HospitalInspections.org

Based on review of facility policy, patient record, and staff interviews, the facility governing body failed to ensure that medical staff rules and regulations were being followed per policy.

Findings were:

Facility policy " Consent to Medical Treatment " Policy number CM-PC-H-0100 stated " 4.1 Every patient admitted or registered must complete, or have completed by an authorized person, a general consent form ...The requirements are: 4.1.1. Adults A. Patient able to sign: If the patient is in condition to understand and sign the consent form(s), the patient must sign the form(s). B. Patient unable to sign: If any adult person is comatose, medicated, confused, or for any other reason is not able to understand the risks of medical treatment or surgical procedures, the spouse (if married), father, mother, adult child ...may sign consent for the patient. However, the exact reason making it medically infeasible to obtain informed consent of the patient should be documented by the physician in the medical record of the patient. C. Incompetent adult: If the adult patient has been judged to be mentally incompetent by a court, then the court-appointed guardian must present a copy of that court order before the guardian ' s signature can be accepted on a consent form. "

Review of the medical record revealed no evidence that the physician documented that the patient was not capable of providing informed consent on 11/19/11, the date of the patient ' s admission, or any other date throughout the patient ' s admission.

-On 11/19/11, the daughter of Patient #1 signed the " Plum Creek Specialty Hospital Clinical Data Base/Screening Criteria " which stated (in part) " I agree with the information and it reflects my needs as a patient. I have been given a copy of the Patient Bill of rights and understand my rights as a patient. " On the same form, the " Validation Statement: A registered nurse has reviewed the information on this document. RN Signature ________ " was left blank and was not signed by the RN.

-On 11/19/11, the " Consent for Medical Treatment " was signed by the daughter of Patient #1.

-The " Admission Authorizations " form, which states in part, " Treatment Consent: ...Patient consents to examinations, treatments, medications, and procedures prescribed for the patient by his physician, his designated alternate, or by another physician in case of emergency " was signed by the daughter of Patient #1 on 11/19/11.

-The " Verbal Release of Information " was signed by the daughter of Patient #1 on 11/19/11.

-However on 11/19/11, Patient #1 personally signed the " Plum Creek Specialty Hospital PICC Line Disclosure and Consent " Form.

-On 11/19/11, Patient #1 personally signed the " Acknowledgement of Receipt of Notice of Privacy Practices. "

-The " Specialty Hospital Admission Record Patients Bill of Rights " form was signed by the patient but was undated by the patient, and the " Facility Representative " witness signature space and facility representative " Date " space were left blank.

In an interview with the RN Case Manager and the Chief Nursing Officer at 4 pm on 2/15/2012, the RN Case Manager stated, " If the patient can make their own decisions, and they are not declared incompetent, the patient makes their own decisions. If there is a guardianship, the family presents the papers and the family makes the decisions ... Any time I went in and spoke to [Patient #1], he was making sense, asking reasonable questions, and was oriented. "