HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure consent for treatment was obtained prior to providing treatment in the Emergency Department (ED) for two of seven medical records reviewed (MR1 and MR4).

Findings include:

Review of on November 14, 2014, of the facility document "Patient Rights and Responsibilities," dated November 2013, revealed "... Patient's Rights: ... 9. Except for emergencies, the physician must obtain the necessary informed consent prior to the start of any procedure or treatment, or both. Informed consent is defined in section 103 of the Health Care Services Malpractice Act ... "

Review of on November 14, 2014 of facility policy "Permissions and Informed Consent," last reviewed December 20, 2013, revealed "Purpose/Objects: Geisinger respects each patient's rights to be informed of proposed surgical or medical interventions and the patient's right to accept or refuse any proposed interventions. Permission and informed consent must be obtained and documented pursuant to this policy before proceeding with a proposed procedure or treatment, except in emergency situations. However, even with emergency situations it is also recommended that permission and informed consent be obtained whenever it is reasonably feasible to do so. ... III. Policy: A. What is informed consent? A person does not give up the right to control what is done with his or her body when he/she seeks medical care at a hospital or clinic site. Geisinger patients have the right to accept or refuse any medical treatment or procedures recommended to them. A patient's right to decide whether or not to receive medical treatment should be meaningful and understanding. As such, physicians are responsible for educating their patients or the patient's surrogate decision-maker, the nature of the treatment or procedure; the risks; complications and expected benefits of the proposed treatment or procedure; and any alternatives to the proposed treatment and their risks and benefits. ... C. Who may give informed consent: 1. If the patient has decision-making capacity, the patient has the right to consent to, or refuse, treatment. 2. If a patient lacks decision-making capacity, a legally authorized representative may make medical decisions on behalf of the patient. The determination of who may act in the capacity of a representative for a patient can occur through a number of mechanisms including court appointed guardianship, designation through an advanced directive such as a living will or durable power of attorney or through use of a next of kin decision-maker. ... F. Documenting Permission and Informed Consent 1. Prior to undertaking any treatment or procedure, the consent process must be documented within the medical record. ... N. Incompetent Adult Patients and Informed Consent ... 6. If an adult patient is incompetent or incapacitated for purposes of medical decision-making, permission and informed consent must be obtained from the patient's legally authorized representative. The practitioner must make a reasonable inquiry as to the availability and authority a substitute decision-maker for the patient. ..."

Review on November 13, 2014, of MR1 revealed the patient was seen in the ED for a fever on May 5, 2014, and May 6 2014. The "Consent Emergency Medicine" form dated May 5, 2014, did not have a signature of the patient or a responsible person authorizing treatment. Further review of MR1 revealed no signed "Consent Emergency Medicine" form for the ED visit of May 6, 2014.

Review on November 13, 2014, of MR4 revealed MR4 was seen in the ED on May 6, 2014, for a fever. The "Consent Emergency Medicine" form dated May 6, 2014, did not have a signature of the patient or a responsible person authorizing treatment.

Interview at approximately 1:00 PM on November 13, 2014, of EMP2 confirmed the "Consent Emergency Medicine" form in MR1 dated May 5, 2014, did not have a signature of a responsible person authorizing treatment. EMP2 also confirmed MR1 did not have a "Consent Emergency Medicine" for the ED visit on May 6, 2014. EMP2 stated permission for treatment is assumed for patients from residential living facilities who cannot provide consent for themselves. Additional interview with EMP2 confirmed the "Consent Emergency Medicine" form in MR4 dated May 6, 2014, did not have a signature of the patient or a responsible person authorizing treatment.

Based on review of the medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure the patient's designee was provided with a copy of the autopsy report for one of one medical records reviewed (MR1).

Findings include:

Review on on November 13, 2014, of MR1 revealed a completed "Authorization To Release Medical Information" form, dated August 16, 2014. The form was completed and signed by the patient's legal representative, requesting a copy of the patient's autopsy report.

Interview on November 13, 2014, with EMP1 confirmed EMP1 spoke to the Medical Records Department staff regarding the request for the autopsy report. The Medical Record staff informed EMP1 the autopsy report was not sent to the patient's designee/legal representative who had completed the Authorization To Release Medical Information form. This error was discovered on November 13, 2014, at the time of the unannounced investigation. EMP1 confirmed MR1's autopsy report was not sent to the patient's designee as requested.