HospitalInspections.org

Based on record review and interview the facility failed to ensure properly executed informed consents were completed for 2 of 3 patients (ID#s 10 and 11).

Findings include:
Review of facility policy titled "Disclosure and Consent for Medical and Surgical Procedures," dated September 2024 showed the following:
1. Requirements for Disclosure and Consent
Informed consent is one type of informed decision that a patient or his/her surrogate decision maker may need to make with respect to a medical treatment or surgical procedure related to his/her plan of care ...
b. Written informed consent from the patient, or his/her surrogate decision maker is required for medical treatments and surgical procedures as indicated below except in medical emergencies.
iii. Obtain informed consent from the patient's surrogate decision maker if the patient lacks decision making capacity (In the following order of priority):
1. a court appointed guardian with guardianship over the person;
2. the patient's agent under a medical power of attorney, or proxy under a directive to physicians and family or surrogates ...
3. the following individuals, in order of priority:
a. patient's spouse;
b. patient's reasonably available adult children;
c. patient's parents;
d. patient's nearest living relative or;
e. the attending physician, with the concurrence of a second physician not involved in the treatment of a patient.

Medical record review for patient (#10) showed Disclosure and Consent for Ultrasound Guided Percutaneous Intra-Abdominal Drainage w/ Cath Placement. On the consent form where the patient is to initial, the patients initials are written in and in parentheses it has verbal, i.e., (verbal). On the patient signature portion is has the patient's name printed and in parentheses it has verbal, i.e., (verbal).

Interview with quality director (staff A) on 4/2/2025 at 4 PM she acknowledged the above findings and stated that the consent does not address verbal consent.

Medical record for patient (ID# 11) showed medical decision maker as his sister-in-law followed by his sister with names documented. Nursing note and Case Management notes have documented the patient's sister-in-law was the Medical Power of Attorney (MPOA). There was no MPOA document in the medical record. Consent for Bronchoscopy with Possible Interventions dated 3/24/25 has the patient's sister' s name printed with telephone consent documented.

Interview with quality staff (Q) on 4/2/2025 at 3:00 PM acknowledged the above findings.

Based on interview and record review, an RN failed to adequately supervise and evaluate the nursing care for four (4) of 12 sampled patients ( Patient ID # 1, 2, 11 and 12 ).

Nursing staff failed to reposition the patients at least every 2 hours and perform skin assessments per hospital policy.

Findings included:

Review of facility policy titled "Hospital-Acquired Pressure Injury (HAPI) Prevention, Assessment and Documentation (Adult)," dated December 2024, showed:

"B. Perform Assessment:
1. Perform the Braden Scale Risk Assessment and 2 RN head-to-toe skin assessment at the following intervals:
a. Within 4 hours of admission
b. Within 4 hours of the start of the shift...

C. 3 (a) If Braden mobility subscale score is less than or equal to 2; reposition the patient at least every 2 hours or more frequently based on patient risk factors ( e.g. skin and tissue tolerance, medical condition, comfort and pain); level of activity; and ability to independently reposition."

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Patient ID # 2:

Review of Patient ID # 2's History & Physical exam, dated 2/15/2025, showed he was a 49 year-old male with past medical history of quadriplegia with neurogenic bladder with suprapubic catheter , and status post-colostomy. This patient sustained a total spinal cord injury (TSCI) following a motor vehicle accident in 2009.

Further review of Patient ID #2's electronic medical record was conduced with Staff-M, RN, Patient Safety Program Manager on 4/1/2025.

Review of the flowsheets ( 2/16/25 through 2/25/2025) indicating daily care /safety & comfort measures; and Braden scale showed the following:

- 2/16/2025 : repositioned only twice: 11 hours apart [midnight and 1121 AM] ; Braden subscore for mobility was assessed as "2" at 1121 and 2100.

- 2/17/2025: repositioned only twice: 12 hours apart [ 1047 AM and 1144 PM] ; Braden subscore for mobility was assessed as "1" for both shifts.

- 2/19/2025: no repositioning between 6 AM and 1 PM ( 7 hours) ; Braden subscore for mobility was assessed as "2" at 0800 and 1431.

- 2/21/2025 : no repositioning between 4:30 AM and 7 PM ( 14 hours); Braden subscore for mobility was assessed as "1" for night shift.

During an interview with Staff-M, RN, Patient Safety Program Manager, during the record review, she verified the findings. She said that given Patient ID #2's diagnosis of quadiplegia and Braden mobility score, he should be repositioned every 2 hours, unless he refused. Both should be documented.


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Medical record review for patient (ID# 1) on 4/2/2025 showed that the patient had been in the hospital for 105 days. The only 2 RN skin assessment titled "4 eyes in 4 hours" was documented on 3/19/2025. On 3/19/2025-3/20/25 there was a ten-hour period where there was no documentation demonstrating the patient was repositioned per facility policy. Braden scale risk assessments were not documented per policy.

Medical record review for patient (ID #11) showed that he did not receive any 2 RN skin assessments performed from 3/23/25-3/28/25. Braden scale risk assessments were not documented per policy.

Medical record review for patient (ID# 12) showed that he did not receive any 2 RN skin assessments performed from 3/18/25-3/24/2025. Braden scale risk assessments were not documented per policy.


Interview with staff (Q) on 4/2/25 at 4 PM acknowledged the above findings.