HospitalInspections.org

Based on document review and interview, the facility failed to insure informed consents for treatment was obtained for 2 (#3 and #12) of 31 sampled patients.

This deficient practice had the likelihood to cause harm in all patients.
Findings include:

On 1/22/15 at 2:00 p.m. in the medical records department the electronic medical record (EMR) for patients #3 and 12 were reviewed and revealed the following:

Patient (Pt/pt) #3's consent for services and financial responsibility had no patient or patient representative signature. The only documentation found was on the line identified for "Reason individual is unable to sign". The statement read, "pt has AMS (Altered Mental Status)". A two letter initial was observed below as the witness. No other staff signature or discipline was found on the consent form. Pt #3 resided in a nursing home and the documentation provided by that facility indicated pt #3 had two (2) persons listed with emergency contact information.

Pt #12's consent for services and financial responsibility had no patient or patient representative signature. The only documentation was found on the line identified for "Signature of patient or Legal Representative for Health Care". The statement read, "pt unable to sign r/t (related to) dementia". A two letter initial was observed below as the witness. No other staff signature or discipline was found on the consent form. Pt #12 resided in a nursing home and the documentation provided by that facility indicated pt #12 had two (2) persons listed with emergency contact information.

The above lack of documentation was confirmed by staff #28.






























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