HospitalInspections.org

Based on medical record review, and document review, the hospital failed to document general consent for treatment, and video monitoring. Specifically, there was no evidence of documentation of general consent for treatments or written consent acknowledging video monitoring and "videotaping" of the patient. Documentation was absent in 1 out of 10 medical records reviewed.

Findings:

On 5/23/17 at 9:30am the Neuroscience Unit (C-6) was toured. One patient room is dedicated to monitoring of patients with epilepsy. Patients being evaluated for seizure activity may be hospitalized for 2-5 days. During this time the patient is monitored 24 hours a day with video and audio recordings obtained for the review of seizure activity.

The medical record of a patient being monitored for seizure activity was reviewed. The record did not have general consent for treatment, as well as a written consent acknowledging video monitoring and "videotaping" of the patient for diagnosis and treatment. Upon request, staff were unable to provide either of these documents. This occurrence was confirmed with the Unit Director and the Patient Care Manager of C-6 on 5/23/17 at 10:30 am.

Facility policies and procedures were reviewed regarding general and video consents. The Organizational Policy, "Informed Consent", # 7043, effective Oct. 2013 under the heading "Informed Consent-General", states, "The Informed Consent", healthcare provider performing the medical or surgical procedure on a patient is responsible for the informed consent process. Documentation of the patient's consent/refusal to consent may be completed by the same healthcare provider or his/her designee using the appropriate consent form.

The Organizational Policy, "Photography & Videography of Patients", #7316, effective Feb. 2016, under the heading "Procedures-Clinical", states, "Upon physician's orders and with the written consent of the patient, photographs and/or video may be taken when required for diagnosis or treatment." Additionally, "The nurse manager or designee is responsible to ensure the patient consent form is in the patient's medical record."