HospitalInspections.org

Based on clinical record review, staff interview, and facility policy/procedure review, it was determined the facility failed to have a policy related to obtaining verbal consent.

The findings include:

On 8/30/2021 and 8/31/2021, the surveyors reviewed the medical records for eight (8) patients.

A review of the medical record for four (4) out of eight (8) patients' general consent to receive medical treatment forms, contained evidence of the handwritten "Verbal" in lieu of the patient's actual signature for the consent. The consent forms did not contain documentation of a reason that the patient was unable to sign the consent. The medical records also contained evidence of the typed name of the "Witness" on the witness line and the date.

During an interview on 8/30/2021 at 1:51 p.m., Staff Member #1 stated that there is no COVID policy related to the procedure for patient's signing consents. SM #1 stated that the staff will usually get the patient's signature for consent on an iPad. SM #1 stated that if a patient is unable to sign for consent, then the registration staff will document "Verbal" and put a note on the patient's account stating that the patient is unable to sign due to a medical condition. SM #1 stated that there is no written policy or procedure for obtaining verbal consent, but the staff have been taught to write "Verbal" on the consent if the patient is unable to sign for any reason.

A review of the "Informed Consent Policy" provided evidence that the policy failed to contain a policy or procedure specific to obtaining verbal consent, although the facility staff were routinely obtaining verbal consent from patients.

A review of the facility's procedure titled, "Informed Consent," states in part:
...General Consent: At the time of admission, the patient/surrogate decision-maker will sign a general consent to receive medical treatment...In addition to this general consent, written informed consent must be obtained from patients undergoing the procedures or treatments listed in this policy...
...Administrative Considerations:...
...C. Inability to Sign: If the patient is unable to legibly sign his/her name, an "X" is acceptable if there are two (2) witnesses.
D. Telephone Consent: When the patient's surrogate decision-maker is not able to come to the hospital to sign the consent form, consent may be obtained by the doctor via telephone. Two witnesses should verify the procedure with the party on the telephone and document the conversation on the consent form...

The above concerns were discussed during the exit conference on 8/31/2021.

Based on medical record and document review, it was determined the facility failed to document the administration of pain medication during two (2) of six (6) infusions for Patient #1.

The findings include:

The Surveyor conducted a review of Patient #1's medical record on 8/30/21 at 1:15 p.m. Documentation in the medical record provided incomplete data entry for the administration of the pain medication, morphine. Six (6) medication flow sheets specific for the morphine infusion for Patient #1 were missing the following information:

a. Medication time total was missing on two (2) of six (6) flowsheets.
b. Unit of measure (dosage of the medication) was mission on two (2) of six (6) flowsheets.
c. Amount infused was missing on two (2) of six (6) flowsheets.

A review of the policy "Medications Administration-Nursing-Procedure" states in part, " Full Documentation of Non-Scanned medication...2. Document the dose.
Miscellaneous Information for Medication Administration...7. Document all reassessment and follow-up interventions on appropriate unit forms/screens. "