HospitalInspections.org

Based on document review and interview the facility failed to ensure that all patients or their representative sign a consent to be treated prior to admission in 2 of 13 (#7 and #8) medical records reviewed. Resulting in the potential for the unapproved provision of care.
Findings include:

On 1/6/2016 at 1530 during review of medical records the consent for treatment document had blank lines where the patient or their representative could sign giving consent to be treated in 2 of the 13 records reviewed (#7 and #8). Both records had a signature on the witness line but nothing written on the time or date line provided for them.

On 1/6/2016 at 1545 during interview with staff A the Director of Nursing, she stated, "I do not know why they are not signed, registration is supposed to get the consent signed when the patient is admitted."

On 1/7/2016 at 0800 the policy titled, "Informed Consent-Risk Management" version: 7, effective: 09/09/2015 was reviewed. The policy stated on page one of twenty ".......a patient or patient representative shall give voluntary and informed consent for all care, treatment, and services..."

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on January 5, 2016, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated January 5, 2016 for Life Safety Code findings.
K-0029
K-0050
K-0062