HospitalInspections.org

Based on record reviews and interviews, the hospital failed to inform a patient of his/her rights in advance of providing care for one (1) of ten (10) sampled ED patients (ED Patient #1).

Findings:

The hospital's "Consent to Treatment" policy, last revised 6/2/2021, stated, in part, "A patient or his/her Authorized Representative will sign a Consent to Treatment form when seeking care at Northern Light Health Member Organization"; the consent would be signed upon every emergency department visit; and a note would be entered on the form if the patient could give verbal consent to treatment but was unable to physically signed the form or if the patient lacked the capacity to sign the form.

The "Consent to Treatment" form, in the signature section, stated, "I have received or declined a copy of the ... b) Patient's Rights and Responsibilities, ..." and there was an area for the patient or the authorized representative to sign, date, and enter the time.

ED Patient #1's medical record for his/her visit to the ED on 1/3/2022 was reviewed. There was no evidence the Consent to Treatment form was signed by the patient or an authorized representative or any notes documented on this form as to the reason there was no signature.

On 2/9/2022 at 10:30 AM, the ED Nurse Manager and the Patient Access Supervisor confirmed the form was not signed and there was no note indicating the reason the form was not signed.