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Based on interview, and record review, the Nursing staff failed to document the communication with the family member regarding the updated Informed Consent for Surgical and Special Procedures for the correct finger to be amputated for one (1) of 32 sampled patients (Patient 27).

This failure had the potential to result in an ineffective care provided to patient and misunderstand the risks and consequences of the procedure which could potentially cause injury, and/or harm to patient.

Findings:

During a review of Patient 27's "History and Physical" (H&P), dated October 20, 2022, at 10:24 PM, the "H&P' showed, 56-year-old patient with multiple medical problems including hypertension (high blood pressure), hyperlipidemia (high concentration of fats in the blood), type 2 diabetes mellitus (elevated sugar in the blood and urine), and end-stage renal disease (kidney failure), dependent on hemodialysis (machine filters wastes and remove fluid from the blood).

During a concurrent interview and record review, on November 16, 2022, at 8:45 AM, with Director of Operating Room (DOR), Patient 27's "Informed Consent for Surgical and Special Procedures" showed, "Procedure(s) proposed: left fourth finger partial amputation" was signed by Patient 27's mother on November 13, 2022. The DOR stated and confirmed, he was involved with the case, they found the mistake on documentation after the procedure was done, "correct body part was amputated left fourth (4th) finger." DOR stated, consent was obtained before the procedure, Recovery nurse discovered the wrong body part was documented. DOR further stated, Third (3rd) finger was called out during the timeout, everyone noticed there was only one (1) finger that was black, the fourth (4th) finger. DOR stated, there was a mistake in documentation, informed consent is important for patient safety and to make sure the right procedure is done, specific procedure should be written on the consent.

During a review of Operative/ Procedure report dated November 10, 2022, the Operative/ Procedure report showed,
"Correction: Left 4th finger partial amputation (not 3rd finger) signed by Doctor of Medicine 1 (MD 1) on November 11, 2022, at 9:32 PM.
Date of procedure: November 10, 2022.
Time: 9:13 AM."

During an interview, on November 16, 2022, at 2:38 PM, with DOR, DOR stated, he called the patient's mother to obtain the updated consent after the procedure was done, the mother came on Sunday November 13, 2022, to sign the updated consent. "I did not document the conversation with the mother", but the mother said they agreed and came back to sign the consent.

During an interview, on November 16, 2022, at 9:39 AM, with Registered Nurse 11 (RN 11), RN 11 stated, informed consent is important and should have the specific type of procedure and specific body part written on the consent for patient safety and at least patient knows what's going on. RN 11 further stated, not having the consent delays the care of the patient.

During a review of the facility's policy and procedure (P&P) titled "CORE: Informed Consent" dated June 2021, the P&P showed,

"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.
POLICY
This policy of [Hospital Name] applies to all surgical and special procedures that involve material risk to the patient, regardless of their repetitive nature. Some items require informed consent by law or regulatory standard, such as HIV testing or blood/blood product administration.
DEFINITIONS
H-PC 08-006 A CORE: Procedures Requiring Informed Consent: An attachment to this policy that lists all procedures that require an informed consent.
PROCEDURE
1. Obtaining Informed consent ...
2. Mechanisms of Documenting Informed Consent. Informed consent must be documented on one of the following:
a. A completed Hospital-approved Informed Consent Form signed by the patient or patient's legal representative ...
3. Telephone consents ...
4. Duration of Consent ...
5. Requirements for Informed consent ...
d. Documentation of the informed consent must be completed prior to the procedure and
documented in the patient's medical record as evidence that consent has been obtained.
6. Medical emergencies
c. The physician must show the need for proceeding without informed consent by documenting in the medical record the reasonable and diligent efforts as time allows to acquire consent from the next of kin or legal representative; and the immediacy and magnitude of the threat to the patient if the medical or surgical procedure were not immediately done."