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Based on interview and document review, the hospital failed to ensure they complied with the Condition of Patient Rights when the hospital failed to ensure that each patient or her representative exercised her right to make an informed decision for 1 of 10 patients reviewed, when Patient #1 (P1) had surgery without the consent of her legal guardian. A Condition level deficiency is issued. See A131.

Based on interview and document review, the hospital failed to ensure that each patient or her representative exercised her right to make an informed decision for 1 of 10 patients reviewed, when Patient #1 (P1) had surgery without the consent of her legal guardian. Findings include:

Medical record review revealed P1 was admitted to the hospital on 2/28/2018.

P1's discharge summary dated 3/14/2018, revealed P1's history included spina bifida, deafness, and developmental delay. P1 lived in a group home. P1 came to the emergency room on 2/28/2018 with abdominal pain and nausea and vomiting. Hospital staff diagnosed P1 with a bowel obstruction and P1 underwent surgery on 3/5/2018 for the obstruction.

The surgical consent form dated 3/5/2018 revealed P1 signed a consent for Laparoscopic or open abdominal exploration.

During an interview with P1's guardian on 4/26/2018 at 9:40 a.m., she stated P1 was admitted to the hospital and had been at that hospital before. When P1 was admitted, staff at the hospital had the information from the previous admission that P1 had developmental delay and had a legal guardian. P1 does not have capacity to understand or consent to surgery. Although the staff had that information related to guardianship from the previous admission, no staff contacted P1's guardian before P1 had surgery on 3/5/2018, or at any time during P1's admission until they started the discharge process. P1's guardian stated she thought she should have been called prior to surgery as she is P1's legal guardian, and the guardian, not P1 should have consented to the surgery.

During an interview on 4/25/2018 at 3:15 p.m., P1's surgeon stated he was not aware that P1 had a guardian prior to her surgery on 3/5/2018. P1's surgeon stated usually staff in the emergency room check the guardianship status of patients when they are admitted from group homes or if they have developmental disabilities to determine if there is a guardian. That did not happen this time. He acknowledged that P1 had surgery without the consent of her legal guardian. He would expect the emergency room staff to check the status of guardianship on a person admitted form a group home, but ultimately it was his responsibility.

During an interview on 4/25/2018 at 1:50 p.m. with Care Transitions Manager (TCM)-D, Quality Consultant (QC)-E and Chief Nursing Officer (CNO)-C, they stated the hospital became aware of the concern related to P1's surgery without consent of her guardian during a safety huddle. The team stated they investigated the incident and determined that on P1's previous admission the hospital was aware that P1 had a guardian. Although staff had that knowledge, they failed to get copies of the guardianship papers, and failed to get that information into P1's permanent electronic chart. The hospital did not complete a root cause analysis related to this incident, so they did not know why the staff from the previous admission did not get a copy of the guardianship papers.

The policy titled Informed Consent, provided by hospital staff and dated revised 6/2017 revealed: Policy: II. Except in emergency circumstances or court-ordered treatment, treatment decisions will be made after an informed and shared decision making discussion has occurred between the patient or authorized surrogate decision maker(s) and the provider/practitioner. III. Informed consent involves much more than just obtaining a signature. The informed consent process: A. Requires the participation of the patient or authorized surrogate decision maker in: 1. Development of the plan of care, including consent for or refusal of medical or surgical interventions; 2. Planning for care after discharge from the facility.