HospitalInspections.org

Based on interview and records review, it was determined that the CAH failed to have evidence of properly executed consent forms for 2 of 20 inpatient records reviewed (Patient Identifiers are #1 and #2) and 2 of 10 surgical records reviewed (Patient identifiers are #47 and #54).

Findings include:

Patient #1

Review on 5/25/23 of Patient #1's "Diagnostic, Therapeutic, or Operative Procedure Authorization" form dated 2/11/23 revealed a signed consent for surgery with no time.

Interview on 5/25/23 at 10:12 a.m. with Staff B (Registered Nurse) confirmed above finding.

Patient #2

Review on 5/25/23 of Patient #2's "Consent to Treat" form revealed a patient signature with no date and time.

Interview on 5/25/23 at 10:56 a.m. with Staff C (Director of the Birthing Suite) confirmed the above finding.


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Surgical records

Patient #47

Review on 5/24/23 of Patient #47's surgical record with Staff A (Registered Nurse) revealed that Patient #47 had a surgical procedure done on 1/12/23.

Review on 5/24/23 of Patient #47's "Consent for Anesthesia" form revealed it was signed by the anesthesiologist but did not have the time the anesthesiologist signed the consent.

Patient #54

Review on 5/24/23 of Patient #54's surgical record with Staff A revealed that Patient #54 had a surgical procedure done on 5/17/23.

Review on 5/24/23 of Patient #54's "Consent for Anesthesia" form revealed it was signed by the anesthesiologist but did not have the time the anesthesiologist signed the consent.

Interview on 5/24/23 with Staff A confirmed the above findings.

Based on interview and record review, it was determined that the CAH failed to ensure that a patient had a History and Physical (H&P) within 30 days of surgery for 1 of 10 surgical records reviewed (Patient #46) and failed to ensure a patient had a post-anesthesia evaluation for 1 of 10 surgical records reviewed (Patient #48).

Findings include:

Patient # 46

Review on 5/24/23 of Patient #46's surgical record revealed that Patient #46 had a surgical procedure done on 1/12/23. Further review revealed the H&P was completed on 12/7/2022.

Interview on 5/24/23 with Staff A (Registered Nurse) confirmed that above findings.

Patient #48

Review on 5/24/23 of Patient #47's surgical record with Staff A revealed that Patient #47 had a surgical procedure done on 2/8/23. Further review revealed there was no post anesthesia evaluation completed.

Interview on 5/24/23 with Staff A confirmed the above finding.

Review on 5/24/23 of the facility's policy titled "Completion of Medical Records" last approved 9/2021 states:
"History and Physical Examination (H & P):
a. Must be documented on patient medical record within 24 hours of admission.
b. Must be present in Day Surgery/Operating room prior to surgery.
c. If office H & P is used must be written within 30 days and changes or lack of changes must be documented...
Complete Medical records:
a. Medical records must be completed including signatures within 30 days of discharge."

Review on 5/24/23 of the facility's policy titled "Medical Staff Rules and Regulations" last approved 5/2022, states:
5.4. "Content of the Medical Record
1. Only authorized individuals may make entries in the medical record in accordance with state law. All handwritten entries will be legible in blue or black ink. All documentation must be authenticated, timed, dated, and signed...

5.6. Completion of Records
1. All records should be completed with 2 weeks of discharge, and must be completed within 30 days."