HospitalInspections.org

Based on medical record reviews, the facility failed to ensure there was a properly executed consent form in the patients chart prior to surgery for 27 out of 31 sampled patient medical records.

Findings include:

An Electronic Medical Record (EMR) review was done. Thirty one (31) medical records were reviewed of patients who had a surgical procedure, looking at the surgical and anesthetic consent forms. One of these medical records belonged to a patient undergoing an emergency caesarean section, the consents is this medical record were reviewed as being completed. Of the 31 medical records reviewed 17 had completed surgical consents and 14 were incomplete. Of these 14 incomplete, one was missing a patient signature and another separate one was missing a physician's signature. All 14 of the surgical consent forms were missing dates and/or times. Out of 31 medical record reviews 27 anesthetic consent forms were not complete. 14 of the consent forms did not have a physician named on the the line "I hereby authorize". 23 of the anesthetic consent forms were missing dates and/or times.