HospitalInspections.org

Based on record review and interview, the facility failed to follow policy for obtaining verbal consent for 2 of 2 (P-1, P-2) sampled patients. Findings include:

On 1/27/2025 at 1400 during record review of P-1 medical record it was revealed the verification of verbal consent obtained on P-1's visit on 12/12/2024 contained one witness.

On 1/27/2025 at 1530 during record review of P-2 medical record it was revealed the verification of verbal consent obtained on P-2's visit on 3/15/2024 contained one witness.

On 1/28/2025 at 1000 an interview was conducted with Registrar staff G, who was asked if two witnesses were required for verbal consents for general consent taken over the phone. Staff G stated, "Only one witness is required for verbal consent since the form changed a while back." Staff G brought the form up to view on her computer monitor to show one witness line on the electronic form.

On 1/28/2025 at 1025 an interview was conducted with staff K, the manager of registration. Staff K was queried if she was aware staff were only obtaining one witness signature rather than two witnesses when taking verbal consents over the phone. Staff K stated, "I was not aware of only one witness being used when obtaining verbal consents until today, but I understand the confusion due to the change in the form."

On 1/28/2025 at 1300 record review occurred of the policy titled, "Obtaining consent for Treatment," policy # CP-22.25, dated 9/15/2021. According to the policy it reads under the subtitle, "verbal consent, b. Two ProMedica employees (excluding volunteers) witness the patient or the patient's legally authorized representative providing legal consent."

Based on record review and interview, the facility failed to ensure the medical record for one (P-1) of four psychiatric patients reviewed contained the Community Mental Health (CMH) assessment and safety plan in the medical record, resulting in the inability for all healthcare professionals involved in the patient's care to access vital mental health information. Findings include:

On 1/27/2025 at 1500 during record review of P-1's medical record it was revealed the CMH assessment and safety plan from P-1's 12/12/2024 ED visit was not available.

On 1/27/2025 at 1520 an interview occurred with staff B, Intensive Care Unit and Emergency Department manager. Staff B was queried if a copy of P-1's CMH assessment and safety plan should be in the patient record. Staff B stated the record should be available for access, and she would make an inquiry to find the assessment and safety plan. On 1/28/2025 at 0910, staff B provided a copy of P-1's CMH assessment and safety plan. Staff B stated that the assessment and safety plan had not been sent to the facility for the patient record.

On 1/28/2025 at 1100 a review of the contract between CMH and the facility, dated 10/10/2023, on page 2, under the subtitle, "II. Coordination of Care,...D. (CMH) and (facility) agree to jointly develop the process of timely referrals, how best to track referrals back and forth, how to effectively manage any care transitions, how to coordinate the transfer of health and medication information, and any medical notes regarding diagnosis, treatment, prescriptions, and specific follow up care."