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UNIVERSITY OF MICHIGAN HEALTH
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on document review and interview the facility failed to obtain a consent for treatment for 10 out of 22 (#2, 3, 4, 5, 6, 7, 8, 9, 18, & 20) patients resulting in the potential for the inability to make informed decisions regarding care. Findings include:
On 10/8/14 between the hours of 1130-1215 review of patient #18's medical record revealed a lack of consent for treatment. The patient was admitted to the facility on 9/30/14. Findings were confirmed at time of review with staff C, who was navigating the electronic medical record. Staff C was queried as to if a general consent signed by this patient to which she replied "I don't see one." Staff was queried as to if any general consents were in the medical record for the year 2014 to which she replied "No."
On 10/8/14 between the hours of 1130-1215 review of patient #20's medical record revealed a lack of consent for treatment. The patient was admitted to the facility on 10/4/14. Findings were confirmed at time of review with staff C, who was navigating the electronic medical record. Staff C was queried as to if a general consent signed by this patient to which she replied "I don't see one." Staff C was queried as to if any general consents were in the medical record for the year 2014 to which she replied "No."
29955
On 10/7/2014 at approximately 1045 during the medical record review of patient #2 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1047 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/7/2014 at approximately 1050 during the medical record review of patient #3 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1053 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/7/2014 at approximately 1055 during the medical record review of patient #4 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1057 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/7/2014 at approximately 1100 during the medical record review of patient #5 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1104 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/7/2014 at approximately 1106 during the medical record review of patient #6 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1109 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/7/2014 at approximately 1111 during the medical record review of patient #7 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/7/2014 at approximately 1114 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."
On 10/8/2014 at approximately 0900 during the medical record review of patient #8 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/8/2014 at approximately 0915 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. I do not see one for this patient."
On 10/8/2014 at approximately 0924 during the medical record review of patient #9 a general consent for treatment was unable to be located for the patient's current in patient hospitalization.
On 10/8/2014 at approximately 0930 an interview was conducted with staff B. Staff B was queried if a patient should have a general consent for treatment. Staff B responded, "Yes. Maybe it hasn't been scanned into our system yet."