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REGIONAL HOSPITAL OF SCRANTON 746 JEFFERSON AVENUE SCRANTON, PA 18501 June 30, 2015
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to obtain consent for treatment prior to treatment for five of ten Emergency Department records reviewed (MR1, MR2, MR3, MR4, and MR5).

Findings include:

Review on June 30, 2015, of the facility's "Consent" policy, last reviewed October 17, 2014, revealed, "It is the responsibility of the Admission clerk and/or corresponding hospital department to explain to every patient the reason for signing the consent form. This is an all inclusive consent form which covers the following: 1. Release of information 2. Consent for treatment ... The consent form must be signed by the patient or the patient's representative, and witnessed and dated by the Admissions Staff. ..."

Review of MR1 on June 30, 2015, revealed the patient presented to the Emergency Department (ED) at 9:03 AM on April 9, 2015. The patient was taken to an ED room after being triaged by the nurse at 9:30 AM. Physician exam was completed at 10:09 AM. Further review of MR1 revealed the consent for treatment form was not signed by the patient or the patient's representative. The consent form was signed by the registration clerk at 11:00 AM, who indicated the consent was not signed by the patient because the patient left without treatment.

Interview with EMP2 at approximately 10:30 AM on June 30, 2015, confirmed the consent for treatment in MR1 was not signed by the patient.

The following open records were reviewed on June 30, 2015:

Review of MR2 revealed the patient presented to the ED at 7:18 AM on June 30, 2015, for abdominal pain. The patient was seen in the triage area from 7:24 AM - 7:29 AM and then returned to the waiting area. At 7:32 AM a registered nurse (RN) escorted the patient to a room for the RN assessment. At 7:32 AM, the patient was seen by the physician with orders written at 8:02 AM. Further review, at approximately 10:00 AM, revealed treatment continued. The consent for treatment form was not signed by the patient or the patient's representative.

Review of MR3 revealed the patient presented to the ED at 8:26 AM on June 30, 2015, for nausea and vomiting after a fall at home. The patient arrived via ambulance and was taken directly to a room. The RN triage assessment was completed at 8:35 AM. The patient was seen by the physician at 8:40 AM and orders were written at 8:41 AM. Further review, at approximately 10:15 AM, revealed the treatment continued. The consent for treatment form was not signed by the patient or the patient's representative.

Review of MR4 revealed the patient presented to the ED at 8:29 AM on June 30, 2015, for left knee pain. The patient was seen in the triage area at 8:34 AM - 8:43 AM and then taken directly to a room. At 8:46 AM, the patient was seen by the physician with orders written at 8:52 AM. Further review, at approximately 10:30 AM, revealed the patient received discharge instructions. The consent for treatment form was not signed by the patient or the patient's representative.

Review of MR5 revealed the patient presented to the ED at 9:36 AM on June 30, 2015, for chest pain. The patient arrived via ambulance and was taken directly to a room. The patient was seen by the physician at 9:51 AM with orders written at 9:51 AM. Further review, at approximately 10:45 AM, revealed the treatment continued. The consent for treatment form was not signed by the patient or the patient's representative.

Interview with EMP1 and EMP5 on June 30, 2015, at 11:45 AM, confirmed treatment in the ED continued for MR2, MR3, MR4 and MR5, and the consent for treatment forms were not signed by the patient or the patient's representative. EMP1 and EMP5 further confirmed the consent for treatment form, patient rights and responsibilities form, and financial forms were not completed until the patients were discharged from the ED.

Interview with EMP6 on June 30, 2015, at 1:45 PM, confirmed the consent for treatment form, patient rights and responsibilities form, and financial forms were not signed by the patient or the patient's representative until the patient was discharged .