HospitalInspections.org

The Hospital failed to ensure that the Health Care Proxy, was informed of Patient #1's Hospital Admission, consented to procedures and services and was invoked, when Patient #1 was incapacitated due to being intubated and sedated.

Refer to tags: A-131, A-132 and A-133

Based on interviews and documentation review, the Hospital did not obtain consent from Patient #1's Health Care Proxy, for care and treatment of Patient #1, prior to performing a TIPS procedure (transjugular intrahepatic portosystemic shunt, to reroute blood flow in the liver and gastrointestinal tract to reduce high blood pressure), an upper endoscopy and an anesthesia consent.

Findings include:

The Hospital Policy, titled informed consent, dated 3/2020, indicated that in the event that an adult patient is unable to make or communicate his/her own health care decisions, informed consent must be obtained from the patient's legal representative or surrogate decision maker.

The Face Sheet indicated Patient #1 was admitted to the Hospital on 5/11/21 at 5:46 A.M.

Patient #1's medical record documentation indicated a Massachusetts Health Care Proxy form, dated 12/13/17, authorized the designated Health Care Proxy to make all health care decisions for Patient #1, including life sustaining treatment, if Patient #1 was unable to make health care decisions for him/herself.

The Physician's Emergency Medicine Note on 5/11/21, indicated Patient #1 had hematemesis (vomiting blood), and bloody stool, and had vomited nonstop, prompting him/her to call the Emergency Medical Services. He/she was alert and oriented times three. The most likely cause was and upper gastrointestinal bleed with a history of enlarged liver and alcohol abuse. Patient #1 had a low hemoglobin of 4.2 (normal range 13.5 to 17.5) and liver dysfunction with an in INR (international normalized ratio) of 3.2 (normal in less than 1.1) despite not being on anticoagulation, had metabolic acidosis with a bicarbonate of 17 (normal range 22 -26). He/she was transferred to the Intensive Care Unit.

The Physician's Intensive Care Unit (ICU) Note, dated 5/11/21 at 9:45 A.M., indicated he/she had hypertension and hematemesis. Gastroenterology was consulted and deferred an endoscopy (a procedure using a scope to examine a cavity), until the hemoglobin was above 7. Patient #1 was a full code and his primary emergency contact was his/her designated Health Care Proxy.

The Consent for the Upper Endoscopy Procedure, dated 5/12/21 at 9:25 A.M., indicated Patient #1 was sedated and a telephone consent for an upper endoscopy was signed by Patient #1's friend (not by the Health Care Proxy) on the signature line required for the surrogate decision makers name.

The Procedural Note for Intubation, dated 5/11/21 at 2:55 P.M., indicated Patient #1 was intubated for airway protection.

Review of the Medical Record indicated that the Health Care Proxy was not invoked.

Interview with the Critical Care Provider on 8/4/21 at 10:00 A.M., indicated the Health Care Proxy should have been invoked when he/she was intubated and could not make decisions for him/herself, subsequently the HCP was not invoked.

The Interventional Radiology Note, dated 5/11/21, at 4:57 P.M., indicated Patient #1 was hemodynamically unstable, had a life-threatening esophageal bleed secondary to alcoholic liver cirrhosis, was referred for an emergency TIPS placement, it may be noted that its outcome was exceedingly poor per the literature.

The Procedure Consent Form, dated 5/11/21 at 5:20 P.M., indicated Patient #1's consent for a TIPS procedure was signed by Patient #1's friend (not by the Health Care Proxy) on the signature line required for the surrogate decision makers name.

The Physician's Note, dated 5/11/21 at 6:43 P.M., indicated there was extensive discussions with Patient #1's friend and Health Care Proxy (the friend was incorrectly identified as the Health Care Proxy, but the Physician did not know) about the gravity of his/her situation and the extremely high mortality rates.

The Anesthesia Consent Form, dated 5/11/21 at 5:09 P.M., indicated Patient #1's consent for anesthesia was signed by Patient #1's friend (not by the Health Care Proxy) on the signature line required for the surrogate decision maker.

The Initial Social Work Note, dated 5/15/21, at 4:33 P.M., indicated Patient #1 was referred to Social Service Worker for confusion regarding who was the Health Care Proxy. It was unclear in the Emergency Department why Patient #1's friend was contacted for making health care decisions, but the Health Care Proxy was not.

Interview with the Social Service Worker on 8/4/21 at 1:20 P.M., indicated that Patient #1's Health Care Proxy had not changed during the admission of 5/11/21, and there was already an Advance Directive on file with the Health Care Proxy who was designated legally for making health care decisions. Patient #1's friend (who was not the Health Care Proxy) had provided consent, but was not the Health Care Proxy and was not authorized to provide consent.

The Health Care Agent said on 8/4/21 at 2:36 P.M., that Patient #1's choice for his/her Health Care Proxy had not been followed, and she would not have consented to the TIPS procedure that had been consented for by the wrong person (Patient #1's friend).

Based on record review and interview for Patient #1, the Hospital failed to provide care in the Hospital to comply with Patient #1's Advance Directives and invoke Patient #1's Health Care Proxy when he/she could not make decisions.

Findings include:

The Hospital Policy, titled Advance Directives, dated 7/2021, indicated that the Health Care Agent's authority under a Health Care Proxy does not become effective until the patient becomes unable to make or communicate their own decision regarding medical care. Once the patient has been determined to be incapacitated the responsible provider must notify the patient and the person appointed as the Agent.

Patient #1's medical record documentation indicated a Massachusetts Health Care Proxy form, dated 12/13/17, authorized the designated Health Care Proxy to make all health care decisions for Patient #1, including life sustaining treatment, if Patient #1 was unable to make health care decisions for him/herself.

The Physician's Intensive Care Unit (ICU) Note, dated 5/11/21 at 9:45 A.M., indicated he/she had hypertension and hematemesis (vomiting blood). Gastroenterology was consulted and deferred an endoscopy (a procedure using a scope to examine a cavity), until the hemoglobin was above 7. Patient #1 was a full code and his primary emergency contact was his/her designated Health Care Proxy.

The Procedural Note for Intubation, dated 5/11/21 at 2:55 P.M., indicated Patient #1 was intubated for airway protection.

Review of the Medical Record indicated that the Health Care Proxy was not invoked.

Interview with the Critical Care Provider on 8/4/21 at 10:00 A.M., indicated the Health Care Proxy should have been invoked when he/she was intubated and could not make decisions for him/herself, but subsequently the HCP was not invoked.

Based on record review and interview for Patient #1, the Hospital failed to notify the Health Care Agent of Patient #1's admission to the Hospital.

Findings include:

The Hospital Policy, titled Advance Directives, dated 7/2021, indicated that inpatients will be asked if they have an advance directive during the admission process. The Health Care Proxy is a document that is executed by the patient and that appoints another person to make health care decisions when and if the patient lose the capacity to make such decisions themselves. The law in Massachusetts recognizes the Health Care Proxy.

The Face Sheet indicated Patient #1 was admitted to the Hospital on 5/11/21 at 5:46 A.M.

Patient #1's medical record documentation indicated a Massachusetts Health Care Proxy form, dated 12/13/17, authorized the designated Health Care Proxy to make all health care decisions for Patient #1, including life sustaining treatment, if Patient #1 was unable to make health care decisions for him/herself.

The Physician's Intensive Care Unit (ICU) Note, dated 5/11/21 at 9:45 A.M., indicated he/she had hypertension and hematemesis. Gastroenterology was consulted and deferred an endoscopy (a procedure using a scope to examine a cavity), until the hemoglobin was above 7. Patient #1 was a full code and his primary emergency contact was his/her designated Health Care Proxy.

The Procedural Note for Intubation, dated 5/11/21 at 2:55 P.M., indicated Patient #1 was intubated for airway protection.

Review of the Medical Record indicated that the Health Care Proxy was not invoked, even after intubation.

Interview with the Critical Care Provider on 8/4/21 at 10:00 A.M., indicated the Health Care Proxy should have been invoked when he/she was intubated and could not make decisions for him/herself, subsequently the HCP was not invoked.

The Initial Social Work Note, dated 5/15/21, at 4:33 P.M., indicated it was unclear in the Emergency Department why Patient #1's friend was contacted for making health care decisions for Patient #1, but the Health Care Proxy was not.

Interview with the Social Service Worker on 8/4/21 at 1:20 P.M., indicated that Patient #1's Health Care Proxy who was designated legally for making health care decisions and had not been notified of his/her admission to the Hospital.

The Health Care Agent said on 8/4/21 at 2:36 P.M., that Patient #1's admission to the Hospital was never disclosed to her by the Hospital, even when Patient #1 could not make health care decisions for him/herself due to being sedated and intubated.