The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

YAVAPAI REGIONAL MEDICAL CENTER 1003 WILLOW CREEK ROAD PRESCOTT, AZ 86301 Feb. 10, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient #1's medical record, consent manual, and staff interviews, it was determined the hospital failed to require patient #1's representative gave informed surgical consent prior to a non-emergent surgery.

Findings include:

Chapter 4 of the Coppersmith Schermer & Brockelman Consent Manual, identified by the hospital as their standard of practice required: "...It is the responsibility of the practitioner(s) performing the surgery to obtain the patient's informed consent before the procedure, except in emergencies...."

Patient #1, an elderly female, was admitted on [DATE], after a ground level fall at a long term care facility. The patient's chief complaint was right hip pain. Documentation in the record indicated the patient had dementia and a medical power of attorney (MPOA) form was completed and in the medical record.

Evaluation in the ED revealed the patient had a "non-displaced subcapital fracture" of the right hip. Physician # 15 evaluated the patient in the ED and wrote a note that indicated he planned to take the patient to surgery the next day. The patient had the following surgery "Percutaneous Pinning of Right Hip Fracture" on 12/09/12 at 1930 hours. The hospital personnel first documented calling the MPOA for consent for the surgery on 12/09/12 at 1600 hours, and were unable to reach the MPOA, after multiple attempts. The patient underwent surgery at 1730 hours. No consent was obtained from the MPOA prior to the surgical procedure. The surgeon did not document the surgery was an emergency.

On 02/09/12 at 1200 hours, physician # 10, confirmed the surgeon did not document the surgery was an emergency as required by the Consent Manual, and verified the MPOA should have signed the surgical consent or physician #15 should have documented the surgery was an emergency.