HospitalInspections.org

A. Based on document/record review and staff interview, it was determined in 2 of 10 (Pts #9, #10) medical records reviewed in which the patient received surgery or an invasive procedure, the Hospital failed to ensure all patients had a completed written informed consent in the medical record prior to surgery or procedure.
Findings include:

1. The Hospital policy and procedure titled, "Consent for Surgery or Procedure" (With an effective date of July 12, 2013) was reviewed on 11/13/13 at 10:00 AM. It indicated under, "Guidelines for Use of the "Consent for Use of the "Consent for Performance of Operation or other Procedure and/or administering Sedation/Anesthesia form: A patient Consent form must be completed and filed in the patient's chart prior to performing a procedure and/or administering sedation/anesthesia."

2. The medical record of Pt #9 was reviewed on 11/13/13 at 10:45 AM. It indicated Pt #9 was admitted on 5/7/13 with a diagnosis of a kidney stone. Documentation in the medical record indicated Pt #9 was to have a cystoscopy, left retrograde pyelogram, left urescopy and possible left ureteral stent. The document titled, "Consent for Performance of Operation or Other Procedure and/or Administration of Sedation/Anesthesia" was reviewed. There was no documentation that a physician explained "The nature and purpose of the operation or procedure, alternative methods of treatment, risks involved, possible complications as well as possible results of not having this procedure..."

3. The medical record of Pt #10 was reviewed on 11/13/13 at 9:45 AM. It indicated Pt #10 was admitted on 5/6/13 with a complaint of urinary retention and hematuria. Documentation on a "Procedure Note", dated 5/7/13, indicated, "Description of procedure: After verbal informed consent was obtained,...A flexible cystoscope was used to cannulate the urethra, after use of UROJET; cystourethroscopy was performed..." There was no documentation in the medical record that indicated Pt #10 was provided an informed, written consent in accordance with the established policy and procedure.

4. During an interview with the Emergency Services Administrator, conducted on 11/13/13 at 2:45 PM, it was verbalized that all patients having surgery or invasive procedures are to have a completed informed consent in the medical record prior to the surgery or procedure.