Riverside Medical Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 52206 Based on record review, document review, and staff interview, the Hospital failed to ensure that for 2 of 10 patients (pt. #1 and pt. #8) reviewed, a properly executed surgical informed consent form was completed prior to the procedure. Findings include: 1. During record review, Pt.#8’s Surgical and Procedures Consent form, a telephone consent was obtained from the Pt. #8’s husband, but the form did not have a second witness signature as required by the hospital. 2. During record review, Pt.#1’s Surgical and Procedures Consent form, in the authorization of the physician to perform “the following operations or procedures” section, it listed “insertion of percutaneous endoscopic gastrostomy tube” ( a flexible feeding tube surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication), but not the insertion of a tracheostomy (a surgically created opening in the neck that leads directly into the windpipe to aid breathing) which was completed on the same day. 3. Review of the Hospital’s Consent for Treatment (Operative and Invasive Procedures (Approved 08/2025) states “Policy: ...E. Completion of the Form ...1. The name of the procedure should be documented, preferably in layman’s terms, without abbreviations ...7. The person witnessing the form must be present when the patient signs the consent. The full signature and title of the witness should be utilized. F. Other Methods of Documenting Consent ...2. Telephone ...When obtaining telephone consent, it is still the physician’s responsibility to explain the procedure, risks, benefits, and alternatives to the person who is authorized to give consent. It is the nurse’s responsibility to ascertain that the person giving consent understands what the physician has explained and then confirms the authorized consent to the treatment/procedure over the telephone. 4. In an interview with the ICU Manager (E #5), E # 5 verbally confirmed that the witness signature was missing on the procedure telephone consent and confirmed that the witness signature should have been completed per the hospital’s policy. 5. In an interview with the Director of Quality (E #2), E #2 nodded agreement that a percutaneous endoscopic gastrostomy tube (PEG tube) and a tracheostomy (trach) were performed on the same day, but the Surgical and Procedures Consent form only listed the PEG tube as the procedure being consented to. E #2 stated, “We are aware. We are looking for it. It has not been found.””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 1 of 10 ED clinical records (Pt. #1) reviewed for pain assessments, the Hospital failed to ensure a complete pain assessment and reassessment was conducted. Findings include: 1. On 4/21/2025, the Hospital’s policy titled, “Organizational Patient Assessment/Reassessment Plan” (dated 5/2024) was reviewed and required, “The goal of the assessment/reassessment process is to provide the best care and treatment possible, taking into consideration the patient’s physiological, psychological, social/environmental situation and needs across the continuum of care. In order to achieve this goal, the following processes are performed: A) Data is collected to assess/reassess the needs of the patient. B) Data is analyzed to determine the appropriate approach to meet the care of treatment needs. C) Patient needs are identified and prioritized. ...Assessment/Reassessment Criteria -Reassessments are performed by RNs and physicians when: a) There is a change in the patient’s status b) There is a change in the patient’s vital signs prior to discharge c) As indicated by patient condition and/or treatment.” 2. On 4/21/2025, the “Documentation Guidelines in Emergency Department” (dated 10/2024) was reviewed and required, “Pain assessment - Use a pain scale appropriate for age and/or condition, specify location of patient’s pain, reassessment after intervention should include an appropriate pain scale with location, reassessment within 1 hour if pain score greater than 4 on 1-10 scale.” 3. On 4/21/2025, Pt. #1’s ED clinical record (dated 10/20/2025) was reviewed and indicated: ED triage nurse’s (E #1) notes (dated 10/20/24 at 8:57 PM) indicated, “Pt. #1 arrives with reports of increasing seizures; Pt. #1’s [parent] reports Pt. #1 fell last week and has had arm and back pain since. Pt. #1 has a history of epilepsy. Pt. #1 had vomiting episodes x 2 on arrival. Approximately 20 second seizure prior to placement in bed; airway stayed protected; was able to place himself in the ED cot per himself per his request; able to position himself on the cot - placed in ED 16.” ED triage nurse’s (E #2) notes (dated 10/20/2024 at 8:59 PM) indicated, “Pt. #1 arrived to ED via private vehicle, accompanied by Pt. #1’s [parent], with complaints of back pain after experiencing multiple seizures last week and falling. Pt. #1’s [parent] states Pt. #1 was also complained of right arm and chest pain. Pt. #1 states Pt. #1’s right arm is broken and believes Pt. #1 may have an infection. Pain assessment scale used 0-10, pain score: 10 worst possible pain. While on the way to ED room, Pt. #1 began to seize in wheelchair for approximately 30 seconds. Pt. #1 was lowered to the ground and placed on cot. Pt. #1 had one bout of emesis after seizure. Pt. #1 had no postictal phase. Pt. #1 alert and oriented, per Pt. #1’s baseline. E #2’s notes at 9:35 PM indicated, “Pt. #1 had another seizure lasting approximately 10-15 seconds. Pt. #1 alert and oriented times four, per baseline and is maintaining a patent airway. Pt. #1 had no postictal (altered state of consciousness after an epileptic seizure) phase.” There was no documentation in Pt. #1’s clinical record regarding location or duration of Pt. #1’s pain. There was no documentation of any pain reassessment in Pt. #1’s clinical record. ED provider (MD #1) notes dated 10/20/24 at 10:03 PM indicated, “Pt. #1 presented to the ER for chief complaint of seizures. On my assessment, Pt. #1 stated [Pt. #1 just needs something for seizures and that Pt. #1 does not want to be here anymore.] Pt. #1 states that Pt. #1 that Pt. #1 takes Pt. #1’s medications as prescribed, just needs something to make the seizures stop. Review of symptoms - Neurological: positive for seizures, negative for light-headedness, numbness and headaches. Respiratory - Negative for choking, chest tightness and shortness of breath, HENT(head, eyes, ears, nose and throat) - Negative - Negative for congestion and dental problem. Physical exam - blood pressure 172/113, pulse 105, respirations 24, temperature 97.7 and spO2 98%. Cardiovascular - rate and rhythm: Normal rate and regular rhythm. Heart sounds: No murmur heard. Pulmonary: Effort - Pulmonary effort is normal. No respiratory distress. Breath sounds - normal breath sounds. Musculoskeletal - Cervical back - neck supple. Skin - General - skin is warm and dry. Neurological - Mental status - Pt. #1 alert and oriented to person, place, and time. Psychiatric - Mood and Affect - Mood normal. Behavior: Behavioral normal ...Clinical impression - Seizure ...Medical Decision Making - Pt. #1 feels comfortable plan for discharge, provide with Ativan (anti-anxiety medication) will be discharged home.” There was no documentation in MD #1’s notes regarding a pain assessment. Pt. #1 was discharged at 10:06 PM on 10/20/2024. 4. On 4/22/2025 at 8:10 AM, an interview was conducted with the ED Director (E #6). E #6 stated that there should have been a reassessment within 1 hour if score greater than 4 on 1-10 scale. E #6 stated that the pain assessment should include location and duration of pain.”