HospitalInspections.org

Based on document review and interview, it was determined in 3 of 10 (Pt's #1, #4 and #12) patient's records reviewed, the Hospital failed to ensure a consent for treatment was obtained. This has the potential to affect all patients who receive care at the Hospital with an average daily census of 7 patients.

Findings include:

1. The policy titled "General Consent for Treatment" (revised 4/17) was reviewed on 6/7/17. The policy noted "Policy: ...Consent forms are completed and signed by the patient or the legally responsible person and witnessed by Hospital personnel... Procedure... A. General Consent for Medical Treatment: It is the responsibility of the hospitals admitting/ registration personnel or designee to obtain a general consent for medical services prior to the delivery of medical treatment/diagnostic services. This consent is obtained for all patients."

2. The clinical record of Pt #1 was reviewed on 6/6/17 at approximately 10:30 AM. Pt #1 was admitted on 4/19/17 with a diagnosis of Pneumonia and discharged on 4/21/17. A blank consent form labeled with Pt #1's name noted "Pt d/c (discharged) no consent obtained".

3. The clinical record of Pt #4 was reviewed 6/7/17 at approximately 11:00 AM. Pt #4 was admitted on 4/16/17 with a diagnosis of Shortness of Breath and CHF (Congestive Heart Failure) and discharged 4/19/17. The record lacked a consent form signed by the patient. The consent form noted "pt. unable to sign consent."

4. The clinical record of Pt #12 was reviewed on 6/7/17 at approximately 10:30 AM. Pt #12 was admitted on 4/21/17 with a diagnosis of CHF and discharged on 4/24/17. A blank consent form labeled with Pt #12's name noted "Pt tried... to sign..." although lacked date, time and witness.

5. During an interview on 6/7/17 at 11:30 AM, E#1 (Director of Care Management) stated "If a patient is unable to sign the consent on admission, then the signature should be obtained later."