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Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to obtain consent for treatment for 7 (#1,#2, #4, #5, #7, #9 and #11) of 12 (#1-#12) patients. Failure to obtain signed consents for care did not afford the patient or their representative the opportunity to make informed decisions regarding his or her care. The failed practice affected 7 (#1,#2, #4, #5, #7, #9 and #11) of 12 (#1-#12) patients on 01/17/13. Findings follow:

A. Review of 12 (#1-#12) clinical records revealed seven (#1,#2, #4, #5, #7, #9, and #11) did not contain consents for treatment, verified by the Director of Nursing at 1230 on 01/17/13.

B. Review of the policy and procedure titled "Informed Consent", numbered RI-028, revision 5, revealed ... I. Consent for Routine Hospital Care, 1. Upon admission to the hospital, a Conditions of Admission Form will be signed by the patient or a person authorized and empowered to give consent on behalf of the patient. This consent form documents the patient's consent to routine hospital services, diagnostic procedures and medical treatment. The Form shall not be used in the place of a Consent For Procedures Form or the Consent for Medications Form ...

C. Review of the policy and procedure titled "Admission Procedure", numbered PC-002, revealed...7. The following documents are required: c. Consent for Admission and Treatment (all patients).

D. During an interview with the Director of Nursing at 1230 on 01/17/13 she stated that if a minor patient was admitted via a court ordered hold, the Facility would call the Minor's parent or authorized person to get consent for treatment.