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Based on medical record review, staff interview, and policy review the facility failed to ensure informed consent for treatment was obtained on all patients. This affected five of ten medical records reviewed (Patients #1, #2, #4, #6, and #8). The facility census was 270.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 04/02/15 for altered mental status and urinary tract infection. The "Consent for Treatment, Guarantor of Accounts and Release of Medical Records" form contained the statement that the patient was unable to sign due to condition and was witnessed by two staff members at the time of admission. The patient presented to the emergency department by ambulance with no family present on arrival to the emergency department. The medical record lacked documentation of any attempt to obtain consent from the patient or authorized representative.

Review of the medical record for Patient #2 revealed an admission date of 03/31/15 for altered mental status and generalized weakness. The "Consent for Treatment, Guarantor of Accounts and Release of Medical Records" form contained the statement that the patient was unable to sign due to condition and was witnessed by two staff members at the time of admission. The patient presented to the emergency department by ambulance with no family present on arrival to the emergency department. The medical record lacked documentation of any attempt to obtain consent from the patient or authorized representative.

Review of the medical record for Patient #4 revealed an admission date of 03/25/15 for dysphagia, dizziness, and aphasia. The "Consent for Treatment, Guarantor of Accounts and Release of Medical Records" form contained the statement that the patient was unable to sign due to condition and was witnessed by two staff members at the time of admission. The patient presented to the emergency department by ambulance with no family present on arrival to the emergency department. The medical record lacked documentation of any attempt to obtain consent from the patient or authorized representative.

Review of the medical record for Patient #6 revealed an admission date of 03/04/15 for altered mental status and hyperglycemia. The "Consent for Treatment, Guarantor of Accounts and Release of Medical Records" form contained the statement that the patient was unable to sign due to condition and was witnessed by two staff members at the time of admission. The patient presented to the emergency department by ambulance with no family present on arrival to the emergency department. The medical record lacked documentation of any attempt to obtain consent from the patient or authorized representative.

Review of the medical record for Patient #8 revealed an admission date of 04/19/15 for respiratory failure. The "Consent for Treatment, Guarantor of Accounts and Release of Medical Records" form contained the statement that the patient was unable to sign due to condition and was witnessed by two staff members at the time of admission. The patient presented to the emergency department by ambulance with no family present on arrival to the emergency department. The medical record lacked documentation of any attempt to obtain consent from the patient or authorized representative.

Staff A verified the above information on 05/14/15 at 8:50 AM. Staff A verified that on some of the above patients procedural consents had been signed by either the patient or a family member after admission to the hospital. Staff A stated that there was no documentation that anyone had attempted to obtain general consent to treat from the next of kin even though it was documented that the patients had visitors or procedural consents were signed at a later date. Staff A stated that it was the facility ' s expectation that the " Consent for Treatment, Guarantor of Accounts and Release of Medical Records " would be completed on all patients or documentation that no next of kin was identified.

Review of the "House Wide Consent for Treatment and Financial Guarantor Agreement" policy revealed an identified hierarchy of who could be the patient's authorized representative if the patient was unable to sign. The policy also detailed the process to obtain verbal consent by phone if the authorized representative was unable to be physically present to sign.

Based on medical record review and policy review, the facility failed to ensure all restraints were monitored per the facility policy. This affected one of one patient with restraint use. (Patient #8) The total of ten medical records were reviewed. The facility census was 270.

Findings include:

Review of the medical record for Patient #8 revealed the patient was restrained with bilateral soft wrist restraints from 12:00 PM on 04/19/15 to 3:00 PM on 04/22/15, from 10:00 PM on 04/22/15 to 12:00 PM on 04/23/15, and from 6:33 AM on 04/27/15 to 05/13/15. The medical record lacked documentation of two hour safety checks from 12:00 PM to 4:00 PM and 4:00 PM to 8:00 PM on 04/19/15 and from 2:00 PM to 6:00 PM on 04/30/15, and from 8:00 AM to 12:00 PM on 05/08/15. The medical record lacked documentation of one hour safety checks on 04/30/15 at 4:00 PM and on 05/04/15 at 7:00 AM.

This was verified by Staff A on 05/14/15 at 8:50 AM.

Review of the "Restraints/Seclusion" policy revealed one hour observations for type and location of restraint as well as observation of the restraint itself while the patient was restrained. In addition, every two hours, circulation checks, release of restraint with range of motion, skin integrity checks, toileting needs, and food and fluids should be offered while the patient was restrained.