HospitalInspections.org

Based on findings from document review and interview, the hospital lacked a written policy and procedure (P & P) addressing informed consents. Also, 2 types of consent forms in use at the hospital referred to an informed consent policy which did not exist.
Findings include:
--Per interview of the Director of Quality Improvement on 06/11/13 at 10:00 am, the hospital did not have a written P & P addressing the specifics of obtaining informed consents from patients. He/she indicated the hospital's Patients' Right Policy addressed informed consents.
--Per review of the hospital's "Patient's Bill of Rights" P&P, last revised 01/2010, it stated that each patient shall "... receive the information that he/she needs to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment." This policy did not describe exactly when informed consent should be obtained and the procedures involved (who, what, when, et cetera).
--Per review of the hospital form titled "Consent to Endoscopic Procedures," last revised 03/10/10, it stated, "Persons authorized to consent are .... Emancipated minors (refer to policy on consents)." Also, per review of the form titled "Consent to Transfusion of Blood or Blood Components..." last revised 09/28/12, it directed staff to refer to the hospital's administrative consent policy in order to determine what persons are authorized to give consent.
--During the interview with the Director of Quality Improvement on 6/11/13 at 10:00 am, he/she acknowledged the findings above and confirmed that the administrative consent policy referenced on the hospital consent forms did not exist.