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ST PATRICK HOSPITAL
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on record review, staff interview, and policy review, the hospital failed to ensure 1 (#1) of 10 sampled patients, and/or their representative, were given information needed to make an informed consent related to a procedure administered to the patient. Findings include:
Patient #1's medical record was reviewed on 11/16/11. The patient had the following diagnoses: hematochezia, acute post hemorrhagic anemia, gastrointestinal bleed, history of cirrhosis and hepatitis C. The patient was scheduled to receive procedures in the endoscopy department as an out-patient on 8/25/11. The record documented the patient received a colonoscopy on 8/25/11, at the hospital's endoscopy department. There was an informed consent signed by the patient in the record for the colonoscopy procedure. Immediately following the colonoscopy, there was documentation in the record that the patient received an upper endoscopy. There was no documentation in the patient's record of a consent for the second procedure.
The manager of the endoscopy unit was interviewed on 11/16/11 at 12:20 p.m. She stated she could not find a signed consent by the patient or her representative for the upper endoscopy. In addition, she acknowledged a consent should have been obtained for the procedure.
On 11/16/11 at 1:00 p.m., the hospital's consent policy was reviewed. It documented the following: "Informed Consent shall be obtained from all patients, by their physician, if a major therapeutic or diagnostic procedure is to be performed... SUCH PROCEDURES INCLUDE BUT ARE NOT LIMITED TO: ... F. All endoscopies except rhinoscopy, nasopharyngoscopy, and laryngoscopy..."
The patient was admitted to the hospital on 8/25/11, after the above procedures were performed in the endoscopy department. She received the following treatments/procedures during her admission: a blood transfusion, PICC (peripherally inserted central catheter) line insertion, and two additional colonoscopies. There were consent forms signed by the patient for all of these procedures.