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Based on interviews and documentation review the Hospital (Hospital #1) failed to ensure that informed consent for invasive procedures was obtained and/or documented in one of one medical records.

Findings included:

Review of the medical record documentation, dated 1/13/10, indicated that the Patient arrived at Hospital #1's Emergency Department (ED) at 7:24 P.M. The Patient's vital signs were: pulse = 30 beats per minute(normal range is 60-90 beats per minute); respirations = 24 breaths per minute (normal range is 12-20 breaths per minute), and blood pressure = 60/30 (normal range is 100-140/60-90). The Patient was lethargic with decreased heart sounds and decreased respiratory effort. Diagnostic testing determined the Patient had a left bundle branch block.

Review of the medical record documentation indicated that there were several family members present in the ED with the Patient. One family member signed the General Consent for Care and Treatment Form.

Review of Hospital #1's Policy/Procedure titled Health Care Decisions indicated that procedure that require written consent include any line or or catheter placed in central circulation. If an emergency exists when delay in treatment will endanger the life, limb, or mental well-being of the patient then treatment may be given without consent. As soon as circumstances permit after the emergency treatment is provided, the physician shall give the same information that would have been given before the procedure if there had not been an emergency and document the communication in the medical record.

The medical record documentation, dated 3/1/10, indicated that during the course of treatment in the ED the following invasive procedures were performed: an intraosseous (inserted directly into the bone to provide extremely rapid intravenous access; used in emergent situations where access was necessary and was considered temporary) catheter was inserted in the Patient's left thigh; an external pacer (a device used to stimulate the heartbeat electrically by means of impulses conducted through the chest wall, as used in emergency care of significant bradyarrhythmias to improve heart rate) was placed, and a triple lumen (catheter with 3 ports and 3 different colored caps, red, white, and blue) central line was inserted through the Patient's right jugular vein using ultrasound guidance into the inferior vena cava.

The ED Physician who cared for the Patient was interviewed on 3/23/10 at 10:25 A.M. and throughout the survey. The ED Physician said his standard practice was to keep family informed of the plan of care.

Review of the medical record documentation indicated that although there were no written consents, there was no documentation to indicate that information regarding invasive procedures was provided to family members.

Based on interviews and documentation review the Emergency Department (ED) Physician failed to ensure that the retained central line guidewire was reported to Hospital #1's Quality Assurance Department.

Findings included:

Hospital #1's Policy/Procedure titled Patient and Visitor Occurrences indicated that the individual most closely involved or the individual discovering the occurrence should complete an Occurrence Report as soon as possible.

Review of Hospital #1's Incident Report Log, dated 9/1/09 to 3/23/10, indicated that there was no documented evidence that the retained central line guidewire was reported and/or addressed.

The Manager of Quality was interviewed on 3/23/10 at 11:00 A.M. The Manager said she did not know of this incident.

The Emergency Department (ED) Physician who inserted the Patient's central line was interviewed on 3/23/10 at 10:25 A.M. and throughout the survey. The ED Physician said several days after the Patient's transfer he was told the ED had received a call that the central line guidewire had not been removed. The ED Physician said he was unsure as to who took the call however; he was sure it was not a physician. The ED Physician said he went back and reviewed the post insertion x-ray and determined he had misread the x-ray. The ED Physician said he did not report the incident to the Quality Department.