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.

BAPTIST HEALTH CORBIN ONE TRILLIUM WAY CORBIN, KY 40701 March 1, 2011
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, it was determined the facility failed to afford the patient's representative the right to make an informed decision regarding the patient's care and treatments. The facility failed to inform patient #1's representative that the patient was having a Modified Barium Swallow test performed on August 23, 2010.

The findings include:

1. Review of patient #1's medical record revealed the patient was admitted to the facility on on an outpatient basis to have a Modified Barium Swallow test performed due to a diagnosis of Choking. Review of patient #1's medical record revealed the face sheet listed the resident as being a ward of the state and having a state guardian with a telephone number listed for the state guardian. Review of the patient's Inpatient and Outpatient Condition and Consent form revealed the patient's mark and a statement that the patient gave verbal consent for treatment. There was no documentation in the medical record that the patient's representative/state guardian was notified that the procedure was being performed on the patient.

An interview conducted on March 2, 2011, at 10:00 a.m., with patient #1's state guardian revealed the facility did not inform the guardian that patient #1 was at the facility having a procedure performed on August 23, 2010. The interview revealed the state guardian did not give consent for treatment for patient #1 on August 23, 2010.

2. Review of patient #2's medical record revealed the patient was admitted to the facility on on [DATE], with diagnoses of Anxiety, Gastroesophageal Reflux Disease, and Paranoia. Review of patient #2's medical record revealed a yellow alert sheet in the front of the chart stating the patient had a state guardian. Review of the patient's Surgery/Procedure Informed Consent form dated February 26, 2011, for bilateral second toe nail removal, revealed patient #2 signed the consent form. There was no documentation in the medical record the patient's representative/state guardian was notified the procedure was being performed on the patient.

An interview conducted on March 2, 2011, at 10:00 a.m., with patient #2's state guardian, revealed the facility did not inform the guardian that patient #2 was having a procedure (bilateral second toe nail removal) performed on February 26, 2011. The interview revealed the state guardian was informed the patient's toe nails had been removed on February 28, 2011, when the nursing home readmitted the patient.

Review of the facility's Consent to Treatment and Informed Consent policy revised August 2009 revealed every individual had the right to make informed decisions involving the patient's health care or to have those informed decisions made by the patient's legally authorized representative. The policy stated, "To the degree possible, no individual should be subjected to any medical treatment or procedure without his/her or his/her legal representative's consent." The review revealed employees responsible for admitting patients to the hospital were responsible to obtain written consent for the patient to be admitted and treated on the form provided by the facility. General consent to treat allowed the health care provider to perform non-invasive, non-surgical, and/or routine medical treatment, and HIV, Hepatitis, or any other blood-borne infectious disease testing, according to the policy.

An interview conducted on March 1, 2011, at 10:55 a.m., with the Patient Care Coordinator, revealed nursing staff was required to obtain consent from a patient's guardian for any procedures such as x-rays, blood work, or surgery.

An interview conducted on March 1, 2011, at 2:17 p.m., with RN #1 revealed on February 26, 2011, the physician came to the facility to clip patient #2's toe nails and the decision was made to remove the toe nails. The interview revealed the RN obtained a surgical consent form and had patient #2 sign the consent. RN #1 denied that patient #2's guardian was informed concerning the toe nail removal before or after the procedure.