HospitalInspections.org

Based on interview and record review, the facility failed to ensure there was a process was in place to verify consent to treat forms were obtained prior to receiving care in the facility for 4 (#s 7, 9, 11, and 19) of 26 sampled patients. This deficient practice had the potential to affect all patients who received care in the hospital. Findings include:

A review of patient #7's electronic medical record showed no consent to treat was obtained during an emergency room visit on 5/4/24.

A review of patient #9's electronic medical record showed no consent to treat was obtained during an admission to labor and delivery on 10/19/22.

A review of patient #11's electronic medical record showed no consent to treat was obtained during an acute inpatient admission on 5/25/24.

During an interview on 8/28/24 at 11:55 a.m., staff member AA stated patient #19 was admitted directly to the facility's inpatient status from the cancer center and his consent to treat must not have been obtained on admission to inpatient status.

During an interview on 8/28/24 at 1:33 p.m., staff member BB stated she was responsible for the medical records department. Staff member BB stated there was not a current process in place to ensure all documents in the medical record were completed or accurate. Staff member BB stated there was no current policy or procedure in place, but she was working on getting one implemented.

Based on interview and record review, the facility failed to have a complete medical record for 4 (#s 7, 9, 11, and 19) of 26 sampled residents. This deficient practice had the potential to affect all patients coming into the facility for treatment. Findings include:

A review of patient #7's electronic medical record showed no consent to treat was obtained during an emergency room visit on 5/4/24.

A review of patient #9's electronic medical record showed no consent to treat was obtained during an admission to labor and delivery on 10/19/22.

A review of patient #11's electronic medical record showed no consent to treat was obtained during an acute inpatient admission on 5/25/24.

A review of patient #19's EMR in the facility's EHR showed an informed consent form that was unsigned.

During an interview on 8/28/24 at 11:55 a.m., staff member AA stated patient #19 was admitted directly to the facility's inpatient status from the cancer center and his consent to treat must not have been obtained on admission to inpatient status.

During an interview on 8/28/24 at 12:05 p.m., staff member AA stated consent to treat forms were to be completed when a patient arrives to the facility and did not know why the consent to treat forms were not completed.

During an interview on 8/28/24 at 1:33 p.m., staff member BB stated there was not a current process in place to ensure all documents were completed.

A review of a facility policy titled, "Condition of Admission Forms," with a revision date of 6/2010, showed:

... "Procedure:

... 2. Patients and/or the designated Power of Attorney, guardian/parent or family member will need to sign the Conditions of Admission.

a. This form gives permission for the patient to be treated, either by the attending physician or the staff."


47752

Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility's Quality Assurance Program (QA). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include:

During an interview on 8/27/24 at 11:03 a.m., staff member B stated she was the staff member primarily responsible for the facility's organ procurement program and the organ procurement program was not currently included into the facility's Quality Assurance Program.

A review of the facility's Quality Assurance minutes showed no documentation for the inclusion of the Organ Procurement Organization program (OPO).