HospitalInspections.org

Based on review of the General Consent to Treat and the Financial Agreement and Patient #1's clinical record and interview with Caretaker #1, the Hospital failed to ensure that general consents were properly executed for 1 of 12 sampled patients (Patient #1).

Findings include:

The Permanent Decree of Guardianship, dated 10/26/98, indicated that Patient #1 was adjudicated to be incapable of making informed decisions.

The Complainant's Letter to the Department of Public Health, dated 5/25/12, indicated that Patient #1 was monitored under a state-run program and resided in an apartment with round the clock caretakers. The Complainant's Letter indicated that on 11/18/11, at 5:00 P.M., Patient #1 was brought to the Hospital's Emergency Department (ED) by Caretaker #1.

Surveyor #1 interviewed Caretaker #1 on 8/9/12 at 9:05 A.M. Caretaker #1 said she brought the Emergency Fact Sheet, a sheet indicating that Patient #1 had a Legal Guardian and the Legal Guardian's contact information, to the Hospital and gave it to an ED nurse.

Review of the Emergency Fact Sheet indicated that it contained information that Patient #1 was adjudicated to be incapable of making decisions and listed the name and contact information for Patient #1's Legal Guardian.

The Policy/Procedure titled Informed Consent and Healthcare Decisions, approved 9/7/11 and updated 3/28/12, indicated that when an adult patient did not have the capacity to make health care decisions, the following responsible individuals (in the following order) may make healthcare decisions on behalf of the patient: a Health Care Agent or a court appointed legal guardian with the authority to consent to the medical treatment.

Review if the General Consent for Care and Treatment and the Financial Agreement, dated 11/18/11, indicated that Patient #1 signed both the consents.