HospitalInspections.org

Based on interview and record review, the facility failed to ensure 3 of 5 sampled patients were afforded the opportunity to complete an advanced directive or living will at admission to the hospital (#1, 2 & 6).

Findings:

1. Patient #1 was admitted on 1/04/14 and expired on 1/08/14 from a history of CHF and a history of cardiac ejection fraction (EF) of 35%. On 1/08/14 during a procedure to place an automatic internal cardiac defibrillator (AICD), the patient became hypotensive, had a cardiac arrest, and the code blue was unsuccessful. The patient was pronounced dead from the cardiopulmonary arrest.

Review of the advanced directive-nursing screens for advanced directive were all blank and the Consent of Admission form dated 1/2/2014 read, "I have received and/or offered a copy of the Patient Bill of Rights and Advanced Directive information."

During a phone interview on 3/25/14 at 10:30 a.m., the lead registration person confirmed the document "Health Care Advanced Directives - The Patient's Right to Decide" is not printed and given to emergency department patients when admitted or other inpatient admissions. He also said the registration staff does not offer patients an explanation regarding the document "Health Care Advanced Directives - The Patient's Right to Decide", and other advanced directive information or explain the meaning of the document. He said he is not sure if the patient gets a copy when they arrive at their room, but this is the nursing staff's responsibility.

2. Patient #2 was admitted on 1/04/14 and expired on 1/14/14 from acute respiratory failure, bilateral pneumonia, and hypertension.

Review of the advanced directive - nursing screens for advanced directive - were blank, except for "End of Life request" showed-resuscitate. On 1/14/14, the screen still showed the patient did not have a living will, but did not document asking "Does the pt (patient) wish to complete one?" The Consent of Admission form dated 1/04/14 read, "I have received and/or offered a copy of the Patient Bill of Rights and Advanced Directive information."

During an interview on 3/25/14 at 10:40 a.m., the Emergency Department/Intensive Care Director confirmed patient #2's advanced directive documentation screen was blank and lacks the documentation as to whether or not he received a copy of document "Health Care Advanced Directives - The Patient's Right to Decide" or any additional information related to advanced directives.

3. Patient #6 was admitted on 3/19/14 for respiratory failure. The history and physical (H&P) showed history of chronic obstructive pulmonary disease (COPD) and cardiomyopathy. In the ED, the patient had CO2 retention around 60 and needed to be intubated because of periods of sleep apnea and acute mental changes.

Review of the advanced directive - nursing screens for advanced directive document no -for does the patient have a living will, and did not document asking "Does the pt (patient) wish to complete one?" The Consent of Admission form dated 3/19/14 read, "I have received and/or offered a copy of the Patient Bill of Rights and Advanced Directive information" and was signed by patient #6's spouse.

During an interview on 3/24/14 at 12:50 p.m., the patient said his spouse oversees his care. He said he was very sick at admission and thinks his spouse signed all of the papers.

During an interview on 3/25/14 at 12:15 p.m., the performance improvement/patient safety coordinator provided information related to the nursing staff responsibility for documentation for patient advanced directives titled "Tracer Questions". Review of the Tracer Questions read, "Show me your documentation. #3 For the patient without a living will, there must be a one (1) time follow-up (each visit) to see if the patient now wants to complete a living will." This one time follow-up was not evident in the medical record.