HospitalInspections.org

Based on medical record review, staff interview and facility document review, it was determined the facility staff failed to ensure the patient signed the consent to treat for two (2) of three (3) records reviewed (Patients #1 and #2).

The findings were:

Staff Member (SM) #1 assisted with navigation of the medical records. The surveyor requested to review the signed document for consent to treat for Patient #1. SM #1 was unable to locate a signed document. SM #1 printed the admission packet for Patient #1 and acknowledged that none of the documents had been signed.

While reviewing Patient #2's medical record, the surveyor requested to view the signed consent to treat. SM #1 was unable to locate the form in the medical record. SM #1 located a signed consent for a procedure in Patient #2's chart; but not a consent to treat obtained at admission.

A review of the facility's policy titled, Admission Process, reads in part: "It is the policy of [Name of facility] to ensure patient admissions are based upon documented consent... PROCEDURES... 4. Patient Admissions...c. Completing Admission Forms:... ii. All fields shall be completed on admission documents and the documents must be signed by the patient/legal representative upon admission... 5. Admission Documents... c. The Admissions Manager, Coordinator, or other designee is required to present the following forms to the patient/legal representative. The required Inpatient Admissions Forms are: i. Admission Agreement/Conditions to Treatment ii. Consent to Treat iii. Patient Rights and Responsibilities...".

During the medical record review, the surveyor discussed the finding with SM #1. At the exit conference on 10/27/2021, the finding was reviewed with SM #1, SM #2, and SM #3.