HospitalInspections.org

Based on record review and interview in 1/10 medical records reviewed out of a sample of 10 the facility failed to ensure that the patient (#1) understood the risks of refusing treatment.

Findings include:

Medical records for #1 reviewed on 12/19/2017. Patient Care Summary (PCS) flowsheet lists that "Hygiene Care" which includes bathing/skin care, oral care, and perineal care was provided to #1 during inpatient stay from 9/2-9/15/2017 except when refused. PCS flowsheets states #1 refused cares on following dates:

9/6/2017: 1020 Refused oral care; 2115 Refused bathing, skin care, oral care, perineal care
9/7/2017: 1821 Refused bathing, skin care, oral care, perineal care
9/8/2017: 2000 Refused oral care.

Reviewed nursing progress notes on 12/19/2017. Nursing progress note dated 9/9/2017 at 2051 states "Spoke to Dr ...about pressure area to L buttocks and that mepilex was applied ..."

12/20/2017 review of policy "Patient Rights and Responsibilities" policy #RI-044-EthC page 3 under Refusal of Treatment states: "The patient has the right to refuse treatment to the extent permitted by law and to be informed of the consequences of such refusal ..." The medical record for #1 contained no documentation that staff informed #1 of consequences of refusing hygiene care.

Interview with Quality Director B on 12/20/2017 at 1:30 pm regarding lack of documentation reflecting #1 was informed of the consequences of refusing bathing, skin, oral and perineal care. B confirmed the findings and stated "We cannot find any documentation, this may be a teaching opportunity for us."