HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 3 of 3 MRs reviewed, Patients #2, #3, and #4, there was no documentation indicating, that at the time of a patient's admission to the hospital, the patient was asked whether he/she wanted a family member or representative notified of their admission to the hospital.

Findings include:

-- Per review of the hospital policy and procedure (P&P) titled "Family, Representative and Physician Notification," last revised 8/2017, it indicated that while performing the nursing admission assessment, nursing staff should ask patients if they would like a family member or representative notified of their admission to the hospital. The notification should occur promptly and no later than 24 hours after the admission order was written.

-- Per review of Patient #2's MR, she was admitted to the hospital on 9/1/17 with elevated sodium level and deep vein thrombosis. The MR lacked documentation that hospital staff inquired as to whether Patient #2 wanted her family or representative notified of her admission.

The same lack of documentation regarding whether patients wanted their family or representative notified about their admission was found in MRs for Patients #3 and #4.

-- During interview of Staff A on 9/6/17 at 2:00 pm, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, interview, and document review, in 1 of 11 MR's, Patient #5, nursing staff did not notify the attending physician that a restraint had been applied. Also, the hospital's policy and procedure (P&P) did not instruct staff to notify the patients attending physician of restraint application to nonviolent patients.

Findings included:

-- Review of Patient #5's MR identified that an order was written on 8/25/17 by the physician assistant (PA) for a vest restraint for 24 hours. There was no documentation that the attending physician was notified of the restraint order.

-- During interview of Staff B, on 9/6/17 at 11:30 am, he/she confirmed this finding.

-- Per review of the facility's P&P titled "Restraints, Physical, Chemical and Safety, Suicide (Suicidal) Risk and Prevention Adult," last revised 5/2017, it incorrectly indicated that the attending/covering physician notification for restraint application for nonviolent patients was not required.

Based on findings from medical record (MR) review, document review, and interview, in 1 of 11 MRs, Patient #5, the hospital's informed consent form for an interventional radiology procedure did not contain the name of the physician performing the procedure for which consent was being obtained. Also, the hospital policy and procedure (P&P) addressing informed consent did not require that the name of the physician in a radiology group be specified on the consent form. Additionally, in 4 of 5 MR's (Patient's #8, #9, #10 and #11) reviewed informed consent for vaginal delivery, possible Cesarean Section and consent for transfusion of blood and/or blood components lacked the physician signature.

Findings include:

-- Per review of Patient #5's MR, she was admitted to the hospital on 7/31/17. Consent forms signed by her daughter for image guided left chest tube insertion and sonography guided left thoracentesis were present in the MR. There was no documentation on either consent form indicating the name of the responsible practitioner who would be performing the procedure at the time the consent was signed by the patient's daughter.

-- Per review of the hospital's P&P titled "Consent Policy," last revised 3/2017, it indicated that for medical imaging and interventional radiology procedures, if the procedure will be performed by a radiologist, the name of the physician listed on the consent should be Prospect Hill Radiology PC and the physician listing for Prospect Hill Radiology should be provided to patients who are having interventional or invasive procedures performed by a radiologist. The P&P does not require that the name of the physician performing the procedure be specified on the consent.

-- During interview of Staff A on 9/7/17 at 2:30 pm, he/she indicated that patients are provided with the names of the radiologists during the informed consent process. Regardless, he/she acknowledged that the name of the radiologist is not documented on the consent form.

-- Per review of the hospital's P&P titled "Consent Policy," last revised 3/2017, it indicated the Consent to Operation and the Consent to Transfusion of Blood and/or Blood Components will be obtained by the surgeon. Signatures, dates and times are required on both pages by provider and patient.

-- Per review of Patient #8's MR, she was admitted to the hospital on 9/4/17. Consent forms signed by the patient for vaginal delivery, possible Cesarean Section and consent for transfusion of blood and/or blood components lacked a physician signature.

-- Per review of Patient #9's MR, she was admitted to the hospital on 9/4/17. Consent forms signed by the patient for vaginal delivery, possible Cesarean Section and consent for transfusion of blood and/or blood components lacked a physician signature.

-- The same lack of physician signature on consent forms was found in Patient #10's MR and Patient #11's MR.

-- Per interview of Patient #9 on 9/6/17 at 9:50 am, a registration clerk obtained her signature for consent for vaginal deliver, C-section and blood transfusion.

-- Per interview of Staff C on 9/6/17 at 10:00 am, he/she obtains patients signature on consent forms for vaginal delivery, possible Cesarean Section and blood transfusion. If patients have questions he/she refers them to their physician.

-- During interview of Staff D on 9/6/17 at 10:15 am, he/she acknowledged the above findings.