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Based on interview and record review, the hospital failed to ensure the informed consent was obtained prior to performing the surgical procedure for one of four sampled patients (Patient 4). This failure had the potential for the patient to not be fully informed of the risks and benefits prior to the surgery.

Findings:

Review of the hospital's P&P titled Informed Consent dated 6/26/22, showed the hospital will not perform any medical or surgical procedure without the risk of liability unless the patient or person legally authorized to act in the patient's behalf, has consented to the treatment. Consents must be witnessed by licensed hospital personnel. The witness should be present with the form is signed by the patient or the patient's legal representative, and should state that they witnessed the signing in the designated place on the form.

On 8/14/24 at 0920 hours, an interview and concurrent review of Patient 4's medical record was conducted with the CNO.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 8/13/24.

Review of the Physician Operative Procedure Report showed Patient 4 had a surgical procedure on 8/13/24 at 1346 hours.

Review of the Consent to Surgery or Special Procedures form showed the procedure to be done and the name of the practitioner who would perform the procedure. However, the signature section to show the patient authorized and consented to the performance of the operation or procedure was left blank.

The CNO stated the informed consent should be obtained and signed prior to performng the surgical procedure and verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for medication reconciliation for one of four sampled patients (Patient 1). This failure put the patient at risk of not receiving the medications based on the most current information.

Findings:

Review of the hospital's P&P titled Medication Reconciliation dated February 2022 showed all patients admitted to the hospital with be asked what home medications they are on. If patient is unable to provide, a good faith effort will be attempted by contacting family, support person, sending facility to see if they could provide the information.

On 8/14/24 at 0920 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the CNO.

Patient 1's medical record showed Patient 1 was transferred to the hospital from Facility A on 7/10/24, and discharged on 7/14/24.

Review of the physician H&P dated 7/11/24 at 1145 hours, showed Patient 1 was not alert and oriented so no reliable history was available.

Review of Patient 1's Facesheet showed Patient 1 had a Power of Attorney (POA).

The CNO was asked to show documented evidence the medication reconciliation was done as per the hospital's P&P. The CNO stated Facility A did not send the current medications list when Patient 1 was transferred to the hospital. The CNO was unable to show documented evidence the hospital had contacted the POA or Facility A for the current medication list. When asked how the medication list was obtained, the CNO stated the hospital used the medication list from the previous hospital admission from March 2024. The CNO verified the above findings.