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HCA HOUSTON HEALTHCARE KINGWOOD
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on interview and record review, the facility failed to fully implement its informed consent policy. Two of 4 current patients on 4-North tower lacked a completed consent per facility policy ( Patient IDs # 4, 12 ).
Findings included:
Record review of facility policy titled "Consent for Treatment (Adults and Minors)," dated 06/2023, showed hospital responsibility included: to provide a mechanisms to assure completion of the consent form prior to procedure including all signatures dates, and times...Witnesses: signatures of those providing consent must always be witnessed.
Record review of facility "Medical Staff Rules & Regulations," last amended September 15, 2012 showed: "...all clinical entries in the patient's medical record shall be accurately dated, timed, legible, and individually authenticated.."
Patient ID #4:
Record review of the clinical record of Patient ID # 4 showed she was 92 years old and admitted to the hospital on 6/24/2023.
Further review showed a form titled "Patient Consent For Inpatient Do Not Resuscitate ('DNR'") Order." The form showed a telephone consent for a DNR was obtained from Patient # 4's daughter on 6/25/2023. There were two witness signatures. Neither of these signatures were timed or dated.
Patient ID # 12 :
Record review of the clinical record of Patient ID # 12 showed he was admitted to the hospital on 6/23/2023. Review of an "anesthesia record," dated 6/23/2023 showed Patient # 12 had a liver biopsy and paracentesis performed on this date.
Review of Patient # 12's seven-page 'Informed Consent' dated 6/23/2023 showed a signature, date, and time by both the patient and the physician. The area for witness signature was left blank. This was verified by Staff E, Unit Director.
During an interview in 6/26/2023 at 11:30 A.M. with Staff C, Quality Director, she verified the above findings. She said the witness signatures on Patient # 4's DNR consent should have been timed and dated. Staff C went on to say the procedure consent for Patient # 12 should have been witnessed.