HospitalInspections.org

Based on record review and interview the facility failed to let the patient exercise their right to request or refuse treatment, in that 1 of 1 (Patient #1) patients did not sign the consent for treatment when the patient was awake, alert and oriented.

Findings included:

Patient #1 was admitted the facility on 10/20/19. The History and Physical dated 10/20/19 at 1749 reflected..." Physical Examination ...Neurological: Alert & oriented to person, place, and time. No focal motor deficits ..."

The Conditions of Admission Authorization for Treatment, and Financial Agreement dated 10/20/19 at 0824 reflected. a signature that is not the patients with no relationship listed.

The Power of Attorney listing (a granddaughter) as the primary person to make decisions in case the patient became incapacitated was not executed until 10/22/19.

During an interview with Personnel #4 on 01/16/2020 at 1115 in the Conference room Personnel #4" stated all patients are to sign their own consent for treatment unless they are incapacitated". Personnel #4 verified that Patient #1 was documented as being awake, alert and oriented to person, place and time., and did not sign the consent for treatment.

The Policy titled Consent to Inpatient and/or Outpatient Admission and Treatment dated 11/04/19 reflected..." 3. Consent for Adult patients who are comatose, Incapacitated or unable to communicate: A. If an Adult patient is comatose, incapacitated or other wise mentally or physically incapable of communicating and has not previously executed a valid medical power of attorney advance directive, an adult surrogate from the following list, in order of priority...1) patient's spouse. 2) an adult child of the patient who has the waiver and consent of all other qualified Adult children of the patient to act as the sole decision-maker..."