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Based on record review and interview, the facility failed to ensure that 1 of 15 sampled patients (Patient 12) in a universe of 47, was provided the information needed to make an informed decision prior to receiving an epidural anesthetic (anesthesia/pain relief which is inserted into the lower spine with a needle and blocks the nerves of the lower spine causing the lack of feeling). This failure resulted in the violation of Patient 12's rights to make an informed decision regarding the care and treatment which was provided.

Findings:

A record review, on 8/21/12 at 9:50 AM, of Patient 12, indicated that the patient was admitted on 8/21/12 for induction of labor (the use of medications to assist in the initiation of the delivery of the baby). Patient 12 was administered an epidural on 8/21/12.

On 8/21/12, at 9:50 AM, a record review of Patient 12 and a concurrent interview with Registered Nurse (RN) 2 was conducted. Patient 12's medical record did not contain an informed consent by the physician who administered the epidural. RN 2 stated that she was unable to find the informed consent in the medical record.

On 8/21/12, at 10:15 AM, an interview was conducted with Patient 12. The patient stated that she did not sign an informed consent prior to the epidural. Patient 12 also stated that the anesthesiologist (physician who administers the epidural anesthetic medication; the physician's name could not be recalled) was "very rude and didn't explain anything. All she said was 'I'm going to numb you'. I cried and told her I was hurting and she rudely raised her voice and said 'stop crying and moving'." Patient 12 stated that the risks and side effects of the procedure were explained by the nurses.

A record review, on 8/22/12 at 10:35 AM, of the hospital policy titled, "Consent and Informed Consent, reviewed on June 2011," was conducted. The policy indicated the following: "The patient shall be given, by his/her physician, as much information about any proposed treatment of procedure as he/she may need in order to give an informed decision or to refuse the course of treatment. Except in emergencies, this information shall include the following: a) nature of the procedure or treatment b) the expected benefits, risks involved in this treatment, and the risks of refusing to undergo the recommended procedure c) the alternative course of treatment and the associated risks d) the name(s) of the individual(s) who will perform the procedure or treatment."