HospitalInspections.org

Based on record review and interview the facility failed to ensure that patient consent for treatment had signatures, time, dates and 2 staff witnessed for verbal and phone consents in 20 of 24 medical records reviewed (Patient #'s 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23 & 24) out of a total universe of 24 Emergency Department records reviewed.

Findings include:

The facility policy titled "Informed Consent Policy and Procedure" ID # 7346548 last reviewed on 12/2019 was reviewed on 6/8/2020. This document revealed "II. WHO MUST GIVE CONSENT: In a non-emergency situation, the patient is involved in the decision-making process, to the extent possible, even if the patient is incapacitated, incompetent, or a minor. The following circumstances shall apply: A. Adults with Decision-Making Capacity: All adults with decision-making capacity must sign their own consent as a prerequisite to any procedure requiring written informed consent. B. Adults without Decision-Making Capacity: If no guardian or health care agent has been appointed and the patient is incapacitated, the caregiver should seek the consensus of the patient's family or loved ones to ensure treatment decisions reflect the patient's likely treatment preferences under the circumstances and to promote the patient's best interest. Depending on who is closest to the patient, a spouse, adult child, [parent, could act as the patient's representative...E. Minors Generally: 1. Natural or Adoptive Parents. A natural or adoptive parent of a minor generally must consent to medical treatment of a minor...B. Verbal Informed Consent: Verbal informed consent is acceptable for procedures with minimal risk. The patient's verbal consent should be documented by a notation in the patient's chart that verbal consent was obtained. The notation should include: 1. Information that was disclosed to the patient prior to securing his or her consent. 2. Date and time that oral consent was given. D. Telephone Consent. If a delay would jeopardize the health of a patient, and if the legally responsible representative can only be reached by phone, consent may be obtained by telephone. The telephone consent will be witnessed by two people."

The facility policy titled "Aspirus Langlade Hospital Medical Staff Organization Manual-Rules and Regulations" ID #7568656 last reviewed on 2/2020 was reviewed on 6/8/2020. This document revealed "B. Consents: Every patient has the right to "informed consent" which means that the patient has the right to an explanation of diagnostic/therapeutic interventions by a physician/provider, as well as the right to give approval or refuse to accept treatment. The patient's consent must be obtained prior to the medical/surgical treatment. The consent must be informed; that is, the patient must understand the nature and purpose of the proposed treatment, the risks, benefits, and alternatives. The procedure for Consents is outlined in the Policy "Informed Consent".

Patient #1 was seen in the Emergency Department on 5/31/2020 for evaluation of a femur fracture. The "AGREEMENT FOR SERVICES" for that visit had "Verbal Consent" documented under the "Signature of Patient" there was 1 signature of staff as a witness with a date entered of 5/31/2020. There was no documented time of verbal consent received by witness.

Patient #2 was seen in the Emergency Department on 4/26/2020 for evaluation of left knee pain and was a minor. The "AGREEMENT FOR SERVICES" for that visit had "Minor" documented under the "Patient is unable to sign because" and "Mother" documented under "Relationship to patient" and "Verbal" written in. There was 1 signature of staff as a witness. There was no documented date of staff "witness" signature or time of verbal consent received by witness.

Patient #3 was seen in the Emergency Department on 4/1/2020 for symptoms of a stroke. The "AGREEMENT FOR SERVICES" for that visit had "Altered mental status" documented under the "Signature of Patient" there was two signatures of staff as a witness. There was no documented date or time of witnesses signatures.

Patient #4 was seen in the Emergency Department on 4/5/2020 for evaluation of a hip fracture. The "AGREEMENT FOR SERVICES" for that visit had two letters hand written under the "Signature of Patient". There was no documented date or time of signature.

Patient #5 was seen in the Emergency Department on 4/6/2020 as was found without a pulse and not breathing at home. The "AGREEMENT FOR SERVICES" for that visit had "Intubated" documented under the "Patient is unable to sign because" there was 1 signature of staff as a witness. There was no documented date or time of signature by witness.

Patient #6 was seen in the Emergency Department on 4/7/2020 for altered mental status at home. The "AGREEMENT FOR SERVICES" for that visit had "Verbal Consent from pt" documented under the "Patient is unable to sign because" there was two signature of staff as a witness. There was no documented date or time by witnesses.

Patient #9 was seen in the Emergency Department on 4/28/2020 for suicidal ideations and was a minor. The "AGREEMENT FOR SERVICES" for that visit had "Patient was unable to sign because Mother" documented. There is a documented signature of the mother. There was no documented date or time of this signature.

Patient #10 was seen in the Emergency Department on 5/9/2020 for complaints of leg pain. The "AGREEMENT FOR SERVICES" for that visit had a patient signature. There was no documented date or time of signature.

Patient #11 was seen in the Emergency Department on 4/13/2020 for complaints of difficulty breathing and a cough. The "AGREEMENT FOR SERVICES" for that visit had a signature of the patient on the "Relationship to patient" signature line. There was no documented date or time of signature.

Patient #12 was seen in the Emergency Department on 4/13/2020 for complaints of a cough, shortness of breath and a fever. The "AGREEMENT FOR SERVICES" for that visit had under "Patient is unable to sign because COVID (POSSIBLE)". Under "Signature of witness" there were two staff names listed. There was no documented date or time of signatures.

Patient #13 was seen in the Emergency Department on 4/13/2020 for a cough and sore throat. The "AGREEMENT FOR SERVICES" for that visit had a signature on the "Signature of Patient" line. There is no documented date or time of signature.

Patient #14 was seen in the Emergency Department on 4/17/2020 for shortness of breath. The "AGREEMENT FOR SERVICES" for that visit had under "Patient is unable to sign because-Resp (respiratory) distress/verbal". There was a signature of 2 staff members on the witness line. There was no documented time of signatures.

Patient #15 was seen in the Emergency Department on 4/18/2020 for shortness of breath. The "AGREEMENT FOR SERVICES" for that visit had under "Patient is unable to sign because: verbal consent given". There was signature of 2 staff as witnesses. There was no documented date or time of signatures.

Patient #16 was seen in the Emergency Department on 5/7/2020 for shortness of breath. The "AGREEMENT FOR SERVICES" for that visit had a signature under "Signature of patient". There was no documented date or time of signature.

Patient #17 was seen in Emergency Department on 5/11/2020 for shortness of breath. The "AGREEMENT FOR SERVICES" for that visit had under "Telephone consent from" with that persons name, position, time and date. There was 1 employee as a witness signature. There was not a second witness signature and no documented date and time of telephone consent.

Patient #19 was seen in the Emergency Department on 12/1/2019 for evaluation of knee pain. The "AGREEMENT FOR SERVICES" for that visit had a signature completed by the patient and a date. There was no documented time of signature.

Patient #20 was seen in the Emergency Department on 2/12/2020 for evaluation of hip pain. The "AGREEMENT FOR SERVICES" for that visit had under "Signature of Patient: Verbal consent". There was signature of 2 staff as witnesses with a date. There was no documented time of signatures.

Patient #21 was seen in the Emergency Department on 1/13/2020 for evaluation of a hip injury. The "AGREEMENT FOR SERVICES" for that visit had a signature and date completed by the patient. There was no documented time of signature.

Patient #23 was seen in the Emergency Department on 12/4/2019 for evaluations after a fall. The "AGREEMENT FOR SERVICES" for that visit had under "Signature of Patient: verbal consent". There was a staff signature under "Signature of witness". There was no documented date or time of signature.

Patient #24 was seen in the Emergency Department on 2/2/2020 for evaluation of a displaced shoulder. The "AGREEMENT FOR SERVICES" for that visit had a signature by the patient. There was no documented date or time of signature.

An interview was conducted on Tuesday, June 9th 2019 with Emergency Director B who, when asked about expectations of signatures on consents and dates and times stated "Yeah I saw we have some issues with that." When examples as listed above were reviewed with Emergency Director B stated "I would expect that all documents are signed, dated and timed for everything and that 2 witnesses would sign when needed and they are not. We are missing a lot of stuff on there."