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MERCY HEALTH HACKLEY CAMPUS 1700 CLINTON STREET MUSKEGON, MI 49442 Aug. 24, 2016
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to obtained informed consent for treatment from 4 (#3, 4, 7 and 8) of 10 patients reviewed for informed consent for treatment from a total sample of 10 patients, resulting in the potential for patients at the facility to receive treatment for which they did not give consent.

Findings include:

Patient #3:
Review of Patient #3's medical record on 8/23/16 at 1150 revealed he was admitted on [DATE] at 0820. Patient #3's "Consent for Treatment and Payment Agreement Payment Agreement/Release Information" form was signed by a witness on 08/19/16 at 0159. The line for "Signature of Patient Signature" and "Patient's Agent/Representative" were unsigned.

Patient #4:
Review of Patient #4's medical record on 8/24/16 at 1030 revealed she was admitted on [DATE] at 0820. Patient #4's "Consent for Treatment and Payment Agreement Payment Agreement/Release Information" form was signed by a witness on 08/16/16 at 1924. The line for "Signature of Patient Signature" and "Patient's Agent/Representative" were unsigned.

Patient #7:
Review of Patient #7's medical record on 8/24/16 at 1035 revealed he was admitted to the Emergency Department for treatment 07/02/2016 at 0119. Patient #7's "Consent for Treatment and Payment Agreement Payment Agreement/Release Information" form was signed by a witness on 07/2/16 at 0128. The line for "Signature of Patient Signature" and "Patient's Agent/Representative" were unsigned.

Patient #8:
Review of Patient #8's medical record on 8/24/16 at 1040 revealed she was admitted on [DATE] at 2341. Patient #8's "Consent for Treatment and Payment Agreement Payment Agreement/Release Information" form was signed by a witness on 07/03/16 at 0138. The line for "Signature of Patient Signature" and "Patient's Agent/Representative" were unsigned.

In an interview on 08/24/16 at 1130, Staff I stated the process for obtaining consent for treatment from patients who are unable to sign at the initial time of treatment is to hit print, so the consent form prints. Then a staff member is to go back later when the patient is able to sign and obtain a signature for consent for treatment. Staff I stated it is expected that staff go to all patients at some point and obtain consent for treatment.

Review of facility "Informed Consent-Risk Management" policy (dated 07/19/16) on 08/24/16 at 1115, revealed, "It is the policy of (name of the facility) that a patient or patient representative shall give voluntary and informed consent for all care treatment and services involving material risk." 2.1 Types of Consent ... 2.1.3.1 Admission to hospital...2.1.3.2 Admission to the Emergency Department.