelchair covered in urine and feces. Further document review revealed there was a note that Patient #8 "agreed to be fully compliant with cares if admitted". There was no evidence to reflect the required signatures of two associates, date, or time with the note, and verbal consent was not checked.

Patient #10's electronic medical record revealed the patient was an 85-year-old male who was admitted to the facility on 04/12/2023 for increased weakness. Document review revealed "Verbal Consent" for treatment was checked. However, there was no evidence of the required signatures of two associates, date, or time with the verbal consent notation.

During chart review on 04/25/2023 at 1300, Staff B was asked if a hard copy of a signed consent for treatment form could be provided for patients #8, #9 and #10. In an interview on 04/25/2023 at 1315, Staff B stated there were no signed consents on the paper medical records for Patient's #8, #9 or #10.

Review of facility "Consent for Treatment" policy, dated 02/21/2023, revealed, "Only those patients who have voluntarily and knowingly consented to any proposed treatment should receive treatment at the facility. Appropriate documentation of informed consent shall be required before commencing any such treatment. Section 1. Competent adult ...B. Before proceeding with treatment, the consent of each and every competent adult must be obtained." 1. Documenting the consent. B ...consent must be witnessed by two Associates and the Associates should sign and print their names, indicating they received the verbal consent. The medical record should reflect who consented, the nature of the consent given, the date and time, and the printed names of the two (2) witnesses."