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Based on review of medical records, it was determined that the hospital failed to obtain consent for treatment on registration for patient #4 and #6. The findings are:

Patient #4 was brought into the Emergency Department on an emergency petition due to altered mental status, dementia, and poor living conditions. Upon review of the chart there is no documentation of an attempt to obtain general consent for admission and treatment.

Patient #6 presented to the ED on 5/24/2016 for swelling of the lower legs, chronic back pain, and a possible UTI. Upon arrival to the Emergency Department, no consent for treatment was obtained.

Per Policy, the patient is to receive a receipt of notice of Privacy Practices upon registration. This form also includes a general consent for admission and treatment. The patient or patient representative is to sign for acknowledgement of this information.

Based on review of medical records, it was determined that the hospital failed to provide notification to patient #4 that they were in observation status.

Patient #4 was brought into the Emergency Department on an emergency petition due to altered mental status, dementia, and poor living conditions. Patient #4 was placed into observation on unit 3NW 06/30/2016 1134. Capacity statements were done x2 and patient was deemed incompetent to make their own decisions. There was no attempt documented to indicate taht the patient or their representative was informed that the patient was being kept under observation status.

Per the policy "Utilization review of patients in observation status" it states that " patients will be informed that they are in observation status and will be considered an outpatient until a decision is made by the physician to admit to the hospital or discharge. ED staff will provide the observation letter to the patient/family/POA " .