Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531310 (X3) Date Survey Completed 05/03/2012
Name of Provider or Supplier Powell Valley Hospital Street Address, City, State 777 Avenue H, Powell, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0304 RECORDS SYSTEMS
CFR(s): 485.638(a)(4)(i)

For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;


This STANDARD is not met as evidenced by:
Based on medical record review and staff interview, the facility failed to ensure informed consents were properly executed for 2 of 7 sample patients (#16, #20) who underwent procedures that required informed consent. The findings were: 1. Medical record review showed patient #16 signed a consent for epidural anesthesia, but neither the date nor the time of the signature of the patient, the CRNA, or the witness were indicated on the consent form. In addition, the space to write the name of the CRNA performing the procedure was blank. During an interview on 5/3/12 at 12:30 PM RN #3 confirmed the consent was incomplete; she stated the consent should be dated and timed when signed. 2. Review of the medical record for patient #20 showed s/he was admitted on 4/29/12 for acute lower back pain. Further review of the record revealed an "informed consent for medical, surgical and diagnostic procedures" was filled out on 11/26/11 allowing for a "left L4-5 transforaminal epidural injection." However, the informed consent form did not have the required patient's signature. Interview with RN #1 on 5/1/12 at 9:48 AM confirmed the consent form had not been signed by the patient.