HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to obtain a properly executed informed consent prior to performing a surgical procedure for one patient (Patient #1) of 5 patients reviewed for informed consent.

The findings included:

Review of facility policy titled "Informed Consent" last revised 4/2019 revealed "...The nurse or other appropriate healthcare professional should place in the patient's medical record an executed informed consent...Specific informed consent is considered necessary for any procedures or treatments which are invasive and/or have potentially serious side effects or complications. These included but may not be limited to...Insertion of devices and/or appliances the skin...all procedures in which anesthesia is administered..."

Review of the medical record revealed Patient #1 was admitted to the facility on 2/5/2021 with diagnosis of Non-ST Elevated Myocardial Infarction (a heart attack with the absence of ST wave elevation on an electrocardiogram).

Medical record review of a Nurse's Note dated 2/6/2021 at 8:00 AM revealed the patient was alert and oriented.

Medical record review of a review of a Cath Post Procedure Report dated 2/6/2021 at 8:27 AM revealed the patient had a Diagnostic Coronary Angiography with Left Heart Catheterization (surgical procedure where a catheter is inserted into the heart for diagnostic and medical treatment). Continued review of a Consent for Surgical or Invasive Treatment dated 2/6/2021 revealed the consent was not signed by Patient #1 or the patient's representative. Continued review revealed no properly executed informed consent was documented in the medical record.

During an interview on 2/23/2021 at 2:30 PM the Quality Director confirmed there was no properly executed informed consent documented in Patient #1's medical record for the heart catheterization performed on 2/6/2021.