HospitalInspections.org

Based on document review and interview, the facility failed to ensure that authorization for admission and treatment was obtained in 4 of 6 closed patient medical records reviewed, patients #2, 3, 4 and 6.

Findings Include:
1. Review of the policy: Consent for Medical Treatment, policy number CLN-2026, effective 10/1/15 and "cancels: 4/15/13; 6/4/13", indicated under "Purpose": 1. To assure compliance with Indiana and federal law pertaining to the requirement of an informed consent for medical treatment. Under "Policy Statements", it reads: 1. All inpatients and emergency room patients must sign (or have signed on their behalf) the Patient Consent Agreement at the time of admission for general medical services.

2. Review of closed patient medical records indicated patients #2, #3, #4 and #6 had no forms in their medical records indicating they, or someone on their behalf, signed giving consent for admission and treatment to the facility.

3. At 9:35 AM on 4/26/16, interview with staff member #50, the risk management coordinator, confirmed that the medical records department could not locate any consents for admission and treatment for patients #2 and #3.

4. At 10:50 AM on 4/26/16, interview with staff member #50 confirmed that, per the medical records department, no consents for admission and treatment could be found for patients #4 and #6 and that is unclear why the admissions process failed for patients #2, #3, #4 and #6.

Based on document review, observation and interview, the infection control practitioner failed to ensure that nursing staff implemented the policy related to PPE (personal protective equipment) for 2 of 2 contact precaution patients on the Cardiac PCU (progressive care unit), patient #10 and patient #11.

Findings Include:
1. Review of the policy: Infection Prevention Policy for Contact Precautions, IPP# 01-C, reviewed/revised 2/2016, indicated on page two under "Text" in 1. B.: "Change protective attire and perform hand hygiene between contacts with patients in the same room." And, on page 3., under "4. Gowns", it reads in C. "Gown must be removed before leaving the patient room. D. If gown is needed outside the patient room, a clean gown must be worn."

2. At 2:06 PM on 4/25/16, while touring the Cardiac PCU, it was observed that 2 face masks were hanging on the door handles of room of patient #11 where the patient was noted to be in contact precautions.

3. At 2:08 PM on 4/25/16, on the Cardiac PCU, it was observed that an isolation gown was hanging on the entry door to room where the patient, patient #10 was noted to be in contact precautions.

4. At 2:06 PM on 4/25/16, interview with staff members #59, the RN (registered nurse) unit manager and #51, the infection preventionist, confirmed that masks were hanging on the door handles of patient #11's room and should not be stored there for future use after having already been worn.

5. At 2:08 PM on 4/25/16, interview with staff members #59 and #51 confirmed that a protective gown was hanging on the door of patient #10's room and should not be there.