HospitalInspections.org

Based on medical record review, staff interview, and policy and procedure review, the facility failed to adequately complete informed consents for 6 of 8 sample patients (#1, #5, #7, #8, #9, #11) who required informed consents for procedures. The findings were:

Review of the medical records for patients #1, #5, #7, #8, #9, and #11 showed each had an informed consent for surgery, anesthesia, or medical diagnostic invasive procedures. The following concerns were noted:
a. Review of an informed consent for patient #1 showed s/he signed the form on 4/24/14. However, the facility failed to ensure the time the patient signed the form was documented in the provided space. In addition, the witness failed complete the date and time as to when they signed the form.
b. Review of an informed consent for patient #5 showed s/he signed the form on 1/24/14. However, the facility failed to document the name of the patient in the required space. In addition, the facility failed to time the document in the spaces provided for the patient and witness.
c. Review of an informed consent for patient #7 showed s/he signed the form on 4/18/14. However, the facility failed to document the name of the patient in the required space. In addition, the facility failed to ensure the time the procedure site was marked was documented in the required space.
d. Review of an informed consent for patient #8 showed s/he signed the form on 2/14/14. However, the facility failed to ensure the time the patient and first witness signed the form was documented in the provided spaces.
e. Review of an informed consent for patient #9 showed s/he signed the form. However, the facility failed to ensure the patient dated and signed the form on the required spaces.
f. Review of an informed consent for patient #11 showed s/he signed the form on 3/19/14. However, the facility failed to document the name of the patient in the required space. In addition, the facility failed to ensure the time the patient and witness signed the form was documented in the provided spaces.

Interview with the interim chief nursing officer on 4/29/14 at 9:35 AM confirmed all procedures that require an informed consent should have that consent completed, which required date and time with each signature.

According to the facility policy and procedure titled, "Informed Consent" last revised on 3/20/14, "All consents will be witnessed and timed. A consent will be determined to be invalid if not signed by the patient or patient representative, witnessed, and dated."