HospitalInspections.org

Based on review of emergency room records and interviews with staff, the facility failed to ensure that 7 patients' medical records who visited the emergency room 2011 through June 2014 did not contain signed consent or documentation of verbal consent for treatment and acknowledgement of patient rights.

Findings were:

Review of facility documentation "consent for medical treatment form CS REG 100" which also contain patient rights, consent for treatment, no guarantee, personal valuables and speak up were not in the medical records of the 7 patients who came to the emergency room in 2011 through the June 2014.

An in-person interview was held with Staff #2, the facility Chief Executive Officer, the afternoon of 6/10/14. Staff #2 acknowledged that the facility failed to obtain signed consent or documentation of verbal consent for treatment and acknowledgement of patient rights for the 7 patients who came to the emergency room in 2011 through June 2014. Staff #2 stated the facility had just incorporated the admission document packet to also be included into outpatient charts.

An in-person interview was held with Staff #16, the facility Chief Nursing Officer, the afternoon of 6/10/14. Staff #16 acknowledged that the facility failed to obtain signed consent or documentation of verbal consent for treatment and acknowledgement of patient rights for the 7 patients who came to the emergency room in 2011 through June 2014. Staff #16 stated she had been notified there were no consents in the emergency room patient charts. She stated the facility has made packets of the required consent forms and other required forms that will be included in all patient records.

Based on review of emergency room medical records and interviews with staff, the facility failed to produce the completed required Memorandum of Transfer form for 1 of 1 patient that was transferred out to another general hospital for continued medical treatment at a higher level of care.

Findings were:

Review of facility emergency room medical record of Patient #4 and the separate notebook of filed Memorandum of Transfer forms revealed no Memorandum of Transfer form for the transfer from facility to another general hospital for continued medical treatment on 4/5/13.

Review of facility policy entitled "Transfer Policy, Last Revision Date: 05/2013, stated "MEMORANDUM OF TRANSFER: (MOT), The hospital will provide a memorandum of transfer, as prescribed by the Texas Department of Health, to be completed for every patient who is transferred."

An in-person interview was held with Staff #16, the facility Chief Nursing Officer, the afternoon of 6/10/14. Staff #16 confirmed there was no Memorandum of Transfer form for Patient #4 for the transfer on 4/5/13 from the facility to another general hospital.