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Based on record review, observation, and interview the facility failed to ensure the physicians were providing information to patients regarding risks and benefits before administering blood to patients in 1 of 1 (#9) chart reviewed.

A review of patient # 9's medical chart revealed she was to receive blood products on 7/31/24. The patient had signed the blood consent along with the nurse on 7/31/24. There was no physician signature or any progress notes that the risks and benefits of blood had been given to the patient before administration. Staff # 12 RN administered the blood product.

An interview was conducted on 7/31/24 with patient #9 and staff #12 RN and #14 RN. Patient #9 stated that she was aware she was getting blood and she did sign the consent, but she stated that she didn't believe anyone told her the risks and benefits. Pt. #9 stated the physician assistant spoke with her about it but not the physician. Staff #12 stated that she obtained the consent and witnessed it. Staff #12 was not aware that the physician had to give the risks and benefits. Staff # 14-unit director of orthopedics reported that she was not aware that the physician had to give the risk and benefits. Staff #14 confirmed the nurses had been getting the consent and giving the risks and benefits.

A review of the Blood Product Administration policy and procedure stated, "Informed consent will be obtained before the transfusion of blood/blood products." The policy failed to state the physician shall provide the benefits and risk to the patient before or while obtaining the consent.

A review of the policy and procedure for Informed Consent for Invasive/Surgical Procedure" Stated, "KEY WORDS: Informed Consent, Consent, Risks, Hazards, Benefits

I. OBJECTIVE/S: To ensure patients are apprised of their rights and afforded the opportunity to make voluntary and informed decisions about medical care and treatment.

II. POLICY STATEMENT: A competent adult patient or a surrogate decision-maker acting on the patient's behalf has the right to receive from the patient's physician/practitioner information necessary to make informed choices and decisions regarding the patient's medical care and treatment. The primary purpose of the informed consent process is to ensure that the patient or his/her surrogate decisionmaker is provided information in a manner that the patient and/or the patient's surrogate decisionmaker can understand to enable the patient and/or the patient's surrogate decision-maker to effectively exercise the right to make informed decisions."