HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to ensure a complete and accurate medical record related to a transfer record for 1 patient (#2) and the facility failed to ensure informed consents were signed by the patient for 9 patients' records (#3, #4, #5, #6, #7, #8, #9, #10, and #11) of 13 records reviewed.

The findings included:

Review of facility policy, Patient Financial Services, last revised 3/7/2023, showed "...the registrar should ask the patient [or the legal representative] to sign all required consent forms. The patient should be the one to sign/date/time in the appropriate signature line...if patient gives 'verbal consent' in the signature line the registrar should sign in the witness space and date and time the consent form. The registrar should continue to attempt to obtain a consent signed by the patient or their legal representative before discharge. This should include checking with the nursing staff throughout the patient's visit to see if the patient is able to sign, checking with the patient or their legal representative to see if they are able to sign the consent form..."

Medical record review showed Patient #2 was admitted on 4/16/2023 at 7:48 PM after suffering a seizure while at home. He was transferred to a higher level of care at an acute care pediatric facility on 4/16/2023.

Medical record review of an ED Physicians record dated 4/16/2023 at 8:06 AM showed the patient suffered a seizure and received Valium (medication used for seizures) per Emergency Medical Services (EMS) with no improvement. There were concerns the patient had aspirated (inhalation of stomach contents to the lungs). The patient was given Ativan (medication used for seizures) 1 milligram (mg) intravenous push with improvement of the seizure activity. Diagnostic testing included a COVID 19 swab, Influenza swab, Rapid Strep swab, Blood culture, Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lactic Acid, Magnesium level, and chest x- ray. The patient was transferred to an acute care pediatric facility for a higher level of care.

Medical record review showed the transfer from was not in the medical record. The facility was able to find the transfer form. This admission occurred on 4/16/2023 and the transfer form was not scanned into the medical record and the medical record was incomplete.

Interview with the Risk Manager on 7/19/2023 at 2:30 PM showed the Risk Manager confirmed the transfer form was not in the medical record and the medical record was not accurate and complete.

Medical record review showed Patient #3 was admitted on 1/21/2023 at 2:02 AM related to a suicide attempt. Diagnostic testing was completed, and a behavioral health consult was completed. The patient was medically cleared and transferred to an inpatient psychiatric facility. The patient was transferred to an inpatient psychiatric facility on 1/22/2023.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 1/21/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #4 was admitted on 2/7/2023 at 1:17 PM with abdominal pain and pregnancy. Diagnostic testing and a cervical examination were completed. The patient was transferred to an acute care hospital for higher level of care related to possible labor.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 2/7/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #5 was admitted on 5/10/2023 at 5:37 PM with complaints of abdominal pain. Diagnostic testing was completed, and she was diagnosed with acute cholecystitis (gallstones). The patient was transferred to an acute care facility for higher level of care on 5/10/2023.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 5/10/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #6 was admitted on 2/7/2023 at 12:55 AM with abdominal pain related to pregnancy. Diagnostic testing and cervical examination were completed. The patient was diagnosed with Vaginal Discharge, Third Trimester pregnancy, fever, and uterine contractions. The patient was transferred to an acute care facility for Obstetric services.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 2/7/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #7 was admitted on 2/4/2023 at 5:35 AM with Abdominal pain with pregnancy. Diagnostic testing and cervical examination were completed. The patient was diagnosed with false labor and high-risk pregnancy. The patient was transferred to an acute care facility for Obstetric services.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 2/4/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #8 was admitted on 4/19/2023 at 10:46 AM. The patient left the facility Against Medical Advice (AMA) on 4/19/2023.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 4/19/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #9 was admitted on 6/30/2023 at 8:32 PM with abdominal pain and cramping. A cervical examination was completed. The patient was diagnosed with labor and premature rupture of membranes. The patient was transferred to an acute care facility for Obstetric services.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 6/30/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #10 was admitted on 6/2/2023 at 11:57 AM with complaints of chest pain and visual changes. Diagnostic testing was completed, and the diagnoses included a Urinary Tract Infection (UTI), Abnormal Computed Tomography (CT) of the brain and hypokalemia (low potassium). The patient refused admission and signed out AMA on 6/2/2023.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 6/2/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

Medical record review showed Patient #11 was admitted on 6/6/2023 at 4:02 PM with complaints of suicide attempt. Diagnostic testing was completed, and a behavioral health assessment was performed. The patient was placed under an involuntary hold. The diagnoses included UTI, Amphetamine abuse, Acute Kidney Injury, and Suicidal Ideation. The patient was transferred to an acute inpatient psychiatric care facility.

Medical record review of the consents for admission and patient rights showed a stamped consent stating "verbal consent" dated 6/6/2023. The patient had not signed the consent and there was no follow-up to get the patient to sign the consent forms.

An interview was conducted on 7/18/2023 at 4:00 PM with the Patient Access Director, and the Patient Access Director confirmed the registration staff had not attempted to get the patient consent forms signed for patients #3, #4, #5, #6, #7, #8, #9, #10, and #11.