HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the hospital staff failed to obtain 4 of 5 anesthesia consents from the appointed guardian for 1 of 1 patients found to lack the capacity to have full understanding or the capacity to make or communicate healthcare decisions. (Patient #5).

The findings include:

Review of hospital policy, "Informed Consent (North Carolina)" with a revision date of May 2014 revealed, "I. SCOPE / PURPOSE...II. POLICY A. ...C. Who May Give Informed Consent 1. Adults capable of making decisions...2. Incapacitated Adult a. ...b. When an adult patient is comatose or otherwise lacks capacity to make or communicate healthcare decisions, the following persons, in the order listed below, are authorized to consent on the patient's behalf: i. a health care agent, to the extent of authority granted; or ii. a guardian ..."

Closed medical record review conducted March 25, 2015 revealed the named patient, a 65 year-old was involuntarily committed to the named hospital psychiatric unit on January 17, 2015 due to mental illness and dangerous to self or others. Review revealed the named patient clinical history included Parkinson's disease (progressive movement disorder) and Schizoaffective disorder (mental disorder with abnormal thought process) and Electroconvulsive Therapy (ECT- shock therapy) for depression. Review of the "Behavioral Health Comprehensive Psychiatric Evaluation" form revealed the named patient received an initial diagnosis of Dementia with Psychosis (loss of contact with reality with declining mental function). Review revealed the named patient had no living will, Health Power of Attorney nor an Advanced Directive. Review of progress note dated January 26, 2015 revealed the named patient family was "very interested" in ECT. Review of the legal document, "INTERIM LETTERS OF APPOINTMENT GUARDIAN OF THE PERSON" revealed on January 30, 2015; the named patient's spouse was issued guardianship of the named patient. Review of physician's orders revealed on February 3, 2015; an order to have "guardian sign ECT consent" and anesthesia consult for ECT clearance. Review of consult report revealed on February 3, 2015; anesthesia performed a "preprocedural clearance for consideration of possible ECT" and the named patient was cleared for ECT treatments. Review of the anesthesia consents revealed on February 2, 2015; February 11, 2015; February 16, 2015 and February 20, 2015; the named patient name signature was documented as to consent for anesthesia. Review revealed no documentation of the appointed guardian consent for anesthesia for the aforementioned dates.

Interview conducted March 26, 2015 at 0915 with Psychiatrist #1 revealed the named patient was confused with confused speech and thought people were trying to harm her. Interview revealed the named patient ECT was part of the named patient treatment.

Interview conducted March 26, 2015 at 0925 with Social Worker #1 revealed the named patient was disorganized with thoughts and had decreased capacity to make decisions. Interview revealed guardianship was changed to the named patient's spouse.

Interview conducted March 26, 2015 at 1000 with Administrative Staff #1 revealed the anesthesiologist that obtained 4 of 5 consents for anesthesia was unavailable for interview.

Based on policy and procedure review, observational tours and staff interviews; the hospital staff failed to ensure the nourishment refrigerator temperature was checked and documented daily for 1 of 2 refrigerator temperature logs in 1 of 2 patient care areas.

The findings include:

Review of hospital policy, "Care of Refrigerators, Freezers, and Ice Machines", with a revision date of December 19, 2012++ revealed, "I. SCOPE / PURPOSE... II. POLICY All refrigerators, freezers, and ice machines will be kept clean, contain the appropriate items and kept at the appropriate temperature to ensure the safe storage of food or medications. ...A. Patient Nourishment Refrigerators/Freezers 1. ...7. In patient care areas; the thermometer must be checked daily and the temperature of the refrigerator/freezer documented. ...

Observational tour conducted March 25, 2015 at 1320 revealed the "Quality Control - Monitor - Refrigeration" form for Medical Surgical Unit - 3 West revealed for March 2015 the nourishment refrigerator temperature was not checked and documented for 6 of 26 days (9, 10, 11, 12, 14 and 19).

Interview with the Administration team during the observational tour revealed the Medical Surgical Unit - 3 West nourishment refrigerator temperature log was not checked and documented daily.

Interview conducted March 26, 2015 at 1010 with the Infection Control Practitioner revealed this personnel monitors nourishment refrigerator temperature logs 2-3 days per week due to work week was split between two facilities. Interview revealed documentation of nourishment refrigerator temperatures was important due to dairy products and if the refrigerator was out of range, the monitoring would prevent the product from reaching the patient.