HospitalInspections.org

31159




31597


RECITED

Based on electronic medical record review and interview, the facility failed to obtain general consent on admission as required by the facility's policy for six (Patient #1, #2, #3, #5, #7 and #9) of eleven electronic medical records reviewed for general consents. This had the potential to affect all of the facility's patients. The facility's active census at the time of the survey was 1040 patients.

Findings include:

1. The electronic medical record review for Patient #1 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The electronic medical record contained a signed general consent form on 09/24/13, three days after admission. The document did not contain documentation of attempts made by the PAS (Patient Access Services) to obtain the consent prior to 09/24/13.

On 09/26/13 at 9:46 AM, these findings were confirmed by Staff J.

2. The electronic medical record review for Patient #2 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The electronic medical record contained a signed general consent form on 09/24/13, three days after admission. The document included documentation the PAS had made one attempt to obtain consent on 09/22/13, the day after the date of admission.

On 09/26/13 at approximately 9:30 AM, the findings were confirmed by Staff J.

3. The electronic medical record review for Patient #3 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The electronic medical record contained a signed general consent form on 09/24/13, three days after admission. The document did not contain documentation of attempts made by the PAS to obtain consent prior to 09/24/13.

On 09/26/13 at approximately 9:30 AM, the findings were confirmed by Staff J.

4. The electronic medical record review for Patient #5 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The record contained a signed general consent form dated 09/24/13, three days after the date of admission. The document did not contain documentation of attempts made by the PAS to obtain the consent prior to 09/24/13.

On 09/26/13 at 9:46 AM, the findings were confirmed by Staff J.

5. The electronic medical record review for Patient #7 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The record contained a signed general consent form dated 09/24/13, three days after admission. The document contained documentation the PAS had made one attempt to obtain consent on 09/22/13, one day after the date of admission.

On 09/26/13 at approximately 9:30 AM, the findings were confirmed by Staff J.

6. The electronic medical record review for Patient #9 was completed on 09/26/13 at 9:46 AM. The patient was admitted to the facility on 09/21/13. The record contained a signed, but undated general consent form.

On 09/26/13 at approximately 9:30 AM, Staff J confirmed without a date on the consent form it could not be determined when the general consent had been obtained.

On 09/26/13 at 8:59 AM, the facility's General Consent Procedure was reviewed. The procedure stated the PAS will make up to three attempts within 48 hours of admission to obtain consent signature. Each attempt should be documented on the consent form with the date and time. Signed and dated consent forms or consent forms with documented attempts to obtain the consent will be scanned into the electronic medical record under the administrative document type.

On 09/25/13 at 4:10 PM, Staff J was interviewed. Staff J reported the facility had a Patient Access Services staff member call off work for a twelve hour shift on 09/21/13. He/she reported several phone calls were made unsuccessfully in an attempt to cover the 12 hours shift. Staff J reported he/she became aware of the missed shift approximately one hour ago.

On 09/26/13, Staff J was interviewed from 9:26 AM to 10:00 AM. He/she reported the facility increased the PAS staffing on 09/23/13 and 9/24/13 in an effort to obtain general consents from patients who were admitted on 09/21/13. Staff J reported the Patient Access Services staff members continues to utilize an old form for the documentation of attempts made to obtain general consent. Staff J stated he/she has reinforced with the PAS staff members the need to have the attempts for obtaining consent documented on the consent form. Staff J provided a list of patients admitted who had not signed general consent forms. The list contained two patients with an admission date of 09/21/13. Staff J reported the PAS staff members do not scan the general consent forms into the electronic medical record until the consent has been obtained. He/she provided examples of general consent forms in which the PAS attempts for consent had been documented.

31159




31597


RECITED

Based on interview, electronic medical record review, policy review, and observation, the facility failed to follow the facility's surgical counts policy on completing a final count at the completion of surgery for one (Patient #13) of two final surgery counts observed and one (Patient #14) of eight electronic medical records reviewed for surgical counts. This had the potential to affect all surgery patients.

Findings include:

1. On 09/26/13 at 2:25 PM, an observation of a trabeculectomy (a surgical procedure to treat glaucoma) surgery for Patient #13 was conducted. At approximately 2:35 PM, Staff A and Staff H were observed completing a relief count as required by the facility's policy. At approximately 2:45 PM, Staff H announced a final suture needle count to Staff A, who was standing across the room, and was unable to visualize the final count.

On 09/26/13 at approximately 3:00 PM, Staff A was interviewed regarding the final count. Staff A stated she considered the relief count as her final count because the relief count had been completed within minutes of the final count.

On 09/26/13 at approximately 3:00 PM, Staff C, Staff D, and Staff E confirmed they had not observed Staff A visualize the final count for Patient #1.

On 09/26/13 at 3:30 PM, the patient's procedure report was reviewed. The report had documentation of an initial count, a relief count, and final count as having been conducted.

2. The electronic medical record review for Patient #14 was completed on 09/25/13. The record showed the patient had undergone surgery on 09/23/13, for strabismus repair (eye muscle surgery). The procedure report contained documentation of an initial count, and a relief count. The report did not contain documentation a final count had been completed.

The findings were confirmed by Staff F on 09/25/13 at 11:00 AM.

On 09/25/13 at 1:04 PM, Staff I reported he/she had spoken with Staff A and Staff B regarding the undocumented final count. Staff I stated Staff A and Staff B reported they had completed a final count on the patient but forgot to document the final count.

On 09/25/13 at 11:23 AM, the facility's Counts Policy was reviewed. The policy stated all items must be audibly counted and concurrently viewed as they are separated and counted by two individuals. The counts will occur prior to commencing the procedure (initial count), when the scrub and\or circulator is permanently relived (relief count) and during skin closure (final count).