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UNITYPOINT HEALTH - MERITER 202 S PARK ST MADISON, WI 53715 Aug. 20, 2012
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on MR review, review of P&P and interview with staff, in 5 of 6 MR (1, 2, 3, 5 and 6) the facility failed to ensure the consent to treatment form is completed with dates, times and full legible names per facility policy; and in 6 of 6 MR reviewed (1, 2, 3, 4, 5 and 6) the facility failed to ensure there are signed discharge instructions to confirm receipt by the patient.

Findings include:

Facility policy reviewed on 8/20/12 at 12:30 PM titled Consents, Agreements and Refusals; Adults effective 9/10 states under II. E. 1. a. "The witness signed and prints her/his name, if the patient is alert, oriented adult, the patient signs and enters the date and time."

Facility policy reviewed on 8/20/12 at 2:40 PM titled discharge of a Patient dated 4/2001 states under II.F. Documentation 2. "Documentation in the patient's record reflects patient and family understanding of the discharge plan and discharge instructions."

Pt #1's MR review on 8/20/12 at 8:50 AM revealed the consent to treat form signed on 1/10/12 is not timed when signed; the witness signature is illegible and they did not print out their name per policy. The consent for Cardiac Diagnostic/Surgery Procedures is not timed by the surgeon when signed on 1/11/12. A Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 8:50 AM.

Pt #2's MR review on 8/20/12 at 1:00 PM revealed the consent to treat form has a sticker with a date and time of 3/7/12 at 4:19 PM, the MR revealed the arrival time of Pt #2 is 4:22 PM; the witness signature is illegible and they did not print out their name per policy. A Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 1:00 PM.

Pt #3's MR review on 8/20/12 at 1:35 PM revealed the consent to treat form has a sticker with a date and time of 1/10/12 at 4:30 PM, the MR revealed the arrival time of Pt #3 is 4:32 PM; the witness signature is illegible and they did not print out their name per policy. A Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 1:35 PM.

Pt #4's MR review on 8/20/12 at 2:00 PM revealed a Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 2:00 PM.

Pt #5's MR review on 8/20/12 at 2:10 PM revealed the consent to treat form signed on 5/10/12 is not timed; the witness signature is illegible and they did not print out their name per policy. A Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 2:10 PM.

Pt #6's MR review on 8/20/12 at 2:25 PM revealed the consent to treat form has a sticker with a date of 7/3/12 with no time; the witness signature is illegible and they did not print out their name per policy. A Pt signed copy of the D/C instructions are not part of the MR confirming receipt. This is confirmed in interview with D B on 8/20/12 at 2:25 PM.