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UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 March 9, 2018
VIOLATION: INFORMED CONSENT Tag No: A0955
Based on a review of facility documentation, medical records (MR) and interviews with facility staff (EMP) it was determined that UPMC Altoona failed to properly execute an informed consent prior to patients surgical procedure in four of nine medical records (MR2-MR5).

Findings Include:

UPMC Policy and Procedure Manual Policy: HS-R * Index Title: Risk & Insurance Subject: Patient Informed Consent. Date: October 5, 2017. "... II. Informed Consent Under Pennsylvania Law. A. Procedures Covered. Pennsylvania law provides that except in emergencies, a physician owes a duty to obtain informed consent from a patient prior to the following: 1. Performing surgery. 2. Administering anesthesia related to the performance of surgery ... VI. Facility Documentation of Informed Consent ... C. Procedures 1. Obtaining Patient Signature. Prior to administering any pre-procedure medication, it should be determined that the facility consent or procedure specific consent form has been properly completed, signed and witnessed. ... ."


1. Review of MR2-MR5 Consent for Anesthesia failed to reveal the type of anesthesia that was to be administered prior to the procedure. MR2-MR5 inclusively revealed, "Anesthesia Consent Form (Generic) My signature below acknowledges that: I understand the following type of anesthesia will be administered in connection with the procedure discussed in the attached consent: [blank]. I understand that the physician responsible for my anesthetic (anesthesiologist) will determine the type of anesthesia to use based upon the type of surgery or procedure and my individual medical and physical characteristics. I understand that during the surgery or procedure it may be necessary to alter the type of anesthesia provided based upon my medical condition and/or conditions related to the surgery/procedure. ... ."

Interview with EMP2 on February 22, 2018, at 12:15 PM confirmed the above findings and revealed, "I agree, the type of anesthesia has to be written on the consent."