HospitalInspections.org

Based on document review and interview, for 1 of 4 patients (Pt. #1) clinical records reviewed for pre-surgical informed consents, the hospital failed to ensure that informed consent was obtained from the appropriate individual.

Findings include:

1. On 9/2/2025, the Hospital's Policy titled "IL Informed Consent for Procedures, Interventions or Medical Care That Require Consent for Adults" (Effective Date 3/19/2025), was reviewed and included, " ... Informed Consent ... A patient and/or substitute decision maker (SDM) must be apprised of the purpose, nature, risks and benefits of the procedure, alternatives to the procedure ... After receiving this information, the patient and/or substitute decision maker (SDM) then either consents to or refuses such a procedure or treatment ... Substitute Decision Maker (SDM) ... The SDM can be a legal guardian of the person; an agent appointed pursuant to a power of attorney for health care; or a Surrogate identified by the Attending Physician pursuant to the Illinois Health Care Surrogate Act if the patient lacks decision-making capacity ... Informed Consent Documentation ... 2. The following information is noted or documented on the consent form ... d. Patient/SDM signature with the corresponding date and time noted ... C. Telephone Consent - 1. Telephone Consent may be given by the representative or substitute decision-maker of the patient if they cannot be present to sign the consent form ..."

2. On 9/2/2025, the clinical record for Pt.#1 was reviewed. On 7/18/2025, Pt.#1 was brought to the Emergency Department (ED) after suffering a mechanical fall. Diagnostic Tests were performed and it was determined that Pt.#1 had suffered a left hip fracture and needed surgical intervention.

- The ED Nurses Note by Registered Nurse (RN-E#9) on 7/18/2025 at 9:52 PM included, "RN spoke with [Name-Guardian], representative from [Name of County] Public Guardian; [Name-Guardian]. [Guardian] verbalized confirmation that the nursing and medical team received the legal documents of pt's guardianship. Pt.#1's son is not allowed to visit [Pt.#1] nor is he entitled to medical information and updates from the medical team. He is allowed to speak with the pt via phone call if pt accept his call. [Guardian] is the on-call public guardian for this pt... if after hours alert them to your need and they will fwd (forward) to 24 hour answering service. SON MAY NOT VISIT OR RECEIVE MEDICAL UPDATES/INFO FROM STAFF. HE MAY TALK TO PT VIA PHONE CALL ONLY."

- The Illinois Consent for Anesthesia Services form dated 7/21/2025 and signed at 3:43 PM was reviewed and indicated that phone consent was given by Pt. #1's son. This was witnessed by RN (E#8) and signed by anesthesia provider (MD#2).

- The Illinois Consent to Surgical/Invasive Procedure form dated 7/21/2025 and signed at 3:43 PM, was reviewed and indicated that phone consent was given by Pt. #1's son. This was witnessed by RN (E#8) and signed by surgeon (MD#1).

3. On 9/3/2025 at 8:55 AM, an interview was conducted with Registered Nurse on 8 West inpatient unit (E#7). E#7 stated that E#7 recalls Pt.#1 was scheduled for surgery on 7/21/2025. E#7 stated that E#7 was not aware that Pt.#1 had a state appointed guardian. E#7 stated that E#7 received a call from the pre-op unit and informed to update Pt.#1 contact information to include the state appointed guardian. E#7 stated that E#7 updated Pt.#1's information to include the state appointed guardian's contact information. E#7 stated that Pt.#1's son had been listed as the primary contact. E#7 stated that E#7 would expect any update regarding a patient guardian to be included in the nurse handover report. This is done during shift changes. E#7 stated that when a patient is admitted to their unit, patient's primary contact information should be reviewed and updated. E#7 stated that if E#7 was aware of any change in patient's primary contact information, E#7 will immediately update the patient's information. E#7 stated that generally, consent for procedure is obtained in pre-surgery.

4. On 9/3/2025 at 9:50 AM, an interview was conducted with Operating Room Registered Nurse (E#8). E#8 stated that consents for procedures are obtained by the pre-op unit. E#8 stated that the pre-op unit charge nurse receives a report from the unit where the patient came from. E#8 stated that with regards to consent, E#8 will verify in the patient's medical record or with the patient's nurse as to who may give consent for procedures. E#8 stated that E#8 will mainly rely on the patient's medical record or the report received from the nursing unit. E#8 stated that consent for Pt.#1's procedure was obtained from the patient's brother or son (could not recall relation). E#8 stated that E#8 was made aware that Pt.#1 had a state guardian by another nurse on their unit. E#8 stated that Pt.#1 was already in the OR (Operating Room) when E#8 found out that Pt.#1 had a state guardian. E#8 stated that the state guardian was listed as the third contact option in Pt.#1's medical record. E#8 stated that it was wrong that the state guardian was not called to obtain the consent for Pt.#1's procedure.

5. On 9/3/2025, interviews were conducted with the Orthopedic Surgeon (MD#1) at 9:34 AM and the Anesthesiologist (MD#2) at 10:20 AM. Both indicated that they were not aware that Pt.#1 had a state appointed guardian and that informed consent for the procedure was obtained from an individual who had no authority to do so.