HospitalInspections.org

Based on document review and staff interview it was determined for 1 of 10 (Pt #1) medical records reviewed the Hospital failed to ensure a consent for treatment was signed by the patient or legal representative. Therefore, the patient did not have the right to make an informed decision regarding care.

Findings include:

1. The undated hospital policy titled, "HSHS Illinois Informed Consent Policy" was reviewed on 8/16/22. Under "POLICY: ...(1) Colleagues and providers recognize a patient's right to be informed of surgical or medical procedures and respect the patient's right to accept or refuse such surgical or medical procedure. (3) Providers document in the informed consent process and professional colleagues as designated in the Policy act as witnesses to the patient/surrogate decision maker's signature."

2. The medical record of Pt #1 was reviewed on 8/15/22-8/16/22. Pt #1 was admitted to emergency department on 7/2/22 with chief complaint of left humerus fracture, multiple rib fractures and abrasions from a motor vehicle accident. On 7/4/22 at 2:45 PM, Pt #1 developed a large pneumothorax requiring chest tube insertion. During the insertion, the catheter "inadvertantly entered into the pericardium and possibly punctured the heart". The medical record lacked documentation of an informed consent being signed by Pt #1.

3. On 8/16/22 at 7:50 AM, an interview was conducted with the trauma medical director (E#8). E#8 was asked if Pt #1 had a signed consent for the procedure. E#8 replied, "No, I am a trauma surgeon, I usually don't get a consent because it is an emergent situation. This case was not emergent and I should have gotten a written consent".

Based on document review and staff interview it was determined for 1 of 10 (Pt #1) the Hospital failed to ensure adverse patient events are analyzed and tracked per policy. This failure has the potential to affect all patients receiving services.

Findings include:

1. The Hospital policy titled, "HSHS Event Reporting and Analysis" with a revision date of 2/19/21 was reviewed on 8/16/22. Under "IV. GUIDELINES /PROCEDURES: B. Details of the event are promptly and accurately recorded, by the end of the Event Reporter's current shift or if necessary, as soon as practical thereafter preferably within 24 hours..."

2. A review of the "Adverse Event Report", dates 7/2/22-8/15/22 was completed on 8/16/22. No record of Pt #1 having an adverse event was recorded in the Adverse Event Report. On 7/4/22 at 2:45 PM, Pt #1 developed a large pneumothorax requiring chest tube insertion. During the insertion, the catheter "inadvertantly entered into the pericardium and possibly punctured the heart". This event led to an unplanned cardiothoracic surgery for Pt# 1 for correction and stabilization. No Root Cause Analysis or Peer Review was provided.

3. On 8/16/22 at 7:30 AM, an interview was conducted with the trauma medical director (E#8). E#8 was asked if he completed an incident report. E#8 replied, "no".

4. On 8/16/22 at 8:00 AM, an interview was conducted with the accreditation manager (E#2). E#2 reviewed the adverse event report and confirmed that there was no event reported for Pt #1.