HospitalInspections.org

Based on medical record review and staff interview it was determined the facility failed to ensure that care and treatment decisions were based on the patient's or patient's representative's informed consent for one (#2) of 30 patients sampled. This practice does not ensure patients or their representative rights for informed consent are maintained.

Findings include:

Patient #2 was admitted to the facility on 01/12/13. A review of the medical record revealed a telephone consent for surgery was obtained from a family member and witnessed by two nurses on 1/13/2013 at 05:25 a.m. The consent authorized the surgeon and/or chosen associates and assistants to perform the following operation(s) and /or procedure(s), which was left blank.

Interview with the nurse manager in a telephone call to the primary nurse revealed the nurse stated "The surgeon was not sure exactly what procedures he would be doing so I left it blank". Interview and record reviews with the primary nurse, the nurse manager and the corporate director of clinical operations on 1/15/13 at 10:00 a.m. confirmed the findings.

Based on observation, record review and interview the facility failed to ensure that nutritional needs were met for allergies for one of three (#14) active sampled patients with food allergies. This practice does not ensure patient safety.

Findings include:

Review of the facility's Diet Worksheet dated 01/15/13 revealed patient #14 had an order for a regular diet with listed food allergies that included tomatoes, oatmeal, corn, lemon, oranges, pecans, beans and peas.

Observation on 01/15/13 at 12:10 p.m. with the Food and Nutrition Services Director of patient #14's lunch tray, which had been delivered on the food cart, revealed the lunch tray contained tomato soup, small tomatoes on the lettuce salad and green beans.

Interview with the Director at this time related this was not appropriate and took the tray back to the food service department.

Record review revealed patient #14 had been admitted on 01/13/13 on a regular diet. Review of the nursing notes dated 01/14/13 revealed the patient was stating she had food allergies. Nursing requested the patient make a list of the food allergies. Nursing inputted into the computer the list of food allergies.

Observation of the food tray slip for the patient's lunch tray on 01/15/13 at 12:10 p.m. stated the list of food allergies. The facility did not ensure that nutritional needs were met for food allergies for patient #14.