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.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 July 26, 2016
VIOLATION: INFORMED CONSENT Tag No: A0955
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, record review, and interview, the facility failed to obtain a signed informed consent prior to the procedure for one patient (#2) of 23 patients reviewed.

The findings included:

Review of the facility's policy titled Informed Consent, effective date 12/2015, revealed, "...Regardless of where the practitioner documents that the informed consent has occurred, the patient must sign and date the Authorization for Procedure(s) form...the authorization form must be completed and signed prior to the performance of the intervention..."

Review of the medical record revealed Patient #2 was admitted to the facility on [DATE] with a diagnosis of Left Mid-Ureteral Obstructing Stone (left kidney stone blocking the flow of urine from the kidney). Further review of the medical record revealed on 9/26/15, the patient had a surgical procedure to remove the left kidney stone. Review of the operative report dated 9/26/15 revealed the patient had a "...Left ureteroscopy with laser lithotripsy and stone removal...left ureteral stent placement..." Review of the Consent to Operation revealed it was unsigned, undated, and unwitnessed.

Review of a progress note by the nursing supervisor dated 9/26/15 at 2:45 PM revealed, "...states she is aware of the risks and benefits regarding operation procedure this morning. She gave implied consent and believed that she had signed the operative consent after speaking to the doctor in the OR holding area..."

Telephone interview with the nursing supervisor on 7/19/16 at 8:45 AM, confirmed Patient #2 had not signed the consent for her operation on 9/26/15 prior to the procedure being performed.



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