HospitalInspections.org

Based on policy review, medical record review, and staff interview; the facility failed to ensure consent for treatment was obtained on all patients. This affected one of ten medical records reviewed (Patient #5). The facility census was 173.

Findings include:

Review of the hospital's policy titled "Informed Consent" revealed if a patient was unable to give consent and the authorized individual was not present the practitioner was responsible for documenting the informed consent discussion in the medical record. Verbal consent was acceptable from an authorized individual, but there must be a witness and it must be documented in the medical record. Staff should always attempt to have informed consent signed by the authorized person in person, but may be obtained by facsimile or email if that is not possible.

Review of the medical record for Patient #5 revealed the patient came to the emergency room on 04/29/16. The patient had dementia and did not remember why he/she was in the emergency room. The Informed Consent form noted that the patient was unable to sign and witnessed by a staff member. The medical record contained numerous phone conversations with the patient's guardian and a faxed copy of the guardianship papers. The medical record lacked documentation of signed consent to treat or documentation of verbal consent received from the guardian. The patient was discharged on 05/09/16 to a skilled facility.

This finding was verified by Staff D on 07/28/16 at 9:15 AM.