HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure the patient or his or her representative had the right to make informed decisions regarding his or her care.

Findings included:

Facility policy titled "Informed Consent and Informed Decision-Making" stated in part, "Purpose: To clarify the procedure for obtaining and documenting the informed consent to be obtained prior to medical treatment and procedures ...
Guidelines
Informed Decision-Making:
...In order to give informed consent, the patient or his/her surrogate decision-maker must have a basis upon which to exercise judgment concerning the recommended treatment or procedure ... before consent can be obtained, a patient or his/her surrogate decision-maker must be given enough information to understand the nature of the treatment to be performed, the risks and benefits of the recommended treatment, and alternatives to the recommended ... The information need not be exhaustive, but must be correct and disclose those factors that could influence a reasonable person in making a decision to give or withhold consent ...
The physician performing the procedure or administering the medical treatment at issue is responsible for advising the patient or the patient's surrogate decision-maker about the recommended treatment or procedure, and answering any questions, so that an informed decision can be made ... The physician should document in the patient's medical record that the informed consent was obtained including the recommended treatment or procedure, its risks, benefits, and alternative treatments.
...It must be obtained before the procedure is performed, and before any preoperative medications, sedatives, tranquilizers, or narcotics have been administered."

Review of the medical record for patient #1 revealed a consent for computed tomography guided celiac block dated 5/15/18 at 7:00 am signed by a designee for patient #1. This consent stated in part, "I (we) realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions and even death ...
SEE ADDITIONAL RISKS (as noted by physician order): [this was left blank]"

The procedure began on 5/15/18 at 1:13 pm and ended on 2:19 pm with an anesthesia end time of 2:40 pm.
Physician orders dated 5/15/18 at 2:18 pm stated in part, "1. Consent ...
2. Risks. Temporary pain or soreness at injection sites, infections, bleeding, spinal block, epidural block, pneumothorax, damage to adjacent organs, injection into adjacent blood vessels or organs resulting in organ damage or death"

The procedure note dictated on 5/15/18 at 3:26 pm stated in part, "After the procedure, risks, [sic] and benefits were discussed with the patient and the patient's family and all questions answered, informed consent was obtained."

With the documentation provided, it is unknown if the patient and/or the patient's family were informed of all the risks and benefits prior to the procedure.
The above was confirmed in an interview with staff #1 on the afternoon of 9/11/18.

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure a post-anesthesia evaluation for proper anesthesia recovery was completed in accordance with State law and with hospital policies and procedures in two of four patients reviewed for anesthesia administration.

Findings included:


Medical Staff Rules and Regulations stated in part, "2.3.4.3.3. Moderate, Deep, and Anesthesia Levels of Care: ...Each inpatient given an anesthetic by an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) shall have a post-anesthesia recovery care note written by an anesthesiologist or CRNA within 48 hours after surgery ... This note should include cardiopulmonary status, level of consciousness, complications, and need for follow-up care. Post-anesthesia notes shall be dated and timed."

Review of the medical record for patient #1 revealed a procedure dated 5/15/18 with an anesthesia end time of 2:40 pm. The post-anesthesia follow-up report was dated 5/27/18 at 9:12 am; it was not signed within 48 hours after surgery. There was no evidence a post-anesthesia recovery care note was completed by an anesthesiologist.

Review of the medical record for patient #2 revealed a procedure dated 9/5/18 with an anesthesia end time of 3:12 pm. The post-anesthesia follow-up report was dated 9/5/18 but was not timed.

The above was confirmed in an interview with staff #1 on the afternoon of 9/11/18.