HospitalInspections.org

Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were incomplete and/or improperly completed per hospital policy for 2 (Patients #1, #3) out of a total sample of five medical records reviewed.
Findings:

Review of the hospital's policy titled, "Informed Consent" revealed in part: Purpose-To assure and document that mutual understanding is established between the patient or his surrogate about the care, treatment and services the patient will receive, so that the patient can participate fully in decisions about his or her care and exercise his right to authorize or refuse treatment. Policy-Informed consent is obtained and documented in the patient's medical record. A General Consent is obtained during the following registration processes: Full registration; upgrade of a pre-registration; ER registration; Inpatient admission. Specific informed consent if obtained for any invasive or diagnostic procedure.
Review of the hospital's policy/procedure Admitting Department Assignment of Benefits (AOB) revealed in part: Purpose - The AOB form is used in every episode of care and incorporates the following: 1. Hospital care consent: consent to treatment/diagnostic procedures. Policy: 1. The "Patient Line" must be signed by the patient in order for the Health System to have permission or consent to treat the patient. If the Patient is Unable to Sign (Due to Medical Reasons): 1. An authorized party (who must be at least 18 years of age and an immediate family member, legal guardian or power of attorney) must sign the patient's name on the "Patient/Guardian" line. 10. If the patient is incapacitated or has an altered mental status, the Access Personnel must write the following on the AOB: "Patient unable to sign due to medical reasons". The Access Personnel must witness and have a co-worker of fellow employee witness.

Review of Patient #1's medical record revealed in part: Patient presented to emergency department 04/04/2022 with weakness and confusion and was accompanied by spouse. Review of the AOB consent revealed the patient was allowed to sign their consent. Patient #1 was later admitted into the hospital with a diagnoses Hepatic Encephalopathy. The Initial Nursing Assessment revealed in part that the nurse was unable to assess the patient's history due to their altered mental status and being cognitively impaired.

In an interview on 04/18/2022 at 2:55 p.m., S2HIM Director stated the patient should not have been allowed to sign their consent due to their altered mental status.

Review of Patient #3's medical record revealed in part: Patient admitted 04/17/2022 with diagnoses of COVID-19 and a gastrointestinal bleed. Patient is awake, alert and oriented to date, time, place and situation. Patient is independent with all activities of daily living. Further review revealed an AOB consent which was electronically labeled with the patient's name but otherwise blank. There was no patient or surrogate signature consenting for treatment and services.

In an interview on 04/20/2022 at 10:00 a.m., S1SVPSQ reviewed Patient #3's AOB consent and acknowledged the form was left blank with no patient or surrogate signature consenting for treatment and services.