HospitalInspections.org

Based on record review and interview, the facility failed to fully uphold the patients right to an accurate informed consent for 2 of 3 patients (ID#s 6 and 7).

Findings included:

Record review of facility policy titled "CORE: Informed Consent", dated 6/2021 showed the following:
PURPOSE:
This policy/ procedure establishes guidelines around the patient's right to be informed of surgical and special procedures that may be rendered and the patient's right to accept or refuse a particular procedure. Informed consent must be obtained and documented according to this policy before initiating a surgical or special procedure, except in an emergency.

PROCEDURE:
1. Obtaining Informed Consent
a. The physician performing, ordering, or supervising the surgical or special procedure shall be responsible for obtaining informed consent.
c. Hospital staff members (including all nurses and other employees) may participate in the informed consent process by witnessing the patient, the patient's representative, or physician's signature regarding informed consent ....
Record review of medical record for patient (ID#6) showed documented family member medical power of attorney.

Record review of consent for paracentesis dated 6/9/24 showed signed consent given by family friend (other than documented appointed medical power of attorney).


Review of medical record for patient (ID#7) showed case manager notes dated 6/7/24 with the following information:
Durable power of attorney for healthcare update: (wife's name). Patient's daughter states she has medical power of attorney, pt's daughter to bring copy to the hospital. No copy was in the patient's medical record.

Informed consent for Dialysis dated 6/6/24 signed by the patient's daughter.
Informed consent for insertion of hemodialysis Tunneled catheter placement dated 6/7/24 signed by the patient's daughter.
Informed consent for Transfusion dated 6/10/24 signed by the patient's daughter.


Interview with Director of Clinical Services on 6/18/24 at 1:30 Pm confirmed the above findings. She stated that the facility has identified this and is addressing the issue.