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.

1. Based on medical record review and staff interview, the facility failed to ensure that the physician, patient, patient representative or witness consistently signed and dated the Consent for Hospital Services and/or the Consent for Operation / Special Procedures, as per hospital policy in six (6) out of thirty-four (34) records reviewed .


A) Review of the medical record for Patient #1 revealed:

1) There is no date next to the witness signature on the General Consent for Hospital Services/Treatment Form.

2) There is no date next to the witness signature on the Radiology Contrast Consents on 06/17/11 and 06/20/11.

3) The physician's name is not completed on the Consent to Operation, Special Treatments and Procedure Form on 6/23/11.

4) There is no physician's signature or date on the VTE Prophylaxis / Treatment Form.

5) There is no physician's signature or date on the Adult Vascular Access Use Form.

B) Review of the medical record for Patient #26 revealed that the General Consent for Hospital Services / Treatment was not completed and there is no physician's or patient / representative's signature on the form.

Review of the facility's Policy and Procedure entitled "Consent for Treatment" dated 11/2010, documents that "The Consent Form must be complete with date and signature of the patient or appropriate representative."

C) There were similar occurrences found in medical records for Patients #6, #10, #18 and #33.

On 12/06/11 in the morning, an interview with the Chief Nursing Officer confirmed the above findings.

2. Based on documentation review and interview the facility failed to establish a policy and procedure pertaining to obtaining Administrative Consents for an incapacitated patient.


Medical record review revealed Patient #22 arrived to the ED on 10/06/11 with diagnosis of Aspirin Overdose related to a suicide attempt. The patient was evaluated and the physician determined that the confused patient required placement of Quinton Catheter and Hemodialysis.

Review of the "Consent to Operation, Special Treatment and Procedures" Form documented on 10/06/11 at 6:00PM "patient unable to consent secondary to altered mental status Administrative Consent for emergent Hemodialysis." The RN signed the witness line but there was no physician's signature or administrator's signature to authenticate the consent.

The consent did not identify by name or title which administrator authorized the consent prior to placing a venous access device and treating with Hemodialysis.

On 12/07/11 at 9:00AM the Administrator stated during interview that a policy does not exist for Administrative Consents and confirmed that the nurses failed to document the name or time that the consent was obtained and why the administrative consent was needed.
Based on record review and staff interview the hospital failed to ensure that a physician order was obtained immediately after the application of a restraint in two (2) of five (5) medical records.


Review of the "Restraint Flow Sheet for Patient #22 revealed bilateral wrist restraints were applied to the patient on 10/06/11 at 3:00PM. The flow sheet revealed restraints were in place until 10/07/11 at 1:00PM. There was no documented evidence of a physician's order for nine (9) hours after the restraints were applied.

Review of the medical record for Patient #31 documented a soft vest restraint and bilateral wrist restraints were in place with documented monitoring every thirty (30) minutes from 12:00AM on 11/15/11 until 12:00AM on 11/16/11. There was no documented evidence of a physician's order for these restraints.

The Policy entitled "Restraints" dated 06/2009 revealed "Restraints require written order by the physician."

On 12/06/11 at 2:15PM these findings were confirmed with the Director of Risk Management on interview.
Based on staff interviews and record reviews in one (1) out of five (5) medical records for patients that required restraints, it was determined that the "Physician Order - Restraint Order Sheet" was incomplete and did not include all required physician documentation in accordance with hospital policy.


Medical record review for Patient #22 documented an RN applied bilateral wrist restraints to the patient on 10/06/11 at 3:00PM to prevent removal of equipment. The "Physician Order - Restraint Order Sheet" dated 10/07/11 revealed an untimed physician's signature. The physician's clinical justification for restraints was not indicated and the physician failed to document that a face to face physical assessment was conducted within one (1) hour of applying restraints as required by the hospital's policy.

Review of the policy entitled "Restraints" dated 06/2009 revealed that the use of non-behavior health physical restraints requires an MD's written order and all orders cannot exceed one (1) calendar day. The physician's order must include behavior requiring restraint, type and placement, starting and ending times (duration), and clinical indication (justification) for restraint and, except in an emergency, a physician must examine the patient prior to ordering this intervention. In an emergency when a patient is engaging in activity that presents an immediate danger an RN may direct the restraint of the patient and notify the physician, who must see the patient and conduct a face to face physical assessment of the patient within one (1) hour of being summoned.

On 12/06/11 at 1415 this was confirmed with the Director of Risk Management on interview.