HospitalInspections.org

Based on document review, it was determined for 1 of 10 (Pt #1) patient, the Hospital failed to ensure the patient's right to refuse treatment was maintained. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. The policy titled "SMD Patient Rights and Responsibilities" (reviewed 4/29/2015) was reviewed on 1/7/2016 at 4:00 PM. The policy indicates under "IV. Guidelines/Procedures 7. You have the right to consent to or refuse treatment..."

2. The medical record of Pt #1 was reviewed on 1/7/2016 at approximately 1:00 PM. Pt #1 was admitted to the Hospital on 11/2/2015 with a diagnosis of UTI (urinary tract infection), acute renal failure and depression. On 11/6/2015 Pt #1 was transfer/admitted as a voluntary admission to the 7th floor psychiatric Unit. Documentation by the registered nurse (E #10) on 11/8/2015 at 7:00 AM states, "Lab personnel here to draw blood. Patient informed of physician's order for blood work. Patient refused so staff held patients arm so blood could be drawn. Patient states she fired both doctors. Staff explained patients daughter (POA-Power of Attorney) request Pt #1 to do as doctors staff asked. Patient responded with "She's not my guardian she is a prostitute."

3. There is no documentation in Pt #1's medical record of the clinical necessity of the blood work or the consent for the blood work and the use of a physical restraint being obtained prior to lab work being drawn.

Based on document review, it was determinged for 1 of 10 (Pt #1) patient, the Hospital failed to ensure the patient's right was not violated by the use of a physical restraint. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. The policy titled "SMD Patient Rights and Responsibilities" (reviewed 4/29/2015) was reviewed on 1/7/2016 at 4:00 PM. The policy indicates under "IV. Guidelines/Procedures 20. You have a right to freedom from restraint used in the provision of acute medical/surgical care unless clinically necessary."

2. The medical record of Pt #1 was reviewed on 1/7/2016 at approximately 1:00 PM. Pt #1 was admitted the Hospital on 11/2/2015 with a diagnosis of UTI (urinary tract infection), acute renal failure and depression. On 11/6/2015 Pt #1 was transfer/admitted as an voluntary admission to the 7th floor psychiatric Unit. Documentation by the registered nurse (E #10 ) on 11/8/2015 at 7:00 AM states, " Lab personnel here to draw blood. Patient informed of physician's order for blood work. Patient refused so staff held patients arm so blood could be drawn. Patient states she fired both doctors. Staff explained patients daughter (POA-Power of Attorney) request Pt #1 to do as doctors staff asked. Patient responded with "She's not my guardian she is a prostitute."

3. There is no documentation in Pt #1's medical record of the clinical necessity of the blood work or the consent for the blood work and the use of a physical restraint being obtained prior to lab work being drawn.