HospitalInspections.org

Based on record review, document review and staff interview it was determined the facility failed to ensure all patients have an informed consent for medical treatment signed by themselves or their representative in six (6) of ten (10) records reviewed of admitted patients (patients #1, 3, 5, 6, 9 and 10). Failure to ensure informed consent for all patients can negatively impact all patients admitted for medical treatment to the facility.

Findings include:

1. Review of the facility policy entitled "Patient Access Consents Policy (Financial and Medical)", last revised 10/2016, revealed it states in part: "If the patient is admitted...a registrar must obtain signatures from the patient or patient's power of attorney, healthcare surrogate or representative prior to discharge."

2. Record review of patient's # 1, 3, 5, 6, 9, and 10 revealed the patients were unable to sign an informed consent upon admission. There was no documentation in the patients' medical records of signed informed consents from either the patients or their representatives. There was no subsequent documentation throughout the patients' stay at the hospital of any informed consent from either the patients or their representatives. All of the above noted patients were discharged and still no informed consents were in their medical records.

3. The Nursing Supervisor for 4 B was interviewed on 11/8/16 at about 11:01 a.m. The above patient records were reviewed and she agreed there were no signed informed consents in their medical records.

4. The Manager of Patient Access (Registration) was interviewed on 11/8/16 at about 11:57 a.m. The above patient records were reviewed and she agreed there were no signed informed consents in their medical records, in any other electronic health record view, or paper for the patients.