HospitalInspections.org

Based on record review and interview, the facility failed to ensure that each patient or patient's representative was informed of the patient's rights in 1 of 10 medical records (Patient #6) per facility policy in a total sample of 10 medical records reviewed.

Findings include:

Review of facility policy #4864999 titled, "Patient Rights and Responsibilites," last revised 04/2018, revealed, "POLICY: All...health care organizations will have in place a means by which all patients will be informed of their rights and responsibilities...RATIONALE:...A clear articulation of patient rights and responsibilities which encourages patients and families to participate in the treatments and services they receive reflects our Values of Development and Excellence...PROCEDURE: 1. Responsible staff will provide a copy of the patient rights and responsibilities to all inpatients, and make copies available to all outpatients. 2. Responsible staff also will provide the Notice of Privacy Practices to all patients..."

Review of facility policy #4452604 titled, "SEWI: Consent for Treatment and Financial Agreement," last revised 06/2017, revealed,
"POLICY:...The Consent for Treatment and Financial Agreement signature is obtained by Registration staff and/or staff of departments where patients present for services: a. Annually medical group services and hospital outpatient services such as radiology, laboratory, nutrition services, cardiac diagnosis, respiratory, pulmonary diagnosis, outpatient behavioral health, rehabilitation and onclology. b. At each episode of care for all other services which would include inpatient, emergency room, surgical services including GI services and observation...RATIONALE: The purpose of this policy is to insure that appropriate consent is obtained for patients accessing services and to define the consistent process to follow in the collection of signatures on the Inpatient and Outpatient Consent for Treatment & Financial Agreement document...PROCEDURE: A. Consent Form 1. When the patient presents for services the Registration staff and/or staff of departments where the patient presents for services will determine if Consent for Treatment and Financial Agreement signature is needed by checking the service type and documented date of last signature in Epic...2. If signature is needed: a. The patient must be provided a copy of the document to review the content prior to signing...b. If the patient does not want to sign electronically, they still have the option to sign the document by hand. The document will then be sent to HIM for scanning...C. Other Information:...2. The original signature on the Consent for Treatment and Financial Agreement is retained in Medical Records for all patients..."

Review of the facility document #192522 titled, "Ascension Wisconsin* Consent for Treatment and Financial Agreement," dated 07/2018 revealed, "GENERAL CONSENT TO CARE...I am coming for care and treatment. I agree to services including examinations, procedures, x-ray and lab services, tests and treatments, medication, monitoring, nursing care, counseling, and education...PRIVACY NOTICE AND PATIENT RIGHTS...I confirm that I received or was offerred and declined a copy of the Patient Rights and Responsibilites..."

Patient #6's closed medical record was reviewed on 10/29/19 at 2:46 PM with Care Management Manager F who confirmed the following:

Patient #6 was admitted to the facility on 9/23/19 for a scheduled, elective left carotid endarterectomy (a surgery used to reduce the risk of stroke by removing material on the inside of the carotid artery, correcting the narrowing in the artery), and was discharged to home on 9/24/19. The document titled, "Ascension Wisconsin* Consent for Treatment and Financial Agreement," on which Patient #6's demographic sticker was placed indicating "Visit Date: 9/23/19," was scanned into the medical record. There were no documented patient, patient's representative, or witness signatures on the form. There was no electronic signature found in Patient #6's electronic medical record.

During an interview on 10/29/19 at 3:59 PM, Registration Supervisor I stated, "If a patient comes in for surgery, Registration should get a consent to treat. There is no signed form for [Patient #6] for this encounter date. There should be one."