HospitalInspections.org

Based on review of facility documents, review of medical records, and staff interview, the facility failed to ensure patients, or their representatives, had the right to make informed decisions regarding their care.


Findings included:

Facility-based policy titled "Consent for Medical and Surgical Procedures stated in part, "Policy: Medical records must contain a properly executed and completed written informed consent for all procedures and treatments ...
Responsibilities: The role of nursing in the informed consent process is to obtain the signature on the consent form and witness the signature, after ascertaining that the patient has been informed.
Telephone consent: Telephone consent may be accepted with two (2) witnesses if the individual authorized to consent it unable to come to the hospital. (Documentation on the form will include who gave consent and two (2) witnesses to the telephone consent must sign as witnesses)

...General Stagements [sic]
...C. Properly Witnessed Consent
...3. The oral or telephone authorization of the patient will require documentation by two (2) witnesses.
...7. The witness signature indicates:
a. The person giving consent it competent, oriented to time and place, lucid, and understands that they are signing consent for treatment ...
b. The consent form was signed in the presence of the witness or in the case of telephone consent; the two (2) witnesses monitored the telephone consent."

Review of the medical record for patient #1 revealed all consent to treat forms including notice of privacy practices, organ procurement and advanced directives, patient rights and responsibilities, the important message from Medicare, Medicare benefits worksheet, and Medicare secondary payer questionnaire were signed on different days with the signature of the patient stated "Verbal [by the medical power of attorney]" which was only witnessed by staff #6. There were no second witness on any of the sheets, which cannot be verified these were done correctly.

The above was verified with staff #1 on the afternoon of 11/21/19

Based on review of facility documents, review of medical records, and staff interview, the facility failed to ensure drugs were administered in accordance with orders of the medical staff and approved policies and procedures.

Findings included:

Facility-based policy titled "Medical General Policies-MARs [medication administration record]" stated in part, "D. Documentation of Scheduled Medications:
1. Upon administration of the medications, the nurse will document in the MAR the real time of medication administered with initials.
...5. Scheduled doses not given are circled and initialed in the MAR with the reason not given."

Review of the medical record for patient #1 revealed several medications given with a slash and initial, with no times indicated when the medication was actually administered. On 9/23/19, an inhaler and two antibiotics were scheduled at the following times: 7:00 pm, 10:00 pm, midnight, and 6:00 am; there were no initials or documentation indicating if these medications were given.

The above was confirmed in an interview with staff #1 on the afternoon of 11/21/19.