HospitalInspections.org

Based on medical record review, staff interviews, and review of policy and procedures; the facility failed to follow their policies related to informed consent. The facility staff failed to ensure consent was provided prior to performing testing for evaluation of an emergency medical condition for 1 (Patient 3) of 11 patients treated at the hospital. This had the potential to affect all patients brought to the facility for care and services, the facility saw in the Emergency Department for April 2024: 8,336 and the hospital admitted for April 2024: 3,729 for inpatient care.

Findings are:

A. Review of the medical record for 43 year old, Patient 3 (Pt 3) identified that the patient was brought to the Emergency Department for evaluation following a motor vehicle accident by local law enforcement (LLE), prior to going to jail. The patient arrived at 3:40 AM on 10/13/23 and was discharged at 4:50 AM on 10/13/23. Upon arrival the Patient Access Staff (person that gathers your information and obtains consent to treat) asked the Pt 3 for consent to treat. Pt 3 refused to provide informed consent to treat verbally and refused to sign the (electronic) consent form. Review of the medical record identified:
-On 10/13/23 at 0340, the local law enforcement officer told the Patient Access Staff that the Pt 3 was brought there for the complaint of FFC (Fit For Confinement-[jail]).
-Pt 3 verbally refused to provide informed consent to the Patient Access Staff.
-Pt 3 was taken to a room at 0340 and the nurse performed triage (initial assessment of concern by nurse). Pt 3 again refused to sign or give verbal consent to treat. Review of the "ED Acuity/Triage Plan" revealed the patient denied complaint of pain, vital signs (VS) completed; Temp 97.9-pulse 112-blood pressure 204/112-respirations-oximetry 100%. The patient was identified as a Patient Acuity of 3-urgent. (Per the Emergency Severity Index (ESI) that identifies patient acuity as: ESI level 1-Patient requires immediate life-saving intervention; ESI level 2-Patient is in a high risk situation, is disoriented, in severe pain, or vitals are in danger zone; ESI level 3-If multiple resources are required to stabilize the patient, but vitals are not in the danger zone; ESI level 4-If one resource is required to stabilize the patient; ESI level 5-If patient does not require any resources to be stabilized.

Review of the Emergency Department Physician (MD-A) examination of Pt 3 documented at 3:58 AM stated the following: "hit a street sign, the patient had no loss of consciousness, denies any pain or discomfort at this time, and alcohol on board." Review of documented revealed, the "patient had no respiratory distress, heart rate normal, abdomen non-tender/non-distended, PERRL (pupils of eyes equal, round, reactive, light, and accommodation) neuro- alert, appropriate with no focal deficits." MD-A placed an order for a CT (Computed Tomography) Scan of the head without contrast. CT Scan completed at 4:09-4:13 AM, , results impression identified, "No acute or post traumatic abnormalities of the brain or skull are detected." MD-A documented, "Patient's blood pressure has gone down without any intervention, last reading 143/66. CT head with no acute findings. (Pt 3) will be discharged in the care of law enforcement at this time."

B. Telephone interview with MD-A (5/15/24 at 1:00 PM) revealed, when asked if Pt 3 refused the CT Scan, does the police without an order override the patient refusal? MD-A stated, "My understanding a patient can refuse a medical work up as long as capable." "I did not know (Pt 3) refused treatment."

C. Review of the policy titled Consent (effective 7/28/23) stated under Procedure/Requirements:
-"3.1 For the purpose of consent, adult means an individual who is 19 years of age or older.
-3.2 Informed consent shall mean consent to a procedure based on information that would ordinarily be provided to the patient under like circumstances by health care providers engaged in a similar practice in the locality or in similar practice in the locality or in similar localities. The failure to obtain informed consent includes failure to obtain any express or implied consent for any operation, treatment, or procedure in a case in which a reasonably prudent health care provider in the community or similar community would have obtained an express or implied consent for such operation, treatment, or procedure under similar circumstances. Surgeons and physicians are thus required to provide their patient with sufficient information to permit the patient to make a fully informed decision to agree upon or refuse the proposed course of treatment or surgery."

Review of the policy titled Inmate Patient Care (effective 11/01/23) stated under Procedure/Requirements:
-"3.1 Medical care for inmate patients is provided in a manner consistent with approved procedures and standers for patient care. All patients, including inmates, have the right to request treatment that is medically appropriate or refuse treatment to the extent permitted by law."

D. Interview with the Director of Security (5/16/24 at 1:40 PM), stated, "It is my understanding that the facility has to have a court order unless the physician feels the issue is emergent." The medical record for Pt 3 lacked a court order for treatment.