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Based on observation and interview, the facility failed to ensure informed consent was executed according to standard of care and hospital policy. The deficient practice is evidenced by failure of hospital staff to complete all requisite sections of the consent forms for 1 (#3) of 3 (#1-#3) reviewed patient medical records.
Findings:

Review of hospital policy OHS.MED.033, titled "Informed Consent," effective 09/2018, revealed in part, "IV. Policy Statements . . . B. It is the responsibility of a provider credentialed and privileged to perform the procedure to present the patient with a clear concise explanation of the proposed treatment plan. The patient should be provided information on the following: 1.His/her condition; 2. Proposed treatment/ procedures; 3. Alternative treatment/ procedures; 4. Material risks and benefits of proposed and alternative treatments/ procedures; and 5. Likelihood of success of treatment."

Review of the medical record for Patient #3 navigated by S2CPI revealed the patient was admitted on 03/16/2024 with a diagnosis of abdominal pain. An esophagogastroduodenoscopy (EGD) was performed on 03/19/2024.

Review of the consent signed by Patient #3 for the EGD revealed the section "Patient Condition/ Indication for Procedure" was not filled out.

Review of the anesthesia consent under the section "Patient Condition/ Indication for Procedure" revealed "See Surgical Consent."

Further review of the anesthesia consent for Patient #3 revealed the section "Treatment/ Procedure- Anesthesia" documented the purpose was "To provide anesthesia for proposed surgical/ medical procedure," and "Procedure: EGD." The section also contained the statement, "See section 5 for types of anesthesia, including those applicable to your procedure, which will be discussed with you by the Anesthesia team." Review of Section 5 revealed in part, "The type of anesthesia most appropriate for your operation will be mutually agreed upon by you, your surgeon, and your anesthesiologist/ CRNA. There are four main types of anesthesia from which to choose: 1. General anesthesia . . . 2. Regional anesthesia . . . 3. Monitored anesthesia care . . . 4. Local anesthesia." The form did not contain any marks or indication on the form that identified the specific type of anesthesia planned for the procedure.

In interview on 04/02/2024 at the time of record review between 10:06 a.m. and 10:16 a.m., S2CPI verified the patient condition or indication for the procedure was not filled out on the surgical consent and the anesthesia consent referred to this incomplete section for the indication for anesthesia. S2CPI also verified the consent did not specify the type of anesthesia planned for the EGD.