Observations:
Based on review of facility policies and procedures, review of medical records (MR), and staff interview (EMP), it was determined the facility failed to obtain patient consent to the administration of local anesthesia for one of one medical record reviewed. (MR1)
Findings include:
Request was made to EMP1 on November 5, 2024, at 10:15 AM, for a policy and procedure regarding local anesthesia. None provided.
Review on November 5, 2024, of facility policy "Informed Consent for Surgery or Procedure" revised March 2022, revealed, "...The informed consent will include the recommended operation, treatments or procedures ..."
Review on November 5, 2024, of facility policy "Informed Consent for Anesthesia" revised Adopted September 2022, revealed, "...The informed consent must include the anesthesia type ..."
Review on November 5, 2024, of MR1's Consent for Anesthesia section, dated October 14, 2024, revealed, no documentation regarding the use of local anesthesia.
Review on November 5, 2024, of MR1's informed consent to operation and rendering of medical services section, dated October 14, 2024, revealed, no documentation regarding the use of local anesthesia.
Review on November 5, 2024, of MR1's intra-operative record, dated October 14, 2024, revealed, "...Marcaine 20 ml injected locally..."
Interview on November 5, 2024, with EMP1 at 10:12 AM confirmed local anesthesia was administered to the patient in MR1. Further interview with EMP1 confirmed the consent for local anesthesia was not documented on the anesthesia/surgical procedure consent form.
| | Plan of Correction - To be completed: 12/06/2024
TImmediate correction for the individual case will be completed by:
The facility will immediately rectify the oversight by updating the Center's Informed Consent for Anesthesia specifically for local anesthesia. The form will be revised to include specific sections for all anesthesia types, including local anesthesia. The patient will be informed of the nature and potential risks associated with local anesthesia.
Indicate how the facility will act to protect patients in similar situations:
To prevent similar occurrences, the facility will review all upcoming surgical cases to ensure that the updated Informed Consent for Anesthesia form detailing anesthesia options, including local anesthesia is obtained from the patient.
Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur:
The facility will review with the surgical and anesthesia staff the updated Consent for Anesthesia and the importance of accurately documenting anesthesia options on consent forms.
Indicate how it plans to monitor its performance to make sure that solutions are sustained to ensure the effectiveness and sustainability of these measures:
A comprehensive audit of consent forms
will occur for the next 3 weeks, with ten charts being audited a week. This proactive approach will safeguard all patients by ensuring that their consents accurately reflect the type of anesthesia to be used. The results of these audits will be reviewed by the Patient Safety Committee, with findings reported to senior management. Any deviations identified during the audit process will trigger immediate corrective actions, including retraining and revising protocols as necessary.
Position(s) responsible for the corrective action and monitoring of plan of correction:
The Director of Nursing will ensure this plan of correction is implemented and monitored.
This deficiency and plan of correction will be reported to the Center's patient safety committee and to the governing body.
Provide dates when corrective action will be completed:
The revised consent form template will be implemented by 11/25/2024. Staff training sessions will be completed by 11/25/2024. Initial and ongoing audits will commence by 11/25/2024 and continue for three weeks.
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